[House Hearing, 105 Congress]
[From the U.S. Government Publishing Office]




                 DEPARTMENTS OF LABOR, HEALTH AND HUMAN

               SERVICES, EDUCATION, AND RELATED AGENCIES

                        APPROPRIATIONS FOR 1998

_______________________________________________________________________

                                HEARINGS

                                BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                       ONE HUNDRED FIFTH CONGRESS
                              FIRST SESSION
                                ________
  SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
                    EDUCATION, AND RELATED AGENCIES
                 JOHN EDWARD PORTER, Illinois, Chairman
 C. W. BILL YOUNG, Florida
 HENRY BONILLA, Texas
 ERNEST J. ISTOOK, Jr., Oklahoma
 DAN MILLER, Florida
 JAY DICKEY, Arkansas
 ROGER F. WICKER, Mississippi
 ANNE M. NORTHUP, Kentucky          DAVID R. OBEY, Wisconsin
                                    LOUIS STOKES, Ohio
                                    STENY H. HOYER, Maryland
                                    NANCY PELOSI, California
                                    NITA M. LOWEY, New York
                                    ROSA L. DeLAURO, Connecticut

 NOTE: Under Committee Rules, Mr. Livingston, as Chairman of the Full 
Committee, and Mr. Obey, as Ranking Minority Member of the Full 
Committee, are authorized to sit as Members of all Subcommittees.
  S. Anthony McCann, Robert L. Knisely, Susan E. Quantius, Michael K. 
                                 Myers,
                  and Francine Mack, Subcommittee Staff
                                ________
                                 PART 3
                 DEPARTMENT OF HEALTH AND HUMAN SERVICES
                          PUBLIC HEALTH SERVICE
              (Excluding the National Institutes of Health)
                                                                   Page
 Agency for Health Care Policy and Research.......................    1
 Centers for Disease Control and Prevention.......................  119
 Health Resources and Services Administration.....................  537
 Substance Abuse and Mental Health Services Administration........  867
                                ________
         Printed for the use of the Committee on Appropriations
                                ________
                     U.S. GOVERNMENT PRINTING OFFICE
 40-522 O                   WASHINGTON : 1997

                                  COMMITTEE ON APPROPRIATIONS

                   BOB LIVINGSTON, Louisiana, Chairman

 JOSEPH M. McDADE, Pennsylvania
 C. W. BILL YOUNG, Florida
 RALPH REGULA, Ohio
 JERRY LEWIS, California
 JOHN EDWARD PORTER, Illinois
 HAROLD ROGERS, Kentucky
 JOE SKEEN, New Mexico
 FRANK R. WOLF, Virginia
 TOM DeLAY, Texas
 JIM KOLBE, Arizona
 RON PACKARD, California
 SONNY CALLAHAN, Alabama
 JAMES T. WALSH, New York
 CHARLES H. TAYLOR, North Carolina
 DAVID L. HOBSON, Ohio
 ERNEST J. ISTOOK, Jr., Oklahoma
 HENRY BONILLA, Texas
 JOE KNOLLENBERG, Michigan
 DAN MILLER, Florida
 JAY DICKEY, Arkansas
 JACK KINGSTON, Georgia
 MIKE PARKER, Mississippi
 RODNEY P. FRELINGHUYSEN, New Jersey
 ROGER F. WICKER, Mississippi
 MICHAEL P. FORBES, New York
 GEORGE R. NETHERCUTT, Jr., 
Washington
 MARK W. NEUMANN, Wisconsin
 RANDY ``DUKE'' CUNNINGHAM, 
California
 TODD TIAHRT, Kansas
 ZACH WAMP, Tennessee
 TOM LATHAM, Iowa
 ANNE M. NORTHUP, Kentucky
 ROBERT B. ADERHOLT, Alabama        DAVID R. OBEY, Wisconsin
                                    SIDNEY R. YATES, Illinois
                                    LOUIS STOKES, Ohio
                                    JOHN P. MURTHA, Pennsylvania
                                    NORMAN D. DICKS, Washington
                                    MARTIN OLAV SABO, Minnesota
                                    JULIAN C. DIXON, California
                                    VIC FAZIO, California
                                    W. G. (BILL) HEFNER, North Carolina
                                    STENY H. HOYER, Maryland
                                    ALAN B. MOLLOHAN, West Virginia
                                    MARCY KAPTUR, Ohio
                                    DAVID E. SKAGGS, Colorado
                                    NANCY PELOSI, California
                                    PETER J. VISCLOSKY, Indiana
                                    THOMAS M. FOGLIETTA, Pennsylvania
                                    ESTEBAN EDWARD TORRES, California
                                    NITA M. LOWEY, New York
                                    JOSE E. SERRANO, New York
                                    ROSA L. DeLAURO, Connecticut
                                    JAMES P. MORAN, Virginia
                                    JOHN W. OLVER, Massachusetts
                                    ED PASTOR, Arizona
                                    CARRIE P. MEEK, Florida
                                    DAVID E. PRICE, North Carolina
                                    CHET EDWARDS, Texas

                 James W. Dyer, Clerk and Staff Director

                                  (ii)

 
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 1998

                              ----------                              

                                        Tuesday, February 11, 1997.

               AGENCY FOR HEALTH CARE POLICY AND RESEARCH

                               WITNESSES

CLIFTON R. GAUS, SC. D., ADMINISTRATOR
LISA SIMPSON, B. CH., DEPUTY ADMINISTRATOR
RITA M. KOCH, CHIEF, FINANCIAL MANAGEMENT
DENNIS WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, DEPARTMENT OF 
    HEALTH AND HUMAN SERVICES
    Mr. Porter. The subcommittee will come to order.
    Our hearings continue with the Agency for Health Care 
Policy and Research, and we're very pleased to welcome Dr. 
Clifton Gaus, the Administrator.
    Dr. Gaus, you'll be happy to know I don't have a sermonette 
or lecture for you. Before we begin, would you introduce the 
people who are with you and then proceed with your statement.

                       Introduction of Witnesses

    Dr. Gaus. Yes, I would. Of course, you know Dennis 
Williams, our able budget officer at the Department. To my 
direct right is Rita Koch, the AHCPR Budget Officer. And to my 
left is Dr. Lisa Simpson, who is the Deputy of the agency.

                           Opening Statement

    Mr. Chairman and members, I am here for the third and what 
will be the last time as AHCPR's Administrator. As you may 
know, Friday is my last day of Federal service. And I'd like to 
submit my formal statement for the record, if I could, and just 
make a few brief opening remarks.
    I have two messages, simple messages, I think, that I'd 
like to leave with you today. One is that AHCPR is not the same 
agency it was three years ago. It's undergone a period of 
dramatic transformation that does parallel the changing needs 
in the health care system today that we're all feeling, 
observing and debating what to do about.

                               customers

    I'm very proud of the new AHCPR. Our primary focus of 
research now is to meet the needs of five customers. We call 
them the five P's and I don't think there's a person in the 
agency who doesn't know what the five P's mean. The P's are 
patients, plans, that is health plans, providers, purchasers 
and policy makers. Our laboratory is in a sense the real world 
of health care. And our research results in very practical 
information that our customers use every day.
    With this new focus, we also more than meet the ideal that 
the Government should be responsive to the needs of customers 
as the 1993 Government Performance and Results Act legislation 
pointed out and required.

                       customers and partnerships

    We work closely with our customers in many kinds of 
partnerships. Those customers and organizations and partners 
include the American Medical Association, the American 
Association of Retired Persons, health plans, and the 
Washington Business Group on Health, really the alphabet soup 
of health care. And every day, we are in constant dialogue, and 
see ourselves as the science partner to those groups.

                        investment in the future

    My second message is that, and I talked about this a lot 
last time, is that virtually every dollar spent by our agency 
is an investment in the future of the health care system. Like 
the National Institutes of Health, our research and the return 
on investment improves not only the health of Americans but 
oftentimes leads to substantial savings in our scarce health 
care resources, and particularly the Medicare program.
    I want to give you two examples of work we completed this 
year. One of those was a study published in the New England 
Journal of Medicine recently that outlined just a simple and 
accurate method to predict which pneumonia patients really 
needed to be in the hospital or which ones could be treated at 
home. We spend $4 billion a year on treating pneumonia in 
hospitals. We have developed a somewhat simple system to 
predict accurately which patients can be sent home early or 
don't even need to be in the hospital.
    Another example of the kind of work that we do that goes to 
the heart of both improving quality and lowering costs is a 
study of elderly patients, again mostly Medicare patients, who 
receive beta blockers following heart attacks. These patients 
are 43 percent less likely to die in the first year following 
that attack. The longevity that comes with prompt and quick 
access to the drug over the long run will reduce health care 
costs.

                        evidence-based practice

    Briefly, and several of these are mentioned in my 
statement, there are other projects that we're starting this 
year with our 1997 funds, and we also will be using 1998 funds 
to do that I'd like to mention here. One project is what we 
call the Evidence-based Practice Initiative. I'm pleased to 
tell you that it's well underway. And the purpose of EPCs is to 
support health plans and purchasing organizations with 
scientific information about what works in medical care and 
what doesn't work. And we hope that they will take that 
information and use it to improve the practice of their 
physicians and health care practitioners.
    This is not us doing guidelines. We're not in the guideline 
business any more. But we are assisting with providing a 
science to many of the health care organizations who are trying 
to improve health care quality.

                  consumer assessment of Health Plans

    The second initiative that we are doing this year and next 
is what we call CAHPs, or the Consumer Assessment of Health 
Plans. This project is producing and testing a national 
consumer questionnaire to be used by both public and private 
organizations to evaluate or survey their members about health 
care, and the quality of health care and access to health care. 
As you know, much of the debate about managed care is whether 
or not the consumer is treated fairly by the plans, whether 
they have access to the services. This is a national 
questionnaire that has been developed by our staff and their 
contractors. And this questionnaire will also become the basis 
of an ongoing Medicare survey of Medicare members of health 
care plans.

                    medical expenditure panel survey

    And lastly, I just want to report about the Medical 
Expenditure Panel Survey. I am particularly proud of the 
progress we've made here. MEPS, as you know, enjoys strong 
support from your committee and the Administration. And like so 
much else of the agency, it's undergone dramatic 
transformation.
    I'm pleased to announce that we will begin releasing data 
from the MEPS survey next month. That data will be for health 
insurance coverage and health expenditures in the calendar year 
1996. So the speed of the turnaround of the date is really 
unprecedented. As you may know, our current statistics in this 
country, coming from this current population survey, are over a 
year old. Our new data will be provided within months of when 
it is collected. And it will be a very valuable information 
base for Congress, the Administration, etc., to evaluate health 
insurance coverage. The new data are in the final stages of 
editing now. And like I said, will be released next month.
    The data base that we are collecting also will be shared in 
March in somewhat raw form with the Congressional Budget 
Office, the Congressional Research Service, and of course OMB 
and other users of this kind of information.

               quality and cost effectiveness initiative

    With respect to, specifically, our 1998 request, I'm just 
going to mention a few initiatives and then close. The most 
important and largest one is our initiative called Quality and 
Cost Effectiveness of Clinical Care. This initiative will focus 
on developing tools and approaches to improve the quality of 
clinical care. It's got two components.
    One of these is just building better scientific knowledge 
through outcomes research about what works and what doesn't 
work in clinical care. The second part of that initiative is on 
quality measurement. And this part will develop some new 
statistical measures of quality that will allow the consumers 
and purchasers, such as the Health Care Financing 
Administration, to better choose their health plans and their 
health providers.
    In summary, I guess I'm as convinced as ever, after having 
been at the helm here for three years, that the results of all 
of our research and the data that's collected in surveys such 
as MEPS both do improve quality of care, and in some cases 
actually save many lives. And in particular, I'm convinced, 
result in significant savings to the health care system, 
including the Medicare Trust Funds.
    And thank you very much.
    [The prepared statement follows:]
    Offset Folios 8 to 17 Insert Here



                        new ahcpr administrator

    Mr. Porter. Dr. Gaus, you mentioned this would be your last 
appearance before the subcommittee. And you said how many days 
until your----
    Dr. Gaus. Three more days.
    Mr. Porter. Three more days before you're leaving your 
post.
    Dr. Gaus. I leave on Valentine's Day.
    Mr. Porter. Well, we'd like to congratulate you and thank 
you for your service. You've done an excellent job there. 
You've been a very skilled administrator. And you've led the, 
in a sense, reinvention of the agency and gone through some 
very difficult challenges. And we thank you for the good work 
that you've done.
    Has Secretary Shalala appointed a successor to you?
    Dr. Gaus. Not yet. They're finishing that process, and I 
think she, and I hope, will appoint someone fairly soon.
    Mr. Porter. Would there be an acting in the meantime?
    Dr. Gaus. Yes, Dr. Simpson will be the acting 
Administrator.
    Mr. Porter. All right. Well, we look forward to working 
with Dr. Simpson, and thank you for your excellent service.

                    evidence-based practice centers

    Let me ask, the original rationale for direct Federal 
development of the clinical guidelines is that they would be 
comprehensive and free of bias if done by your agency. And in 
some instances, you incurred the wrath of interested groups 
like the orthopedic surgeons. Now you're moving to a system 
where professional societies like the surgeons will be tasked 
with developing guidelines based on the Center's reports. How 
can you ensure that the new evidence-based system will be free 
of bias?
    Dr. Gaus. Couple ways, I guess. I think there will always 
be different views in our health care system about what works 
and what the best treatments are. Nevertheless, I think what we 
demonstrated through our guidelines program was that basing 
them on science and what we know about science, and in fact 
really paving the way in how to evaluate science, oftentimes 
developing new statistical methods to do that, is sort of a 
model or a foundation that just about all of the really 
credible professional organizations who now do their own 
guidelines use.
    The quality of guidelines, I believe, has improved 
enormously over the years. And we see our job as providing the 
science to those organizations and letting them evaluate the 
best way to change or conduct clinical practice.
    There is one other thing we're going to do, however, that I 
think will have a very important impact on keeping those 
guidelines that are in use honest and of value. And that is, 
putting them in the sunshine. We're doing this with two 
important partners, the American Medical Association and the 
American Association of Health Plans. We soon will be signing a 
partnership agreement with those two organizations for all 
three of us to jointly sponsor a national clearinghouse of 
clinical practice guidelines.
    And what this will be, Mr. Chairman, is an electronically 
based catalogue of virtually every guideline in the country. 
And in addition to not only the guidelines being available to 
anybody, including the consumers and the press and all of the 
critics, but the staff of that clearinghouse will compare the 
guidelines. So if we have five different guidelines on heart 
failure, this clearinghouse will characterize the differences 
in those guidelines, so that anyone attempting to use them will 
be able to see which ones are built more on science and which 
ones aren't.
    Mr. Porter. So the bottom line on it, though, is that this 
will be public and people will see them.
    Dr. Gaus. Yes. Those two organizations have agreed to work 
with us in making available in a public forum as many of the 
clinical practice guidelines as exist in the country. Now, 
there may be a few organizations that don't want theirs on the 
system. And I think those that don't want them on the system 
may have some good reasons for not wanting them on the system, 
and they'll become suspect.

               medical expenditures panel survey savings

    Mr. Porter. We understand that you're working to reduce the 
projected 1997 costs of the medical expenditures survey. Can 
you give us a sense, at this point, of how much money youmay be 
able to shave off the original estimate of $44.7 million?
    Dr. Gaus. We are, it is work in progress, although we do 
have some accomplishments to date in that area. As you 
remember, your Committee instructed us to do this or asked us 
to do this. And we are hoping, in fact, that by accomplishing 
savings we'll have some funds, as your committee directed, to 
both fund our commitments in our base and several new projects.
    We have, in the negotiation of the contract so far, I feel 
comfortable saying we will probably save in the range of $3 
million to $5 million, but we're not finished, and it may go 
higher.

                         reprogramming request

    Mr. Porter. If you're going to be saving that kind of 
money, do you intend to submit a reprogramming request to 
transfer these funds to other agency activities? If so, which 
activities would you increase? Without a reprogramming, will 
you be able to fund any new costs and access research grants in 
1997? Without a reprogramming, will you have to reduce the 
awards for 1997 continuing grants?
    Dr. Gaus. Our Congressional Justification does say we may 
submit a reprogramming request. I think at that time, we 
weren't sure of the size of the savings. Obviously, as the size 
of the savings increases, the significance of this is more 
important. And it increases the likelihood we would come to you 
with a reprogramming request.
    The first monies that are saved probably would not require 
a reprogramming request. The funds would be used to fully fund 
the commitments that are already in our base. That is our first 
priority, and we feel fairly comfortable that the savings we 
found to date will enable us to fully fund those ongoing 
commitments.
    New savings in addition to the ones I mentioned obviously 
would enable us to do a few new starts. And I think for that, 
if these funds are significant, I presume we would come to you 
with a reprogramming request.

                         technology assessment

    Mr. Porter. All right. You completed a technology 
assessment last year on lung volume reduction surgery. This 
issue became very controversial in our bill. Your report was 
cited in support of broadening the scope of the clinical trial 
NIH was conducting on lung reduction surgery for HCFA. NIH 
opposed broadening the trial to test more methods. How do you 
characterize your agency's report, and do you think the trial 
should be broadened to include additional surgical techniques?
    Dr. Gaus. Our report clearly, I think, laid some new 
groundwork in just the fact that it recommended that HCFA 
assist NIH in a clinical trial through its reimbursement 
system. And it was a technology that to us clearly needed 
further research. We just couldn't answer the question that 
HCFA wanted to know with what we had.
    Our negotiations with NIH and HCFA over the breadth of the 
trial are nearing conclusion. Dr. Simpson and I, I'll ask her 
just to mention the status of that. But I am still hopeful that 
within the next month or so, that trial's scope will include 
both enough patients and enough procedures, for us to answer 
the questions when the trial is completed. We also have had 
some concern about the length of that trial. But that's also 
under negotiation.

                       changing practice patterns

    Mr. Porter. Dr. Gaus, what have you learned from research 
you've supported about methods to change practice patterns when 
new guidelines are introduced? Does the new information have to 
be incorporated into performance measures, or must incentives 
be created for physician behavior to actually change?
    Dr. Gaus. As you know, I think changing behavior of 
physicians is one of the more daunting tasks our agency faces. 
And we have learned that it takes a multi-faceted effort, just 
publishing a guideline, and even accomplishing the task of 
physicians reading that guideline isn't enough.
    In some of the work that actually our partners have been 
doing, the Kaiser Health Plan, in particular, studying the 
process of implementation, the process of clinical change, 
those researchers tell us that you need to combine a whole 
series of both continuing education activities, financing 
incentives where you can. And in some cases, just simple 
administrative reminder systems, so that it's essentially 
always apparent to the physician that, here is a particular 
place to change your practice or improve your practice.
    In our guideline on cessation of smoking, strong 
recommendations were made that in the clinical chart itself 
there should be a red flag for the physician to ask every time 
the patient comes to the office, are you still smoking and what 
can we do about it. Those simple reminders work, too. But all 
told, it's a combination of everything.

                               guidelines

    Mr. Porter. Along the same line, the GAO report last May 
indicated that guidelines are often modified by users to be 
consistent with local standards of care. Doesn't this defeat 
the purpose of developing uniform guidelines which attempt to 
override needless local variations in care standards?
    Dr. Gaus. To the extent those changes are substantial, you 
are right. I think what we have found over the years, and why I 
felt that stepping back from a single national guideline was 
appropriate, is that the modifications at the local level or 
the plan level oftentimes are minor in content, but very major 
in process. And what I mean is, to effect the change that's 
needed, you need a buy-in of the physicians and other 
practitioners whom you are asking to change.
    And oftentimes these plans will bring about those minor 
modifications through their own medical education committees, 
their clinical practice committees. And as a result, the book 
doesn't look like our book, but the principal recommendations 
that really are strongly supported by science often inevitably 
are there. It's sometimes the fuzzier questions where we don't 
have enough science. Or just cosmetic changes that bring about 
better adoption rates without sacrificing the core of the 
recommendations.
    So we're comfortable, basically, that as long as we have a 
strong scientific underpinning, most of the responsible health 
care organizations will have guidelines that kind of look like 
one another in substance. They may not cosmetically look like 
one another.

                      one percent evaluation funds

    Mr. Porter. Although the subcommittee has never been 
enthused about it, your agency is financed in part by the 1 
percent evaluation setaside authorized in the Public Health 
Service Act that taps other health agencies. We have tried to 
limit the size of the tap to the amount needed to support your 
health care expenditure surveys, which benefit all public 
health agencies.
    Of your budget request this year for $62 million in 1 
percent funding, how much of the total is directly related to 
your health surveys?
    Dr. Gaus. Well, the largest part of that 1 percent, about 
$37 million, goes towards the Medical Expenditure Panel Survey. 
I must say, it's always a difficult tradeoff within the 
Administration to sort of set the balance of these two 
accounts. And we have, we probably are pushing that envelope to 
its max. But there are some advantages, I think, to doing it 
through the 1 percent. Your committee obviously is the final 
determinant of that, and in the past, I think we've always 
resolved those budget differences in a way that doesn't 
jeopardize either the providers of the 1 percent or the 
spenders of the 1 percent.
    Clearly, the medical expenditure panel survey is the most 
relevant, and I think the most important of the initiatives to 
continue to have 1 percent money.

                               user fees

    Mr. Porter. At one point, your agency considered private 
sector financing of technology assessment through user fees. It 
was rejected at the time because of conflict of interest 
concerns. The Food and Drug Administration seems to have jumped 
the user fee hurdle successfully. Do you think it is time to 
reconsider this policy for AHCPR in order to better fund your 
technology assessment program?
    Dr. Gaus. I don't know whether specifically I would call 
them user fees. I would support private sector funding to the 
agency, or to our contractors for technology assessments. The 
new evidence-based practice centers that we are soliciting for 
now with our 1997 and 1998 budgets, will be organizations that 
can do technology assessments as well as evidence reports. So 
we're hoping that in fact we could interest some private 
organizations, either large health plans, health insurers, 
large purchasers to kind of offset some of our costs for these 
centers through joint funding. We've in fact set the mechanisms 
up in the procurement in a way that would allow that to occur.
    That's what I would characterize more as a voluntary user 
fee, not a federally-mandated one. But I think we'll have some 
experience in a year from now to come back to you and say, yes, 
there is interest in the private sector to help do these 
technology assessments.

                            aids guidelines

    Mr. Porter. We understand that NIH plans to develop 
guidelines for the use of the new protease inhibitor drugs to 
treat AIDS patients. Do you plan to support any work in this 
area, and how would AHCPR's approach be different from NIH's?
    Dr. Gaus. At the moment, we don't. As you know, we did an 
HIV guideline about a year and a half ago. And we do not have 
plans to update that.
    Lisa, do you want to add to that?
    Dr. Simpson. Sure, I could comment on two levels. One, in 
terms of the area of the science base and sort of the 
effectiveness or guideline area with protease inhibitors. 
Clearly, the NIH is leading the front there. And our guidelines 
that Dr. Gaus referred to, we are not updating, but we are 
working with the Centers for Disease Control to make those 
parts of it that are still relevant, pre-protease inhibitors, 
available to practitioners.
    The second part, which is looking more at the cost and 
utilization of protease inhibitors, we have incorporated a sub-
study into our major national survey of the costs and 
utilization of services by persons infected with HIV to look 
specifically at protease inhibitors. So that will be starting 
this spring, and we hope to have better information about 
access to these drugs, the cost and how they're working in the 
care delivery system.

                        academic health centers

    Mr. Porter. Could I ask you, Dr. Gaus, and I'm not sure you 
were here when we were talking to Dr. Vladeck, I raised a 
question about the future of academic health centers. I wonder 
if AHCPR has done any work in this area and has any thoughts 
about what is happening, very rapidly, to our teaching 
hospitals?
    Dr. Gaus. I have both some personal thoughts and 
professional thoughts about that. We also are doing some 
research that is relevant to the issue of primary care 
physicians and specialists, and how are they referring to one 
another. And what are the kind of quality and cost consequences 
of different referral patterns. That I think is part of the 
dilemma about academic health centers. It goes to, is the money 
that we're spending, both public and private, training the 
right number and the right kind of primary care and 
specialists. And those issues, we do have a lot to say on, and 
do so frequently.
    Professionally, I have been involved in this debate, since 
believe it or not, 1972, when I was in the Health Care 
Financing Administration. It wasn't HCFA then, it was actually 
the Social Security Administration. And the issues haven't 
changed, frankly, since that time. And there is no question 
that managed care now has a large presence in the marketplace, 
and this does create the need I think to look at how we finance 
it. And it's not clear to me that there is a specific enough 
public policy and system to implement that policy to assure 
that our public funds go to the institutions that are producing 
the physicians we need for the next decade or two.
    And I'm hopeful the debate about indirect and direct 
medical education funds includes what kind of physicians we 
need to be training in the future, and does not perpetuate what 
now is almost an ongoing system that in my view may not be 
training the right numbers or the right kinds of physicians.
    Mr. Porter. But you would also say that you need a system 
for training physicians beyond their economic classroom work, 
and that if you debate too long on how many you're going to 
train and don't look at the foundation for the training, you 
could lose it.
    Dr. Gaus. There's no question that there's a public role in 
the training, clinical training of physicians. There has been 
one always since Medicare. And I think yes, you're correct. 
That system needs to be both supported and the Congress needs 
to clarify exactly to what extent and how we're going to 
finance it.
    Mr. Porter. Well, I have additional questions for the 
record that I would ask that you answer for the record.
    Again, we wish you well. And we commend you on the work 
that you have done at AHCPR. You've done an excellent job, and 
we appreciate your leadership and forthrightness before our 
subcommittee as well.
    Dr. Gaus. Thank you very much.
    Mr. Porter. Thank you very much.
    Dr. Gaus. It's my pleasure to be here.
    Mr. Porter. Thank you.
    The subcommittee will stand in recess until 10:00 a.m. 
Wednesday.
    [The following questions were submitted to be answered for 
the record:]
    Offset Folios 32 to 128 Insert here



                                       Thursday, February 13, 1997.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

                               WITNESSES

DAVID SATCHER, M.D., DIRECTOR
HELENE GAYLE, M.D., DIRECTOR, NATIONAL CENTER FOR HIV, STD, AND TB 
    PREVENTION
JAMES M. HUGHES, M.D., DIRECTOR, NATIONAL CENTER FOR INFECTIOUS 
    DISEASES
JAMES S. MARKS, M.D., DIRECTOR, NATIONAL CENTER FOR CHRONIC DISEASE 
    PREVENTION AND HEALTH PROMOTION
MARK L. ROSENBERG, M.D., DIRECTOR, NATIONAL CENTER FOR INJURY 
    PREVENTION AND CONTROL
WILLIAM H. GIMSON, DIRECTOR, FINANCIAL MANAGEMENT OFFICE
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY FOR BUDGET, DEPARTMENT 
    OF HEALTH AND HUMAN SERVICES
    Mr. Porter. The subcommittee will come to order.
    Let me apologize to everyone for starting late. I had a 
radio interview downtown and was held up and got here as fast 
as I could, and I do apologize to everyone.
    This morning we are delighted to welcome Dr. David Satcher, 
the Director of the Centers for Disease Control and Prevention.
    I told Secretary Shalala on Tuesday, Dr. Satcher, that 
while we disagree with some elements of her budget proposal, I 
think we all agree with the priorities that she placed on CDC 
programs like chronic and infectious disease.
    The news of your work follows us world-wide. Some of the 
members of this subcommittee joined me in a trip to Asia in 
January, and we were briefed on CDC's work in China, especially 
in regard to spina bifida and influenza.
    We have received your letter inviting the subcommittee to 
CDC in Atlanta, and we are pleased to be setting that up for 
the month of April. I hope that many members of the committee 
will be able to attend so that we will be able to learn more 
on-site about many of CDC's missions.
    If you would introduce the people at the table and then 
proceed with your statement, please.

                       Introduction of Witnesses

    Dr. Satcher. Thank you very much, Chairman Porter.
    I am delighted to have joining me today from CDC the 
Director of the National Center for HIV, STD, and TB, Dr. 
Helene Gayle; the Director of the National Center for 
Infectious Diseases, Dr. Jim Hughes; on my far left, the 
Director of the National Center for Injury Prevention and 
Control, Dr. Mark Rosenberg; next to him, the Director of the 
National Center for Chronic Disease Prevention and Health 
Promotion, Dr. Jim Marks; Bill Gimson is Director of our 
Financial Management Office, and I think you know Dennis 
Williams, who is from the Department.

                           Opening Statement

    We are delighted to have this opportunity to appear before 
the subcommittee again this year to support the President's 
budget for CDC. We are also delighted to hear that the 
subcommittee will be visiting CDC in Atlanta. We look forward 
to hosting you and introducing you to our facilities, our 
programs, and our people there.

                        Prevention Effectiveness

    As you know, in commemorating our 50th anniversary in 1996, 
CDC attempted to showcase our scientific articles and 
accomplishments of historic interest to public health. For 
example, two weeks ago CDC republished a 1992 MMWR report that 
first described the need for information on the effectiveness, 
as well as the economic and social impact, of disease and 
injury prevention strategies. I know that prevention 
effectiveness is something that you're interested in and how we 
go about evaluating the outcomes of our programs. We are 
putting increased emphasis on prevention effectiveness 
especially, in all aspects of our work at CDC, and we think 
that as we move forward it will help us to continue to enrich 
our programs.
    Prevention is certainly a wise investment. As you have 
heard us say before, while we invest about a trillion dollars a 
year in our health care system in this country, we only invest 
about 1 percent of that amount in population-based prevention. 
We recently did a study with several of the States in this 
country and reconfirmed those figures.
    At the same time, we know that public health continues to 
contribute significantly to longer, healthier lives in the 
United States. When we look back to the year 1900 and compare 
it with today, an infant born today can expect to live 30 to 35 
years longer, and certainly, 25 years of that gain can be 
attributed to our work in public health. So we continue to try 
to make the point that we need to invest more in population-
based prevention.
    CDC over the years has shown the effectiveness of public 
health efforts. Our contemporary efforts in terms of dealing 
with threats to health, such as injury, environmental and 
occupational hazards, behavioral risks, and chronic diseases 
continue to focus on that.
    One of the things we did last year was to ask ourselves not 
only about our 50-year history, but about the future. And we 
decided, in looking to the future, that there were four 
assumptions that we could make about the future. And our budget 
request this year is related to those four assumptions.

                           health assumptions

    The first assumption is that microorganisms will continue 
to be a threat to the health of the American people. And we've 
given you the background for that assumption.
    We also make the assumption that human behavior and 
demographics will continue to create new public health 
challenges for this country and the world. We assume that the 
pressures that are now taking place in the marketplace to 
reduce the cost of health care will lead to the need for more 
prevention and applied research. And many of the managed care 
organizations and others are telling us that, and we're trying 
to work closely with them in dealing with those needs.
    And finally, we assume that new technologies will increase 
opportunities for prevention. For example, as we said before, 
and I know you're interested in the polio eradication program, 
we've tried to continue to remind people that when we have 
eradicated polio, which we think we can do around the year 
2000, this country will save over $230 million a year by not 
having to immunize against the polio virus.
    We were able to participate in a major public health event 
in India in December, in which we, along with the Rotary Club 
and others, organized with the Indian Government and immunized 
120 million children in one day against polio. The significance 
of that is that India has had over one half the cases of polio 
in the world over the last several years. So the fact that 
we're having these immunization days in China and India means 
that we're getting very close to our goal of eradicating polio.

                          emerging infections

    The President has requested $2,315,795,000 to support CDC's 
work. Now, in the area of microorganisms and emerging 
infections, the President has requested $15 million to continue 
our plan for emerging infectious diseases control. As you know, 
that is a five year plan, and we estimate that costs will be 
$125 million a year. Yet, dealing with the reality of our 
budget, we decided to develop that strategy incrementally.
    So this year, if we're funded with an additional $15 
million, we will do several things. Number one, we will 
increase to 23 States the number of States that we're helping 
to strengthen their laboratory and epidemiology program and 
surveillance and response capacity. We also will be able to 
increase the number of emerging infectious disease centers from 
seven to eight. So the $15 million will help us to continue to 
move forward toward our goal.

                           food-borne disease

    The President has also requested $10 million to enhance our 
ability to detect food-borne diseases. We continue to have 
food-borne disease outbreaks, as you know. Last year, we had 
the cyclospora outbreak from raspberries from Guatemala. And 
then later in the year, we had the E. coli 0157:H7 outbreak in 
Washington State, related to apple juice. The fact that we were 
able to respond rapidly to those outbreaks attests to the fact 
that our capacity to respond is critical, and we need to 
continue to strengthen it.

                     sexually transmitted diseases

    The second area of request in this budget is an area of 
behavior and demographics. And there are three requests. The 
first one has to do with preventing sexually transmitted 
diseases, and preventing infertility in women. As we pointed 
out before, about 100,000 to 150,000 become infertile in this 
country every year due to undiagnosed and untreated sexually 
transmitted diseases, leading to pelvic inflammatory disease 
and then infertility.
    We have now demonstrated, working with some of the managed 
care organizations, that by early screening and treatment, we 
can prevent up to 56 percent of pelvic inflammatory disease and 
infertility. This is a very good investment, not just because 
of the cost savings, but the fact that it saves a lot of pain 
and suffering for individuals and families in this country. We 
think it's a good investment that we should make.

                                hiv/aids

    The second area is the request for an additional $20 
million for the HIV/AIDS prevention program. The epidemic is 
still with us, even though we think we're making some 
significant progress. We have noticed, of course, as we pointed 
out last year, that intravenous drug users constitute an 
increasing percentage of persons with AIDS. One-third of the 
new cases of AIDS are now related directly or indirectly to IV 
drug abuse.
    I think what's important about this is also is that when 
you look at the AIDS problem in women, the overwhelming 
majority of cases are related to IV drug abuse, either directly 
or by having sex with a partner who is an IV drug user. What 
that means also, of course, is that a majority of the babies 
and children who have AIDS in this country are now contracting 
it because of IV drug abuse. We believe that this is an area 
where we need to invest more in terms of surveillance and 
working with States to strengthen their programs, and working 
with community planning efforts. So we're requesting $20 
million in that area.

                                tobacco

    The third area under human behavior is preventing tobacco 
use among young people. Every day in this country, 3,000 new 
teenagers become smokers. That's a million new teenage smokers 
every year. One out of three of those teenagers will ultimately 
die because of smoking. And as we have pointed out before 
within the Department, if 90 percent of our smokers begin 
smoking before they are 18 years of age, that means that many 
of them become addicted before they're even old enough to make 
the proper decisions for themselves.
    We think targeting educational programs for teenagers, 
working with States and local communities in this country, and 
also having the laboratory backup to determine the content of 
tobacco, but also looking at second-hand smoke. We have been 
able to determine that over 80 percent of the people in this 
country who do not smoke are significantly exposed to second-
hand smoke. And we're beginning to see the consequences of 
that. Of course, one of the most significant has been the role 
of second-hand smoke in sudden infant death syndrome. So there 
are several indications.

                                diabetes

    Finally, in the area of reducing health care costs, we have 
two requests. One is preventing and controlling diabetes. We 
have requested $10 million to enhance our programs. Again, 
about 16 million Americans have diabetes, even though only 
about 8 million have been diagnosed as such. The cost each year 
is about $92 billion in terms of medical care and lost wages.
    We're proposing to enhance our prevention strategies. We 
know that we can prevent diabetes from developing in the first 
place. We can diagnose it early and prevent complications like 
blindness and end stage renal disease and amputations of lower 
limbs. The opportunities for prevention also include improving 
the quality of care in general. So this $10 million will help us to 
enhance our national diabetes education program, to work with States to 
strengthen their efforts to work with providers, to improve the quality 
of the care they provide.

                       breast and cervical cancer

    Then in the area of breast and cervical cancer screening, 
last year, you added $15 million to our budget. And we now have 
breast and cervical cancer screening programs in all 50 States. 
Still, each year in this country, about 44,000 women die of 
breast cancer, and about 5,000 from cervical cancer. All of the 
cases of cervical cancer deaths are preventable. And at least 
30 percent of the cases of breast cancer death are preventable. 
And we're asking for $2.3 million to be added to this program 
so that we can continue to strengthen these programs in all 50 
States and associated territories.

       national health and nutrition examination survey (nhanes)

    In the area of new technologies, the NHANES survey, which 
has contributed so much to our understanding of things like the 
prevalence of diabetes, the impact of environmental toxins on 
the health of people, is one that we want to move forward with 
now to NHANES 4. We have had NHANES 3 from 1988 to 1994. And we 
would like to implement NHANES 4 and to develop this as a 
continuing program. And we're requesting $2.4 million.
    Again, this is the only objective measure that we have in 
this country as to how well we're doing in our health care 
system. The only program in which we go out, take blood 
pressures, interview people, take blood samples, urine samples, 
and determine how well American people are doing in terms of 
their health. It's a very important program.

                     occupational safety and health

    And finally, the Occupational Safety and Health Research 
Program, one that we have been in the process of implementing, 
the $4.6 million requested will allow us to complete that 
strategy in terms of operationalizing that program in 
Morgantown, West Virginia, so that we can do quality research, 
quality applied research and basic research to improve the 
health of the American worker.
    I especially want to point out this year that $2.5 million 
here is being requested to deal with problems with 
firefighters. We have a little over a million firefighters in 
this country. And only 200,000 of them are actually full time, 
and the rest are volunteers. About 100,000 of them are injured 
every year in this country. And over 100 die in the process of 
fighting fires.
    We would like to intensely study the causes of death and to 
implement programs to prevent the death of people who are 
trying to save the lives of other people in this country.
    Those are our requests. As you can see, they fall in the 
areas of controlling microorganisms and the threat that they 
represent, dealing with the increasing problem of human 
behavior and demographic changes, especially among our youth, 
taking advantage of opportunities to increase prevention 
activities in this country, but also taking advantage of 
opportunities to better use technology to target our prevention 
in such a way as to enhance the health of the people in this 
country.
    Thank you, Mr. Chairman. We'd be happy to respond to any 
questions.
    [The prepared statement follows:]
    Offset Folios 142 to 145 insert here



                               cdc budget

    Mr. Porter. Thank you, Dr. Satcher.
    Dr. Satcher, a 6/10 of 1 percent increase for CDC? Last 
year the increase was 7.4 percent. Doesn't sound like the 
President's putting this at a very high priority. Could you 
tell me what figure you submitted to OMB initially?
    Dr. Satcher. We can get you that. I don't remember the 
exact figure.
    [The information follows:]

    The CDC revised submission to OMB for FY 1998 was 
$2,617,800,000 which represents a 13.7% increase over the FY 
appropriation.

    Mr. Porter. I suspect it wasn't $2.315 billion.
    Dr. Satcher. Well, no, I think you're right, I think CDC is 
like the other agencies in the Federal Government, a part of 
this major effort to control the budget and to have a balanced 
budget in this country. We feel that we represent a good 
investment for the Nation. But we also know that together, we 
have to struggle with this issue.
    Mr. Porter. Well, if I can give you my short sermonette, if 
we don't come to grips with the rate of increase in the major 
entitlement programs, there isn't going to be any money for 
disease prevention or control. There isn't going to be any 
money for education, and there isn't going to be any money for 
biomedical research and a lot of other priorities.
    So I think it's time that both the Republican Congress and 
the Democratic President sit down and work this out, and come 
to the microphone together and say we've got a solution. 
Because if we don't, everybody is going to be squeezed.
    I'd like to have that figure and see what your original 
proposal was. And I have to ask you next, tell me what you're 
cutting. Because this is, obviously there are cuts in there. 
You mentioned a number of new initiatives. I'd like to know 
what is being placed at a lower priority.
    And finally, let me say that a 6/10 of 1 percent increase, 
given the rate of inflation, is a real decrease, which I think 
is not very wise policy.

                          cdc budget decreases

    Dr. Satcher. Let me respond to the question about 
decreases. And they do not represent the fact that we're giving 
these areas a lower priority. Let me start with immunization. 
And there's a $39 million decrease. But I think, as you know, 
we have asked that you exempt the excise tax on vaccine 
purchase. And if that happens, that will save $24.6 million. So 
we would be able to continue to expend at that level, but we 
would still decrease the cost by $24.6 million.
    We've also shown a $14.4 million decrease in 
infrastructure. And we talked about this last year, in terms of 
trying to get the carry-over under control. And we believe that 
we can continue that program at the same level, dealing with 
the States. And they have done a great job of getting the 
carry-over down. And we think that we're on the road to 
completely eliminating it within the next few years. But this 
decrease in infrastructure request is a part of this whole 
strategy for getting the carry-over under control.
    We've asked for a reduction of $8 million in the Office of 
the Director. And I can't tell you that I'm very pleased about 
that. But we realize that again, we have to figure out ways of 
tightening up in terms of our expenditures, and so we feel that 
the Office of the Director has to participate in that.
    The National Center for Health Statistics is actually not a 
decrease, again. What we've done is we've transferred that 
$20.7 million to 1 percent evaluation funds. That means that 
within a department, as opposed to asking for a budget 
increase, we will be taking $20.7 million from the 1 percent.
    Now, there is a down side over time to this. Because it's 
not like having the budget authority. But we will be able to 
carry out the work. But I'm sure that the National Center for 
Health Statistics would prefer to have the budget authority. 
But again, in terms of trying to deal with the need to balance 
the budget, we felt that we could take the money from the 1 
percent evaluation fund.
    And then in terms of building and facilities, the $7 
million there is really not a decrease. Because last year, you 
gave us an increase so that we could deal with security needs 
at CDC. And the request this year is $7 million less than last 
year.
    So as you can see, in all of these areas, we are not 
demonstrating that we're giving these areas low priorities. But 
we have found a way to continue the program without a budget 
increase, and by also finding ways to decrease the amount of 
it.
    Mr. Porter. And I read from the justification that you have 
decreased the preventive health block grant by $10 million?
    Dr. Satcher. Yes, and increased the crime prevention part 
by the same amount. So basically, that represents a shift of 
$10 million into primarily rape prevention and sexual assault 
prevention programs throughout the country. And it did require 
a $10 million decrease in the preventive health block grant.
    And again, that's a very important area, and we will be 
working very closely with the States to try to make sure that 
we continue those programs on the same level.

                            carry-over funds

    Mr. Porter. You've touched on this, but let me ask the 
question, and you can expand in your answer. Last year, we were 
concerned about reports that States had significant amounts of 
funding from previous years' immunization grants that they 
still had not expended. We understand that at the end of 1995, 
States had $129 million in unexpended funds, and $109 million 
at the end of 1996. You are reducing your immunization request 
by $14 million this year, because States continue to have 
unspent funds. I know it is difficult to project State spending 
patterns, but we understand that as much as $60 million to $75 
million may be unexpended at the end of 1997. Doesn't that 
indicate that we could reduce the immunization program's 
funding even further with no real programmatic impact?
    Dr. Satcher. Based on our estimates, as you point out, we 
estimate that in 1997, the figures will go down to $60 million 
to $75 million. But then in 1998, we estimating going down to 
$20 million to $40 million. And again, if you look at the 
implementation of new programs throughout our history, the 
difficulty in terms of the startup of programs that relate to 
adding infrastructure has been common.
    And so even though we are working far more closely with the 
States to try to get this down more rapidly, it is not an 
uncommon problem with new programs all over the country in 
different States. Some States are doing much better than 
others. We believe that we're on the road to completely 
eliminating the carry-over.

                                hiv/aids

    Mr. Porter. The papers have recently reported that AIDS 
deaths in New York City have dropped dramatically in the past 
year. Do you expect this trend to be identified in other cities 
as well, and what implications does this have for your 
nationwide estimates of AIDS mortality in the coming years?
    Dr. Satcher. Let me say we're very happy with that. We do 
expect, and let me ask Dr. Gayle to comment on that 
specifically.
    Dr. Gayle. The trends that we're seeing and report in New 
York City are similar to the national trends. In fact, later 
this month, we'll be releasing, in our Morbidity-Mortality 
Weekly Report (mmwr), a report about the nationwide trends 
where we're seeing a decrease in AIDS mortality overall. We 
think that is probably due both to the fact that the AIDS 
incidence, number of new AIDS cases, are slowing down, but also 
probably better access to health, and people are living longer 
as a result of better access overall. And also newer, better 
therapies, not only the current combination therapies, but the 
ones, AZT along with other drugs that we were using even before 
the new protease inhibitors came on board.
    And we are seeing that. I think the question is an 
important one. We are going to be looking at, given these 
different trends, should we be following other indicators, and 
how are we going to make sure that we can follow reliably AIDS 
trends? We're looking at ways of expanding our following of HIV 
infection, for instance, and also looking for other surrogate 
markers that may give us a good idea of how trends are going, 
since AIDS cases are going to change a lot over the years.
    Mr. Porter. Thank you, Dr. Gayle.
    Dr. Satcher, I have to go down to the floor to engage in 
the debate on international family planning. I'm going to ask 
Mr. Bonilla to take the Chair, and I will return as quickly as 
possible.
    Mr. Bonilla.
    Mr. Bonilla [assuming chair]. Thank you, Mr. Chairman.
    Mr. Stokes, we know that your voice has been suffering a 
little lately, and I'm wondering, would you like to submit your 
questions for the record, or would you like to talk to Dr. 
Satcher?
    Mr. Stokes. I'd love to talk with him.
    Mr. Bonilla. Mr. Stokes is trying as best he can.
    Dr. Satcher. Well, we wish him a speedy recovery. We've 
always enjoyed our interactions with him. But we want him to 
get well soon.
    Mr. Bonilla. He looks great, doesn't he? [Laughter.]
    Mr. Stokes. I'll submit my questions in writing.
    Mr. Bonilla. Thank you, Mr. Stokes.
    Dr. Satcher, welcome back. And Bill, it's always nice to 
see you as well.

                               ergonomics

    I want to start out today by talking about something that 
I've brought up in this committee on a couple of occasions, and 
that is, ergonomics. There's not a person on this committee 
that would not want to do everything they can to help keep 
workers safe on the job, and we all understand that this is 
something that needs attention. Repetitive stress motions and 
disorders have become an issue. There are a lot of companies, 
good companies, that are taking initiatives on their own to try 
to improve the work environment. In spite of what some people 
like to think out there, having a worker that gets injured or 
becomes ill due to this kind of a problem costs them money and 
they lose productivity as well. Therefore, we're all interested 
in trying to keep as many people safe on the job as we possibly 
can.
    So this is not whether or not we should have an ergonomics 
guideline, but ensuring that a reasonable precedent is set, 
based on accurate and definitive science directed to correct 
the problems workers and employers face. Because ergonomics can 
be applied to virtually anything that comes into human contact, 
for example, workplace lighting, tools, equipment, hearing, 
typewriter keys, and the telephone, just to name a few, the 
impact will drastically affect every business in the country, 
especially since we have a wide diversity of businesses.
    This clearly shows that the one size fits all standard 
simply will not be able to be implemented. One cannot set up 
standards for a moving company versus a computer company versus 
a dance studio versus a football team. They're all different, 
and we have to keep that in mind. That's my biggest concern.
    I have one of the poorest districts in the country, 50 
percent of my constituents are at or below the poverty level. I 
represent counties with unemployment rates as high as 39 
percent. Before Washington issues a standard that's too 
complicated to comply with and too costly for small business to 
implement, and in some cases, actually cause them to lose jobs, 
we must agree on a reasonable and scientifically conclusive 
approach.
    Last year, I submitted about 150 questions to OSHA, seeking 
information on the scientific basis OSHA is using to draft its 
ergonomics rule in March of 1995. OSHA did not answer 93 
questions, and in fact, disavowed the very scientific data it 
used to draft an ergonomics rule.
    When you were asked about the scientific basis last year by 
Chairman Porter, Dr. Satcher, you replied that CDC does find an 
adequate science for OSHA to initiate rulemaking for an 
ergonomic standard. So what I'm interested in is learning how 
CDC came to that conclusion. Since OSHA was unable to answer 
any of my questions about the scientific basis, and since CDC 
believes the science exists, I'm submitting for the record the 
same 150 questions that I asked of OSHA last year.
    [Questions were submitted for the record, and are included 
in the back of the hearing transcript.]

                               ergonomics

    Mr. Bonilla. So I'd like to hear about the adequate science 
that you believe exists, Dr. Satcher, for implementing such 
rules.
    Dr. Satcher. Well, let me say two things. One, I think 
NIOSH, especially Dr. Rosenstock, has worked very closely with 
industry, industry of all kinds, including the industries in 
your district, to really look at problems of workers, and to 
try to get a better understanding, and to develop a research 
program and a research strategy that would lead us to the 
information we need to implement prevention programs.
    The role of NIOSH is a combination of research and 
training. And so even though this is not an issue that we 
consider to be completely resolved and the work, the research, 
the studies go on, we're also collaborating with NIH in some of 
this work. But I think as we pointed out, the trend of the 
research is toward showing support for implementing certain 
programs that could reduce the injuries in this area.
    So we will get you more specifics in terms of what we're 
doing, what NIH is doing.
    [The information follows:]

   Interactions Between NIAMS and NIOSH Concerning Repetitive Motion 
                               Disorders

    NIH's National Institute of Arthritis and Musculoskeletal and Skin 
Diseases (NIAMS) and CDC's National Institute for Occupational Safety 
and Health (NIOSH) have had fruitful coordination of research efforts 
in the past and are continuing to work together to plan future research 
endeavors. Some examples are provided:
    1. In 1994, NIOSH senior scientist Marilyn A. Fingerhut was 
appointed as a member of the Arthritis and Musculosketetal Diseases 
Interagency Coordinating Committee (AMDICC) in addition to the CDC 
member who had represented NIOSH along with other CDC centers in 
earlier years. The AMDICC is chaired by the Director of NIAMS and was 
established by the Public Health Service Act to improve all Federal 
activities related to arthritis and Musculosketetal diseases. It meets 
quarterly and produces an annual report to review current agency 
initiatives, and to identify promising research opportunities and 
activities that would benefit from interagency collaboration. Dr. 
Fingerhut has served to connect the researchers in NIOSH with the 
AMDICC activities.
    2. On June 20-22, 1994, a workshop was held on the topic of 
Repetitive Motion Disorders of the Upper Extremity. This workshop was 
sponsored by NIAMS, NIOSH, the National Center for Medical 
Rehabilitation Research of the National Institute of Child Health and 
Human Development (NICHD), the Orthopaedic Research and Education 
Foundation, the Center for VDT and Health Research, and the Public 
Health Service Advisory Committee on Employment of Persons with 
Disabilities. A group of leading basic and clinical scientists gathered 
to discuss the state of knowledge and directions for future research in 
this field.
    In the following year, a publication summarizing the presentations 
was released by the American Academy of Orthopaedic surgeons. In 
addition to the presentations, this book contained a long list of 
recommendations/directions for future research. These included.
    The need for improved epidemiological studies, better surveillance 
systems, and better diagnostic tools:
    The need for development of better methods to measure the biologic, 
biomechanical, biochemical changes in soft tissues subjected to loads, 
to better understand the physiology of injury, and to understand the 
healing process;
    The need for development of animal models to better understand 
these processes:
    The need for development criteria to distinguish between painful 
Musculosketetal syndromes having no physical findings and those with a 
structural mechanism;
    The need for determining clinical indicators of muscle dysfunction;
    The need to determine the clinical management of repetitive motion 
nerve injury;
    The need to conduct studies on the diagnosis of repetitive motion 
disorders;
    The need to establish improved measures of functional capacity;
    The need to conduct studies on therapeutic and rehabilitative 
interventions; and
    The need to determine which work and recreational activities are 
safe following therapy.
    3. In February 1996, the NIAMS participated in developing and 
implementing the National Occupational Research Agenda. The Agenda, 
created by more than 500 organizations, agencies, and individuals 
working with NIOSH, identified 21 priority research areas in 
occupational safety and health for focused and coordinated efforts 
during the next decade, with particular emphasis on intervention 
research. Two priority areas are low back disorders and Musculosketetal 
disorders of the upper extremities.
    4. As part of the implementation of NORA, NIAMs is actively 
participating in two National Occupational Research Agenda teams, the 
federal partners liaison team, and the NORA Musculosketetal research 
agenda team.

    Mr. Bonilla. If I'm understanding you correctly, you're 
talking about a trend, and I can understand that. But so far, 
how about anything conclusive that you believe may exist 
scientifically to say that there should be a standard for this 
great conglomerate of diverse businesses that we have out 
there?
    Dr. Satcher. We'll get you a summary of where we are with 
that research, and how it's being collaborated with work in 
other areas of the Federal Government, and what our conclusions 
are to date. But the studies continue.

                                 rabies

    Mr. Bonilla. Okay. I want to turn now to a different 
subject, Dr. Satcher, and that is, rabies. Because it's been a 
big problem in a lot of the southwest, specifically in my area. 
I discussed last year this problem, because it continues to be 
of great concern to the Texas Department of Health. And as I 
told you last year, it's a significant problem in the State, 
and specifically in my area. The Texas Department of Health has 
been aggressively attacking this problem. After 34 days of 
operation, the 1997 oral rabies vaccination program was 
completed on February 7th.
    In South Texas, 1.5 million vaccine bait units were 
distributed over 24,000 square miles. In West and Central 
Texas, a little over a million vaccine bait units were 
distributed over 18,000 square miles. A supplement drop of 
8,000 units was conducted along the Webb-LaSalle County line in 
response to a canine rabies case reported in January.
    As you know, there's a funding problem for the next phase 
of the Texas program. It's my understanding that the CDC has 
spoken with officials at the Texas Department of Health and 
that grant notifications are being published soon. The State is 
facing a critical time line now, and the funds that need to be 
in place, they actually need to be in place by July 1 of this 
year. This is the deadline for ordering the oral rabies vaccine 
and baits. It's imperative that Texas receive the supplies to 
implement the program in January of 1998 to be effective.
    Will CDC publish the request for grant proposals soon, Dr. 
Satcher? The Department of Health has initiated an effective 
program thus far, and if the CDC provides funding with no 
strings attached, Texas can carry out this program. We need to 
make this investment, and I'm asking about this grant proposal 
and when it's going to happen.
    Dr. Satcher. We expect that the announcement will actually 
be approved within the next two to three weeks. We have been 
working very closely with State and other national efforts to 
improve surveillance and epidemiology and the response to this 
program. And you're right, it's a very serious program, 
especially in Texas.
    But generally, I think we have in recent years seen an 
increase in the rabies problem. Eight thousand rabid animals 
per year are being detected. And I believe in 1995, we had six 
cases among humans.
    So we're at a very high level for rabies for this country. 
And we do need to respond, and we're trying to respond by 
working very closely with State health departments, and they're 
working with local health departments to improve the 
surveillance, the understanding of the epidemiology, the 
laboratory investigation. And of course, that's led to some of 
the programs that you described, in terms of trying to immunize 
animals throughout Texas and throughout other States against 
rabies.
    Mr. Bonilla. The bottom line, Dr. Satcher, will Texas get 
this money that's needed by July 1?
    Dr. Satcher. Well, you know, it's competitive. So, and that 
makes it difficult for me to make a commitment to any one 
State. But certainly I would think, given the problem, Texas 
will compete very effectively.
    Mr. Bonilla. We'll be in touch about that, Dr. Satcher. 
[Laughter.]
     Mr. Istook.
    Mr. Istook. Thank you, Mr. Chairman.

                           amputee coalition

    Dr. Satcher, I appreciate your being here. And I especially 
want to thank, there's certainly been some cooperation with 
your office on some efforts regarding, for example, the Amputee 
Coalition. I think there's a great amount of work being done in 
that area. And we appreciate your efforts and cooperation in 
that and other ways.

                             cdc priorities

    Looking through the numbers of your budget document, I want 
to ask about priorities. I'm looking at page 7 of the budget 
authority by activity which relates to the fiscal year 1998 
budget request. HIV/AIDS programs, $634 million, sexually 
transmitted diseases, $111 million, immunization, $427 million, 
heart disease and health promotion, $61 million, diabetes and 
other chronic disease, $46 million, breast and cervical cancer 
prevention, $141 million, infectious diseases, $112 million.
    Those are just particularly the ones I picked out. Because 
I don't have the exact figures, but I know that each of those 
is a category that affects far more people in this country than 
HIV or AIDS does. But I see that certainly the funding, both 
historically and requested, for HIV and AIDS, is five times 
that for sexually transmitted disease. You are interested, for 
example, in expanding a program that would try to assist women 
who become infertile because of STDs.
    But still you've got the five to one AIDS to sexually 
transmitted disease funding ratio. When it comes to heart 
disease, the AIDS funding is about 13 times higher. And 
diabetes, the AIDS funding is about 20 times higher than 
diabetes funding. AIDS funding is 10 times higher than the 
infectious disease. I say 10 times, it's almost 10 times. And 
it's almost five times as high as the funding related to trying 
to combat breast and cervical cancer in women.
    I, as you can appreciate, question these priorities. What I 
would like to ask is, if you had funding shifted to give higher 
priority to some of these other efforts, could and how might 
you use it in some of these other programs? And even if you 
don't have it with you, I would like to have the information of 
these programs that you submitted to OMB as well as whatever 
the programs themselves submitted originally to you, even if it 
wasn't what you approved to go to OMB. I'd like to know what 
they said they could use, and how much they could accomplish 
with that further funding.
    Could you elaborate on whether you could and how you might 
use the funding, if it were shifted to some of those other 
programs?
    Dr. Satcher. I think the question you raise about, 
basically you're saying how do we go about setting priorities. 
I think it's a very important question, not just for CDC, but 
for the Nation in general. It's a critical question. Let me 
just give you my perspective on how do you go about deciding to 
invest more in HIV/AIDS than cardiovascular disease prevention. 
And I think it has to do not only with the numbers, even though 
as you know----
    Mr. Istook. The severity, of course.

                             cdc priorities

    Dr. Satcher. Yes, the number and severity, and you're 
right, because AIDS has been primarily a fatal disease, almost 
100 percent fatal, as far as we know. And we have seen the 
rapid growth of this epidemic throughout the world.
    Part of what we're doing is responding to a threat, 
responding to an epidemic and trying to get it under control. I 
think it is appropriate for a nation to invest in responding to 
an epidemic, just like you would in responding to a military 
threat, just like you would responding to a threat in nature 
that could kill several people, but you feel that you have an 
opportunity to stop it.
    With the AIDS epidemic, we think we have an opportunity to 
stop this epidemic. If we don't stop it, we don't know how many 
people will be affected within the next 10 years. We've seen 
other countries, for example, where this epidemic has 
continued----
    Mr. Istook. Let me stop you at that point, because I want 
to get on to the question of how might money be utilized----
    Dr. Satcher. I just want you to understand why we are doing 
what we're doing.
    Mr. Istook. Certainly, they are fatal diseases. And you 
know, we've had, as Chairman Porter mentioned, a decline in 
AIDS cases reported in New York City. I won't go through the 
statistics back and forth. We've certainly discussed these 
before, how a jump in AIDS really had a lot to do with 
definitions and actually showed declines. Doesn't mean it's not 
a serious threat and a terrible disease.
    Dr. Satcher. Oh, it is.
    Mr. Istook. And we should be doing something about it. But 
the question is, how many more people in this country have a 
much more significant threat to their health and well-being and 
that of their family and loved ones with some of these others, 
such as breast cancer and diabetes and heart disease. If you 
had funding shifted to those others, could and how might you 
use it in some of those other programs?
    Dr. Satcher. Okay, I'm going to, we had a little bit of 
this discussion last year, and I'm going to just say one more 
thing about the epidemic, then I'll answer your question.
    There's a difference here, cardiovascular disease is stable 
in this country. There's a lot we can do. In fact, if anything, 
we have seen over the years it going down significantly. And 
even though cancer is not decreasing at the same level, the 
stability of those diseases as compared to an epidemic like 
AIDS, is what's different.
    Mr. Istook. They may be stable, but they still impact a far 
greater----
    Dr. Satcher. A large number of people.
    Mr. Istook. Far, far greater.
    Dr. Satcher. Having said that, we as you know have 
requested funds in this budget especially for tobacco control, 
which is a major factor in cardiovascular disease and in cancer 
in this country, diabetes control, which is a major factor in 
cardiovascular disease especially.
    So we think that there are, as you imply, some real 
opportunities for prevention. We also believe, as we pointed 
out in the Surgeon General's report in July of 1996 that 
physical activity alone could decrease deaths from 
cardiovascular disease by 50 percent. Physical activity alone 
could decrease diabetes by 30 percent, even the development of 
diabetes.
    There are areas that we would like to invest more, you 
know, physical activity, tobacco control, diet, working with 
young people in terms of nutrition. These are all areas that we 
could invest much more money than we have in the past.
    Let me ask Dr. Marks to also comment on that. He directs, 
as you know, the chronic disease----
    Mr. Istook. If there is material that you can provide to us 
afterwards----
    Dr. Satcher. Right, but I wanted to make those points.
    [The information follows:]

    I am enclosing for the record supplemental material 
supporting real opportunities for prevention at CDC, (1) 
Unrealized Prevention Opportunities: Reducing the Health and 
Economic Burden of Chronic Disease, (2) Preventing 
Cardiovascular Disease: Addressing the Nation's Leading Killer, 
(3) Breast and Cervical Cancer Early Detection Program, (4) 
Physical Activity and Health, (5) School Health Programs: An 
Investment In Our Future, (6) Preventing Tobacco Use Among 
Young People, (7) Diabetes: A Serious Health Problem, (8) 
Assessing Health Risks in America.

    [Clerk's note.--Material submitted was too lengthy to be 
included. A copy is available in Committee files.]

                            chronic diseases

    Dr. Marks. I'd just add that as Dr. Satcher said, the trend 
in cardiovascular disease had been going down quite steadily, 
though it has leveled off recently. We think that there is a 
lot more that could be done in preventing those deaths. You've 
heard earlier about the budgetary pressures overall, and how 
those have to be weighed in. But there are increases in this 
budget both for tobacco and for diabetes, also a very costly 
condition affecting many millions that we think can 
substantially strengthen the efforts that the States undertake 
in these areas.
    Mr. Istook. I still haven't heard anything specifically 
said that if you shifted funding, what could you be doing to 
help on breast and cervical cancer or on diabetes. But I 
suspect that you have the internal documents that those 
divisions said, I know they wanted more money, they said if we 
had more money, this is what we would use it for.

                                diabetes

    Dr. Satcher. Let me try again, then, in terms of areas 
where we would like to invest more in the prevention of 
cardiovascular disease and diabetes. We'd like to invest more 
in, let's start with diabetes. There are four areas of 
prevention. One is preventing diabetes from developing in the 
first place. And we have the National Diabetes Education 
Program that we'd like to greatly expand.
    We have comprehensive programs only in five States. 
We'dlike to have a comprehensive program in all 50 States. If we had 
it, we not only would be able to prevent the development of diabetes, 
but we would also be able to prevent the progression of diabetes and 
the complications that we see from it, like blindness and end stage 
renal disease and early amputations.
    We can improve the quality of care that diabetics receive, 
getting them into care earlier. Because only 8 million of an 
estimated 16 million diabetics have even had their diabetes 
diagnosed. So you have 8 million people out there who don't 
even know they have diabetes. We could be working with those 
people already, controlling their blood glucose, and therefore 
preventing the blindness that's developing right now in them, 
the renal disease that's developing right now, and the future 
amputation.
    We have a comprehensive program that we've implemented in 
five States. We could implement that program in all 50 States.
    Mr. Istook. And certainly when you mention diabetes, I have 
certainly been told and am still looking into it, that for 
example, diabetes is one where greater efforts at prevention 
could have monumental impact in lowering the amount that we're 
spending through Medicare, in particular.
    Dr. Satcher. Right.
    Mr. Istook. You mentioned in your own presentation that 
focusing on chronic pelvic inflammation and other results of 
sexually transmitted diseases could, for every dollar you 
invest in that effort, could produce a $12 savings, which is 
certainly a strong ratio.
    And obviously, I and as you know, others, are interested in 
looking at the priorities in how we allocate limited resources. 
They're all terrible diseases.

                             anti-lobbying

    There is one final thing I did want to inquire about, Dr. 
Satcher, and I look forward to your getting that information to 
me, knowing of course that you're involved in a lot of 
contracts with different groups that are taking part, certainly 
we learned in testimony from Secretary Shalala this week that 
despite a statutory prohibition of spending Federal dollars for 
lobbying State or local governments, as well as for lobbying 
the Federal Government, the Department of HHS has taken the 
position that a lot of contracts are grandfathered in, as are 
extensions of contracts. And therefore, some groups are still 
being paid with our tax dollars as they lobby, at least at the 
State and local level.
    Are you aware and would you check for me if you are not, 
are you aware of any contracts going through CDC that are 
utilized in that way?
    Dr. Satcher. I think you'll remember we had an incident two 
years ago with a publication that one grantee published, and 
said at the bottom of it, this is in part supported by CDC 
funding. And it was inappropriate, because it was, it could be 
classified as lobbying. We made it clear that they could not, 
they had to return those funds. We have also communicated to 
all of the recipients of CDC funds, making it very clear that 
funds are not to be used for lobbying purposes. So we're 
working very closely with our grantees and contractees in that 
regard.
    Mr. Istook. You're not using a grandfathered in or not 
distinction, you're just saying, it should not be done period?
    Dr. Satcher. Right, we're saying it should not be done. So 
we're doing our best.
    Mr. Istook. And I'm aware that some of them, by the way, 
will talk about, well, we're working on public policy, but I 
know different HHS definitions indicate that well, working for 
changes in legislation is often categorized as public policy.
    Dr. Satcher. No, I understand.
    Mr. Istook. But you're satisfied and I appreciate any 
further information, but you're satisfied that it is not going 
on through CDC?
    Dr. Satcher. Well, I wouldn't go as far as to say I'm 
satisfied, I'm satisfied with our efforts and we have to 
continue to be vigilant. As you know, for some people, this 
represents a fine line in terms of how they define their 
programs and distinguish them between efforts that they make to 
educate their representatives and what others would classify as 
lobbying.
    So I think it's something we have to continue to work on. I 
don't think we can decide if we have completed the job of 
communicating that. We have to monitor it, and we will have to 
continue to interact with our grantees.
    Mr. Istook. Thank you. We'll be in communication with you 
on checking it out.
    Thank you, Mr. Chairman. Thank you, Dr. Satcher.
    Mr. Bonilla. Thank you, Mr. Istook.
    Mrs. Northup?

                     occupational safety and health

    Mrs. Northup. Doctor, I'd like to start with your OSHA 
budget. I notice that there's a particular line item in there 
for mine safety and health. Has your organization been involved 
at all with OSHA in the new black lung qualifications, who 
qualifies for black lung benefits? OWC is in the process, are 
you aware of this, of, or at least I think they're in the 
regulatory process, they're in the comment phase of new ways of 
qualifying for black lung benefits?
    Dr. Satcher. Yes, let me just make it clear, and I'm sure 
you probably know this, that NIOSH's role is research and 
training. And therefore, NIOSH has certainly been involved in 
research related to black lung. By bringing the Bureau of Mines 
into NIOSH, obviously our role in this area will increase 
significantly. And I guess by now all of the employees in the 
Bureau are now employed as NIOSH persons. And we're searching 
for an associate director for the Bureau of Mines.
    So we have been involved in the research component of it 
that helps to define the problem. And therefore, OSHA uses the 
results of NIOSH's work to define the problem.
    Mrs. Northup. Well, just to give you a little history of 
this. Say you were diagnosed with black lung and then 
therefore, eligible for permanent disability payments. This was 
changed by the Federal Government when the benefits exploded, 
almost bankrupting every State.
    Dr. Satcher. Sure.
    Mrs. Northup. Kentucky struggled, politically we had 
trouble rolling back those. And we finally had a Governor that 
called us into a special session in December. We were the 
final, last State that found the courage to roll back those 
qualifications that made it so easy for everybody that worked 
in a mine to qualify for black lung.
    Now, OWC has rewritten the standards at the national level 
to, in a sense, undo what every State has done. We finally did 
it when it truly was bankrupting the workers compensation 
program for all businesses in the State. And of course, United 
Mine Workers is very supportive of this. Butthere's almost no 
health support, there's almost no support any place else. And 
certainly, no outcry from all those States that reversed this. Many of 
them as long ago as 20 years ago.
    So I'm very interested in knowing, now that I see this line 
item, what your involvement is in that, and how supportive you 
all are of changing these standards.
    Dr. Satcher. Again, we'll get you the specifics on what 
we've done. But I do want to emphasize again that NIOSH's role 
is research and training. And OSHA takes the results of that 
and develops regulations and guidelines. We try to keep those 
separate.
    Mrs. Northup. I want to know their standards that they're 
upholding, the standards developed by NIOSH, or whether they 
came up with standards totally separate from your medical 
research you're doing.
    Dr. Satcher. We'll get you the information.
    [The information follows:]

    NIOSH has numerous studies underway relating to work 
injuries. We are often asked for technical assistance by the 
Department of Labor and others because CDC is the only federal 
agency mandated to conduct research on work-related illnesses 
and injuries.
    Yes, NIOSH's mission is to prevent illnesses and injuries 
in the workplace. We provide technical assistance to employers 
at their request regarding suspected health and safety problems 
in the workplace. NIOSH publishes Alerts, which provide 
information to employers in easy to understand terms so that 
they in turn can make their workplaces safer and free from 
illnesses. NIOSH publishes voluntary guidelines to prevent 
illnesses and injuries at work. NIOSH works actively with the 
corporate sector to identify research needs and the best means 
to disseminate research findings.
    NIOSH makes no eligibility determinations for any type of 
disability benefit program. NIOSH conducts research on work-
related injuries and illnesses. Although the research may help 
understand how an exposure might affect individuals, this 
research is not used to determine eligibility for benefits of 
persons who are injured or develop a work-related illness.
    Under the Black Lung Benefits Act of 1981 [30 USC 842(e)], 
NIOSH is required to provide criteria for medical tests that 
accurately reflect total disability in coal miners. However, 
NIOSH has not submitted any new information to the Department 
of Labor regarding criteria for medical tests within the past 
decade.
    On January 22, 1997, the Department of Labor published a 
notice in the Federal Register describing proposed 
modifications to its black lung compensation program. NIOSH was 
not involved in the publication of this notice. The notice 
cited NIOSH's Criteria for a Recommended Standard, 
``Occupational Exposure to Respirable Coal Mine Dust'' 
published in September 1995. This document describes how best 
to monitor workers with exposures but does not make any 
specific recommendations for revisions to the black lung 
benefits program.

    Mrs. Northup. Quickly, please, because that's being, that's 
in the process, it's in the comment phase now.
    Do you have any idea how many grant programs CDC 
administers?

                               cdc grants

    Dr. Satcher. Well, I can tell you that 80 percent of the 
money that we receive at CDC goes out in the form of grants to 
States, primarily. Most of our grants go to State governments.
    Increasingly, we have also funded academic health centers, 
like the prevention centers that we funded, the teenage 
pregnancy projects, which are community programs. We have a lot 
of grants. I can get you the exact figure. But we have many, 
many grants. Most of them go to States. Increasingly, we are 
getting involved with community programs in areas where we're 
trying to make sure that the programs get to the people who 
need them most.
    So we have worked very closely with community 
organizations, and some church groups, like the National 
Congress of Black Churches, working with AIDS prevention and 
immunization outreach and things like that. So I can get you 
the list of the number of grants that we have in total.
    Mrs. Northup. Is there an outcome based audit of these 
grants?
    Dr. Satcher. Well, yes and no. Every grant is monitored by 
a CDC project director and reported on on a regular basis. And 
sometimes when Congress requests it, we report it directly to 
you.
    And so we do monitor them. I don't think any of us are 
satisfied with what we would call our program effectiveness 
program. And we are all working to try to enhance those, using 
prevention effectiveness, using other strategies. So we have in 
place now a program where we're working very closely with the 
States to try to define objectives for all of our grants, what 
do we expect to happen as a result of this grant, and then how 
are we going to measure whether or not that happens.
    So we're trying to get much more specific with our 
technology for evaluating the outcome of our programs.

                            budget decreases

    Mrs. Northup. Do you have any programs that, especially any 
new programs, but programs where you're seeing an increase in 
the budget over the next four years, and then in about the year 
2001 or 2002, they're either zeroed out or cut in half or 
precipitously decline?
    Dr. Satcher. Well, we hope that that will happen with polio 
immunization. We think we're on track to eradicate polio 
throughout the world. As you know, we have not had a case of 
wild virus polio in this country since 1979. And not in the 
western hemisphere since 1991. But we still have to immunize 
our children as long as there's polio in the world. When polio 
is eradicated, and we think that that will happen around the 
year 2000, and it will take us a few more years to certify that 
eradication, once that has happened, we look forward to ending 
the polio immunization program. That will save about $230 
million a year.
    Mrs. Northup. I'm really thinking more of programs that you 
don't think the need will go away. We've had, in some other 
meetings this week, agencies where, or directors where in order 
to make the budget balance in the year 2002, programs went up, 
up, up, and then in the year 2002, they're zero. And the answer 
to the question of, was the need going to be eliminated or why 
did it decrease so fast, it was, that was the only way to make 
the budget balance.
    Any places in your budget where, unrelated to need you see 
the six year forecast taper off?
    Dr. Satcher. Unrelated to need, I would say no. I think we 
will make decisions related to need. And we will try to make--
--
    Mrs. Northup. I'm not talking about you making the 
decision. I'm talking about OMB having made the decision.
    Dr. Satcher. I don't want to speak for OMB. [Laughter.]
    I think that would probably not be the right thing. We will 
try to relate our request to what we see as efficacy and need 
in terms of our program.
    Mrs. Northup. You have surely seen the six year budget.
    Dr. Satcher. Right.
    Mrs. Northup. Was there any place where you were surprised 
at the budgeted amount for 2002? Or maybe you thought it was 
strange that it was smaller than you anticipated?

                            budget decreases

    Dr. Satcher. Well, I always think it's strange when our 
budget is smaller, because as you know--well, you weren't here 
when I did my opening statement. But we have a, and I think we 
still have a way to go to make the point we've been trying to 
make, that as a Nation, we should be investing more in 
prevention. I made the point at the beginning that we spend a 
trillion dollars a year in this country for health care, and we 
spend only 1 percent of that amount for population based 
prevention.
    So I think basically, our opinion on that is well known. I 
don't think as a Nation we're quite there in terms of 
supporting prevention.
    Mrs. Northup. Mr. Williams, I understand you're from the 
Budget Office, maybe you could give me more insight.
    Mr. Williams. The Department's budget through 2002 grows 
slightly in total. It's about a little bit less than 1 percent 
over the five-year period.
    Mrs. Northup. One percent each year, or you mean between 
now and 2002 it grows 1 percent total?
    Mr. Williams. It grows a little bit less than 1 percent 
each year, out to the year 2002. And as the Secretary said, 
that's a budget path. In total, we're part of a broader 
President's budget that lays out a discretionary spending path 
over that period of time. But all of these numbers will be 
reviewed each year. We'll be making decisions on a year by year 
basis as we submit budget submissions to this committee and to 
the Congress.
    Mrs. Northup. And there is no sudden change in spending 
pattern between the year 2001 and 2002 in any area?
    Mr. Williams. Not for the Department, there isn't.
    Mrs. Northup. Not for CDC?
    Mr. Williams. Not for CDC.
    Mrs. Northup. Okay.
    Mr. Bonilla. Thank you, Mrs. Northup.
    Mr. Miller?
    Mr. Miller. Dr. Satcher, it's a pleasure to have you here 
again. I trust you have a fairly conservative budget this year. 
I think we're hopefully going to be able to come down and visit 
you. Is that on the schedule? I know it's penciled on my 
calendar, so I'm looking forward to that.
    Dr. Satcher. We ought to, the Chairman said at the 
beginning that the committee would be visiting.
    Mr. Miller. I'm really looking forward to that. I know you 
do things all around the world, but just seeing, devoting a 
whole day to your place I think would be very beneficial, just 
like we do with visits to NIH.
    Dr. Satcher. We look forward to it.

                              blood safety

    Mr. Miller. An area of interest of mine, as I brought up 
last time, and I'd like to kind of find out where we stand on 
this, is the issue of blood safety and especially as it relates 
to the hemophilia area, but both. As you know, the issue was 
brought up and we are concerned about what's being done in that 
area. With hemophiliacs, what happened in the late 1970s and 
early 1980s is a great disaster in this country, as we all are 
aware.
    But blood disease, infections, passed through the blood, is 
an ongoing problem. So the question is, what is being done? I 
think some people feel they're not seeing as much results from 
what the action is, and sometimes it takes a little while to 
implement policies and all. Can you update me where we stand? 
Because additional revenue is put in there, and wording, both 
in the House and Senate, there was agreement. I don't think 
there is any specific wording in this year's budget proposal in 
that area. So give me an update and then we'll go from there.
    Dr. Satcher. Yes, let me make a couple of comments, and 
then ask Dr. Hughes to comment on the specifics of our program.
    You're right, I think the AIDS epidemic was identified 
around 1981, and I think by 1985, 1986, over 50 percent of the 
hemophilia population had been infected with the HIV organism. 
Very, very critical problem. And in recent years, we've been 
concerned about hepatitis C.

                               hemophilia

    We're working very closely with the Hemophilia Foundation 
and with hemophilia treatment centers in programs for 
surveillance and epidemiology and response. I do want to point 
out, the Congress had also asked, after the Institute of 
Medicine's report on blood safety, that there be a blood safety 
committee set up within the Department. That committee has now 
been functioning for over a year. And we have just recently 
named a blood safety advisory committee of persons outside, 
including industry and others, who will be including people 
from the Hemophilia Foundation, who will be advising the blood 
safety committee and advising FDA.
    So there are several things going on. Let me ask Dr. Hughes 
to comment.
    Dr. Hughes. Yes, thank you. This is a high priority for us. 
When we think about hemophilia and complications for the 
patients, we think about blood-borne infections and joint 
disease. So we put a lot of emphasis on both.
    We work closely with the National Hemophilia Foundation, as 
you know. We have a six state surveillance system for 
complications of hemophilia. We collaborate with State health 
departments and hemophilia treatment centers on this system. 
And in addition, we have a surveillance system that includes 
the 140 plus hemophilia treatment centers around the country. 
We're also placing a lot of emphasis on hepatitis C. We're 
developing professional and public education campaigns for 
prevention of hepatitis C that will apply to the hemophilia 
population as well as the general population.
    When the issues of this new variant for Creutzfeld-Jakob 
disease, that has occurred in England, surfaced, we looked for 
evidence in this country. Among the populations we've focused 
on are patients with hemophilia who get a lot of blood 
products. And there are questions about the possible 
transmission of the agent causing this Creutzfeld-Jakob 
disease. But we've worked closely with the hemophilia centers 
in that regard as well, and have not found any evidence of 
that. There's a lot of activity focused on patients with 
hemophilia.
    Mr. Miller. I asked that question of both the center, of 
the hemophilia treatment centers, which get a lot of their 
funding from you and I think that's a great program. And I 
assume you all are continuing to fund that at a fairly stable 
amount. That's a good program.

                              blood safety

    The question was also about the blood safety supply, not 
just related to hemophilia. Additional money was put in for 
that type ongoing testing and the question of a serum bank 
being developed and surveillance and all that. How are we going 
along those lines, and are the resources being devoted to that, 
and there is a significant increase, for example, in your 
funding for infectious diseases. It was targeted for blood 
safety concerns. What all are your plans along those lines?
    Dr. Hughes. Let me make a few comments. As I said, that is 
a high priority area for us. In addition to the comments that 
I've already made related specifically to hemophilia patients, 
we're concerned about improving surveillance for bacterial 
contamination of the blood supply. We're working to improve 
surveillance for variants of HIV infection that could be 
transmitted by the blood supply. We're working on assessing the 
risk to blood product recipients of infection with Trypanosoma 
cruzi, the cause of American trypanosomiasis that some blood 
donors from Latin America might be harboring in a latent phase. 
And we are working on the national serum bank.
    Mr. Miller. You had a large increase in funding for 
infectious diseases, specifically on blood-borne diseases, is 
that right?
    Dr. Hughes. The President's request is for $15 million for 
emerging infectious diseases. That would include blood safety, 
but it includes many other areas as well.
    Mr. Miller. I have some more questions I'll submit to you 
in writing.
    Dr. Hughes. We'd be happy to answer them.

                              blood safety

    Mr. Miller. And we can talk about it some more when we come 
down, I assume April 14th is still the date.
    Dr. Satcher. This is a very critical area. I agree with 
you. I think the U.S. has the safest blood supply in the world, 
but still a lot of areas where we can improve.
    Mr. Miller. Well, after the disaster of the, as it happened 
in hemophiliacs in the early 1980s, it's something of great 
concern.
    Dr. Satcher. Of course.
    Mr. Miller. Thank you.
    Mr. Bonilla. Thank you, Mr. Miller.
    Mr. Dickey.

                                diabetes

    Mr. Dickey. Thank you, Mr. Chairman. I want to thank you 
all, Dr. Satcher, and your colleagues, for helping Arkansas 
with our diabetes program. I have a bad habit of deciding 
whether I like somebody depending on whether they did anything 
for me or not. [Laughter.]
    I also was impressed, I had recently come into contact with 
the polio eradication and the spina bifida programs in China. 
And I was very impressed. It helped me with what we saw on a 
visit to your center in Atlanta about our responsibility in the 
worldwide thing. So it's coming through.
    I want to know on our next visit if Dr. Rosenberg is going 
to be there. He stiffed us last time. [Laughter.]
    Dr. Rosenberg. I was sorry to miss you.
    Mr. Dickey. And you have the date, April 14th, no excuses.

                            grant recipients

    Dr. Satcher, last year you testified before this 
subcommittee with your colleague from the National Center for 
Injury Prevention and Control, Dr. Rosenberg, in which the 
topic of grant recipients being criticized for refusing to 
release data was discussed. Chairman Porter asked specifically 
about one grant recipient, Dr. Arthur Kellermann, who has 
received millions of taxpayer dollars and yet refused to 
release the data from peer review.
    You assured the subcommittee that Dr. Kellermann was taking 
steps to make those data available, and they will be available 
before the end of the year, which would have been 1996. In a 
letter dated February 5th of this year, addressed to the 
recipients of NCIPC funds, from Dr. Rosenberg, recipients were 
asked to note, ``In accordance with established CDC policy, 
when final information from the CDC-funded research is shared 
externally, the information must not be selectively shared.''
    Dr. Satcher, can you tell me if Dr. Kellermann has released 
his data, and if not, why?
    Dr. Satcher. I'm going to ask Dr. Rosenberg to respond to 
that.

                             global health

    Let me just say a word about your China visit, because I 
think that's really important. I think we have tried to make a 
point that we sort of live in a global community, and it's very 
hard to protect the health of the American people without 
understanding what's going on in other countries. And you saw a 
good example.
    We have about 4,000 cases of neural tube defect in this 
country a year. And as you know, China has 100,000. We don't 
understand all the reasons why. But China also did some other 
things, like the premarital examination, which has allowed us 
to begin the folic acid treatment more effectively. And in some 
areas of China, we have reduced neural tube defects by 70 
percent.
    We've learned a lot that's helping us in this country, is 
what I'm saying. Even the influenza virus and our ability to 
work with our colleagues in China and study that allows us to 
develop an effective vaccine here year after year, which we 
wouldn't be able to without that relationship with China.
    So I think your experience in China is an illustration of 
how important the global approach to health and prevention is 
in the world today. So we appreciate your taking the time to 
make that trip.
    Let me ask Dr. Rosenberg to respond specifically. I 
remember our discussion about Dr. Kellermann and his, and the 
request for data from his studies, so people could analyze it 
more intensely.

                            grant recipients

    Dr. Rosenberg. Well, thanks. I do appreciate your 
mentioning that letter. We did take very seriously the 
instructions we got from this committee last year, and did send 
out a letter to all NCIPC grantees, making them aware of the 
policy and the language in our appropriations bill. And we did 
add this part about non-selective sharing of data. We believe 
it's very important that the data that does get used to decide 
important issues gets equal access by everyone who requests it.
    But this specific case of Dr. Kellermann, he is cleaning up 
his data set right now, and has actually made arrangements for 
those data sets to be sent to the University of Michigan into 
university consortium for political and social research. This 
is the ICPSR. And that will be done very soon, that data will 
become generally available to researchers who request it.
    Mr. Dickey. When you say cleaning up, you're not talking 
about what we hear about sanitizing, are you?
    Dr. Rosenberg. No, I don't think this is sanitizing. This 
is removing personal identifiers and making sure that the 
instructions for how to interpret the data are clear to 
everyone who might use it.
    Mr. Dickey. We want that information, Dr. Rosenberg. Can 
you assure us of a date when we might get it?
    Dr. Rosenberg. What I can assure you is that I will talk to 
Dr. Kellermann when we get back and find out a date, and get 
back to you on that.
    Mr. Dickey. All right.
    Dr. Satcher, let me go back to you. I asked Secretary 
Shalala the other day for a list of the grantees and sub-
grantees of her Department. I wonder if the CDC could help us 
and help her out with the onerous task of providing a list of 
the CDC's contracts and subcontracts.
    Dr. Satcher. Sure, we can. We will provide you with that 
list.
    [Information too voluminous to print, available in 
Committee files.]

                         abortion/breast cancer

    Mr. Dickey. Thank you. Are you familiar, sir, with the 
report compiled at Penn State's Hershey Medical Center on the 
abortion-breast cancer link?
    Dr. Satcher. I'm familiar with the issue, yes. Do you want 
us to discuss it specifically?
    Mr. Dickey. Yes, sir, let me read this question. The report 
compiled 23 epidemiological studies published worldwide since 
1957. Eighteen of these show increased breast cancer incidence 
among women who have had induced abortions. The most 
conservative and statistically rigorous of the 23 studies shows 
that overall, induced abortions significantly increased a 
woman's risk of getting breast cancer by 30 percent.
    Given these reports, is the CDC undertaking any efforts to 
warn women seeking abortions of the potential risk or at least 
is there any collection of data to confirm these reports?
    Dr. Satcher. I'm going to ask Dr. Marks to respond 
specifically. But I do think there have been some very 
important studies since the Penn State study about this issue 
that we need to be aware of.
    Dr. Marks. Yes. This is an area that's been very 
controversial overall, with a number of studies looking at the 
issue of abortion and breast cancer. Looking sometimes at 
mixtures between induced and miscarriages, and looking at 
whether they preceded the first pregnancy or were after. It's a 
very complex area and there have been a number of extensive 
analyses. Not all of which, in fact the most recent analysis 
coming from Europe followed women long term and found no 
increase in breast cancer among women who had had an abortion. 
And they had a registry that had all of the abortions and a 
registry for breast cancer, and were able to do that linkage. 
That's not something that's possible in this country. That 
study was published within the last year.
    Mr. Dickey. Are you collecting data?
    Dr. Marks. We don't collect data on that area. We----
    Mr. Dickey. Why not?
    Dr. Marks. It's been an area where it's very, very 
difficult in this country to get accurate histories on 
abortion. And there is no central registry of who has had an 
abortion. There has also not been any central registry of cases 
of breast cancer, though now with the cancer registries, it is 
easier to get estimates and individuals who have breast cancer. 
But there's no way to get the abortion data in this country.
    Mr. Dickey. Let's talk about that later, then.

                            abortion deaths

    I have one more question. The Centers for Disease Control 
documented the deaths of 108 women and girls who died from 
abortion in the 1980s. Investigative reporter Kevin Sherlock 
listed in his 1996 book, Victims of Choice, by name and/or the 
date of death 150 women and girls who died during the same 
decade. Sherlock also listed all the source data in his book.
    The New York City Commissioner of Health, Stephen C. 
Joseph, noted in 1987 that 176 women died from legal abortion 
nationwide from 1981 to 1984. The CDC reported that only 42 
women and girls died from legal abortion during this time 
period.
    Dr. Satcher, or whoever you designate, can you tell me why 
the CDC abortion researchers found so few maternal deaths from 
abortion compared with Sherlock and Joseph?
    Dr. Marks. I'll respond to that question. I'm not familiar 
with the report that you've mentioned. CDC has for 25 years 
examined all of the deaths that it becomes aware of through 
official and unofficial reporting channels, deaths related to 
abortion, both abortions that are perceived to be illegal, 
legal and related to miscarriage.
    During that time, the vital statistics death certificates, 
for example, report also whether they are related to abortion. 
CDC has found on average about 40 percent more deaths through 
its investigative work than has been through that system.
    We do occasionally hear of deaths that we are unable to 
verify. But in general, we have tried to find out every case 
that does occur. We investigate every case that we hear of from 
any source.
    Mr. Dickey. In that keeping, we understand that the CDC 
destroys all the notes relating to abortion mortality research, 
is that correct?
    Dr. Marks. No, that's not correct.
    Mr. Dickey. Do you keep it?
    Dr. Marks. We do. We don't have personal identifiers.
    Mr. Dickey. But you do keep the data?
    Dr. Marks. Yes.
    Mr. Dickey. That's all the questions I have, Mr. Chairman.
    Thank you all.
    Mr. Porter [resuming chair]. Thank you, Mr. Dickey.
    Mr. Wicker.
    Mr. Wicker. Thank you, Mr. Chairman.
    Dr. Satcher, we're glad to have you back and we appreciate 
the work you're doing. And we look forward to our tour of your 
facility in April.

                         cardiovascular disease

    Let me ask you and your panel first of all about 
cardiovascular disease. Unfortunately, according to CDC 
figures, my home State of Mississippi leads the Nation in the 
rate of deaths from heart disease. In 1994, 11,000, 46 percent 
of the deaths and more than 2,000 or 33 percent of the deaths 
from those under the age of 65 could be attributed to 
cardiovascular disease.
    I appreciate the leadership of CDC in this regard. But I 
would appreciate if you would elaborate for the committee about 
your efforts on this disease, not only in Mississippi but 
across the country, and perhaps tell us what progress you've 
been able to make.
    Dr. Satcher. As you know, CDC doesn't have a categorical 
program in the prevention of cardiovascular disease. Most of 
that work is done by the National Heart, Lung and Blood 
Institute. But let me just, we talked a little bit about this 
before. Let me just mention one or two things.
    You're right, we keep records that demonstrate that 
Mississippi has perhaps the highest rate of deaths from 
cardiovascular disease. I think nationally it's probably 42 
percent of the deaths, and in Mississippi it's closer to 46, 47 
percent. And we have several programs that we believe impact 
upon that figure, and that can impact in the future, especially 
programs to increase physical activity, even though we're not 
specifically funded for that. As you know, the last Surgeon 
General's report which CDC prepared emphasized that if we could 
get Americans active 30 minutes a day, five days a week, 
including things like walking, we could reduce cardiovascular 
deaths by 50 percent.
    We've also tried to demonstrate the relationship between 
diabetes control and cardiovascular death. And we're working 
very closely with Mississippi and other States and we hope 
we're going to be able to expand that program. Because we're 
asking for a $10 million increase in that area. That will also 
impact upon cardiovascular disease death significantly.
    In this particular budget, we're asking for a $15 million 
increase in our tobacco control program. And again, as you 
know, tobacco is a major risk factor for cardiovascular 
disease. So even though we don't have a categorical program in 
cardiovascular disease, we feel that the programs at the CDC, 
the ones I mentioned at others, that relate to human behavior, 
diet and other things, really in the long run will have the 
best payoff in reducing deaths from cardiovascular disease.
    Obviously, we've demonstrated in this country that the 
early diagnosis and treatment of hypertension can have a major 
impact, or efforts to control blood cholesterol can have a 
major impact on cardiovascular disease. So we think altogether, 
if we can get this program working in every State, we can 
continue to move in the right direction in terms of 
cardiovascular deaths.

                                tobacco

    Mr. Wicker. Well, let me ask you about smoking. We've had a 
discussion for three days running now about the proper role of 
the Federal Government and which particular agency, and which 
particular program is most appropriate. It seems that some 
people believe that SAMHSA ought to be the lead agency in this 
area. And there's a question as to whether we have duplication 
and overlapping. Why should your agency be involved in this, 
when SAMHSA is spending so much money on it. I would just 
appreciate it if you would comment on that.
    Dr. Satcher. Maybe I had not understood those discussions. 
One of the things I know you discussed was the Synar Amendment, 
which has to do with regulations against selling tobacco to 
teenagers.
    We don't see our role as regulation. I think CDC sees its 
role primarily as education and prevention. We are especially 
concerned about teenagers and other young people smoking. And 
we have programs in the school systems and other programs that 
are geared toward educating young people about the consequences 
of smoking, but also trying to change peer group norms as it 
relates to smoking.
    And so most of our programs focus on how do we change the 
appeal of tobacco to young people, how do we help young people 
make the right decisions in terms of smoking. Because as you 
know, 90 percent of people who start smoking begin smoking 
before they're 18 years of age. And many of them are addicted 
by the time they're old enough to make the right decision.
    So our role, as we see it, has been primarily education and 
prevention, working with States to help them develop programs 
to prevent and control tobacco use, and basically using our 
laboratory, because we have the only laboratory of its kind in 
the world, to study tobacco contents, but also to study the 
environmental impact of tobacco smoke on people, even people 
who don't smoke.
    So I don't think there's an overlap with FDA's role in 
terms of the regulatory role that it plays, or SAMHSA's 
responsibility for regulating the Synar Amendment. Even though 
I would say that if there is a possibility of some overlap, it 
would probably be with SAMHSA because of its emphasis on drug 
use in general. I think there is a need for us to integrate 
some of our efforts.
    Mr. Wicker. Is there any concerted effort among these 
agencies to coordinate?
    Dr. Satcher. Yes, definitely.
    Mr. Wicker. Would you explain that?
    Dr. Satcher. Yes. We have had meetings recently looking at 
our tobacco control program and SAMHSA's substance abuse 
control program. And basically we're looking for ways that we 
can integrate some of our activities in the school systems and 
other places. So we are trying to make sure that we don't 
duplicate efforts, and yet at the same time, we benefit from 
each others' resources and expertise.
    Dr. Marks wants to add something.
    Dr. Marks. I just wanted to add that the Office of Smoking 
and Health at CDC has the statutory authority to chair an 
interagency committee on smoking and tobacco. And at that 
committee, which is where some of these issues are worked out, 
but there are also regular and ongoing meetings. And in fact, 
there are monthly calls that occur with the Department to help 
coordinate overall tobacco policy and activities.
    Mr. Wicker. Thank you very much.

                                 polio

    Let me ask you about polio. And you, I think you'll 
probably tell me that there's not a specific line item for 
polio, either, is there?
    Dr. Satcher. Oh, yes.
    Mr. Wicker. There is?
    Dr. Satcher. Yes. We have the immunization program, and a 
major part of that is polio, including global polio 
eradication.
    Mr. Wicker. Well, let me ask you about global polio 
eradication, because that's another thing Mr. Dickey and I 
learned about on our recent trip. Tell us how our international 
efforts are coming in that regard. Estimate if you can how 
close we are to eradicating polio from the face of the earth. 
And I think the public would be interested in knowing what the 
potential savings are for citizens of the United States if we 
could get to the point where we don't have to vaccinate against 
polio.
    Dr. Satcher. We think the polio eradication program is 
going well. I think since 1988 we've had something like a 
90percent reduction in reported polio cases, including only 3,500 cases 
reported last year. And you were in China, of course, and I believe, if 
I remember correctly, that in 1991 China had about 37,000 cases of 
polio. They had this major immunization day starting in 1993, but they 
have not had a case of wild virus polio since early 1995, and we think 
that's going to hold up. We can't declare China polio-free, of course, 
until they've had at least three to four years without a case of wild 
virus polio.
    I mentioned earlier that India has had over half of the 
world's cases of polio in the last few years. We participated 
in the largest immunization day in the history of the world in 
India on December 7th. I think before that, China had the 
largest--90 million cases. But they immunized in 1994.
    India immunized 120 million children against polio on 
December 7th. Since India has had over half of the world's 
polio, we think we're getting very close to eradicating polio 
in the world. When we've done that, and we've certified that, 
which will take two to three years after the last case, we will 
not have to continue to immunize in this country. That will 
save about $230 million a year in this country alone. And 
throughout the world, we will save about $1.5 billion.
    Mr. Wicker. Is that a savings for the Federal budget, or a 
savings from our economy?
    Dr. Satcher. What I'm really saying is that we now spend 
about $230 million to immunize against polio. And we can stop 
immunizing against polio after that.
    Mr. Wicker. Who do you mean by ``we''?
    Dr. Satcher. Public and private.
    Mr. Wicker. Public and private.
    Dr. Satcher. Yes. And the same thing is true worldwide.
    Mr. Wicker. Well, I just want to commend you for that 
program, and sometimes at first blush, the public might say, 
why are we spending a dime talking about polio in China or 
India. But in addition to the very real humanitarian aspect of 
that, it could have a great impact on us right here in our own 
country.
    Dr. Satcher. The other thing I think is really good about 
this program, and I know it's something you've been interested 
in, is a public-private partnership. This has not been just a 
governmental program. Rotary International adopted polio 
eradication as its major project several years ago. They have 
contributed over $250 million. But that's just money.
    What I was impressed with when I was in India and in 
talking to people, meeting with them, is how they have gotten 
their membership out all over the world to make these 
immunization days successful. Rotary has worked very hard, 
they've educated the legislatures throughout the world, they've 
gotten their members to volunteer in communities all over the 
world to get children out to be immunized.
    So we have a public-private partnership here that's 
working, and we're very pleased about that.

                        hiv/injecting drug users

    Mr. Porter. Dr. Satcher, you're requesting an increase in 
AIDS prevention and education targeted to prevention in the IV-
drug abusing community. What types of activities will be 
supported with these funds? Will the focus be on condom usage 
and clean needles?
    Dr. Satcher. Let me ask Dr. Gayle to respond to that 
specifically.
    Dr. Gayle. Thank you for the question. As Dr. Satcher said 
in his opening remarks, almost a third of AIDS cases are 
related either directly or indirectly to injecting drug use. 
And it's really the gateway to women and their children. So 
it's clearly a very important issue for us.
    As I think you know, all of the funding that we provide to 
State and local health departments goes through community 
planning groups. And those community planning groups have the 
responsibility of looking at their data, behavioral data, 
epidemiologic data, and determining the priorities, and also 
determining what is the right way to implement programs based 
on their local circumstances.
    So we expect that much of the money that would go for 
injecting drug use, for preventing HIV injecting drug users, 
would go through community planning and a lot of those 
decisions would be made at the local levels. The types of 
things that we expect to be funded would be outreach programs 
that provide information to injecting drug users, helping to 
link people who continue to inject drugs to treatment services, 
overall counseling efforts, testing, so that people know that 
they're infected and therefore can make decisions 
appropriately.
    So we expect a whole range of activities. Clearly, 
providing information to people about not sharing injecting 
equipment is an important part of any strategy. And some States 
are adopting to use a whole range of ways so that people do not 
share injecting equipment. That again is a local and State 
decision of how funds are expended for that.
    We also hope to be able to do important programmatic 
research that will allow us to see what are the ways we can 
make the biggest difference, and also linking with corrections 
systems. As you know, substance abuse is a major issue for 
people in correctional institutions. And it's a major reason 
for HIV in those areas where HIV and AIDS is a tremendous 
problem in our correctional facilities.
    Mr. Porter. Thank you, Dr. Gayle. I was going to ask you if 
you were seeing what works best and sharing that with other 
communities.
    Dr. Gayle. Yes, in fact. Very much so.

                                hiv/aids

    Mr. Porter. Recent findings from Africa indicate that 
greater attention to controlling the spread of STDs is highly 
effective in reducing the spread of AIDS. In this country, we 
have devoted increasing resources to AIDS prevention, while 
funding for STD control has stayed fairly level. Given the 
African findings, should we rethink the allocation of dollars 
between these two CDC programs?
    Dr. Satcher. I'm going to let Dr. Gayle respond to that, 
too, but let me just say that was a very important study, and 
it again is another illustration of why it's been important for 
us to work with other countries. As you know, CDC has some 
major AIDS research going on in Africa, including Tanzania, 
where that study was done, and Abidjan. We didn't necessarily 
fund that study but we've learned a lot from it.
    But I think the question is a very important one.
    Dr. Gayle. Yes, clearly, this research about the 
interaction between HIV and STD is critical. And we hope to be 
able to do increased work with integration of our HIV and STD 
issues. I think it's a two way street. Clearly, primary 
prevention is going to make a big difference for not only HIV 
but STDs as well, getting people to reduce risk behaviors as it 
relates to sexual transmission is going to have a big impact on 
both.
    Also, treating people with sexually transmitted diseases 
can have a major impact on reducing their risk for both 
spreading HIV as well as acquiring it, particularly for 
heterosexual transmission. In the south, we're seeing that 
there's a clear link between high rates of sexually transmitted 
diseases and increasing rates, particularly in women, through 
heterosexual transmission. So it's clearly an aim of ours to do 
more in the area of integrating these two programs.
    I think it's important to remember that HIV prevention will 
take a comprehensive approach, just treating STDs alone is not 
going to make the HIV problem go away. And we feel we need to 
strengthen all components of our HIV prevention program. We 
know that it works, we know it's made a big difference. That's 
where we're starting to see the slowing in the trends, is 
because prevention can make a difference.
    We do want to strengthen the area of STD treatment, though, 
because we think that's another important component.
    Mr. Porter. Thank you, Dr. Gayle.
    Last spring, the Wall Street Journal carried an article 
that was quite critical of CDC's AIDS prevention campaigns, 
charging that CDC spent needless resources warning the general 
public of the dangers of AIDS when it was well known that only 
certain demographic groups were likely to be a threat. How do 
you respond to these charges, and are your prevention efforts 
now more targeted than they were before?
    Dr. Satcher. We felt so strongly about that article, and so 
I do want to respond, and ask Dr. Gayle to respond, too.
    Without being argumentative, I think the strategy that we 
have used in this country has been the right one. And even 
though I was not involved in that decision back at that time, I 
think the decision not to marginalize this problem, but to 
educate all the people in this country about what it means to 
be faced with an epidemic like HIV/AIDS, and how it could 
potentially impact upon every individual was the right 
approach.
    I think as the years have gone by, we have in fact 
increased our targeting of our programs and our efforts. And we 
have also tried to identify community groups, for example, that 
could get to hard to reach populations that our general 
programs were not reaching. And we are funding community 
planning strategies.
    But I just want to say that when I look at what's happened 
throughout the world and how this problem has ballooned, and 
the fact that we in this country have seen a stabilizing of the 
epidemic, and now a down-turning, I think we made the right 
decision. And we've elected not to continue the debate about 
whether we misled people into thinking that when you go out on 
a date, you should be careful about how you conduct yourself. 
Because this is an epidemic that could affect anybody. We 
believe that that's true.
    But the argument is whether we put too much emphasis on the 
general risk as opposed to the high risk groups. I happen to 
think it was the right approach, and I think it has worked for 
this country.

                                hiv/aids

    Dr. Gayle. I'd just add to that, first of all, there were a 
lot of misrepresentations in that article. We never spent 
anywhere near the majority of our funding on general 
information campaigns. In fact, it was more like 1 percent, 
even less than 1 percent of our funding for general 
information. And as Dr. Satcher said, clearly in the beginning 
of an epidemic that in other parts of the world has in fact 
evolved to affect a broad cross section of society, it was 
important that we did get the information out to people 
broadly, so that everyone could understand what their risks 
were, even if they are at low risk, and be able to keep those 
risks very low.
    That again is why we have moved to the approach of 
community planning where we really do let people use their data 
and target the appropriate high risk groups and really be able 
to move funding more and more to the groups that need it the 
most who are currently affected the most, as well as groups 
that are going to be increasingly affected as the epidemic does 
move now more into the populations affected, increasingly 
women, heterosexual populations, etc.
    I just want to also mention relative to your previous 
question, the Institute of Medicine just put out a report that 
really highlighted the importance of treating sexually 
transmitted diseases in this country, and did in fact highlight 
the importance of the interaction between HIV and STDs 
throughout that report. And I hope that, if you have not seen 
that, we can supply that to you, because that's an extremely 
important report that really does highlight the need to put 
greater focus on STDs alone, as well as how they relate to HIV.
    Mr. Porter. Dr. Gayle, you keep anticipating my questions.
    This is related to that, so I'll ask it now. With your $112 
million request for infectious disease control, are you able to 
address all the major areas of the plan developed by the 
Institute of Medicine? Do you expect that we will need to 
maintain this level of expenditures for the foreseeable future?
    Dr. Satcher. Are you talking about the Institute of 
Medicine's report on sexually transmitted----
    Mr. Porter. Infectious disease, yes.
    Dr. Satcher. The earlier one, the 1992 report.
    Mr. Porter. Oh, I got the wrong one.
    Dr. Gayle. Yes, the one I was talking about is a recent one 
that just came out.
    Dr. Satcher. But that's very important, the 1992 one is 
very important. But they didn't develop a plan. They asked CDC 
to develop a plan, and CDC developed a five-year plan in 
response to the Institute of Medicine's report on the emerging 
infectious disease, and Dr. Hughes can respond specifically to 
that.
    Mr. Porter. All right.

                          infectious diseases

    Dr. Hughes. Yes, thank you for asking about my favorite IOM 
report. [Laughter.]
    We took that report at CDC very seriously because we felt 
that over half of the 15 recommendations in it were targeted 
directly at us. And most of them we felt were targeted 
specifically at our Center. So we developed the CDC emerging 
infectious disease plan, which we're implementing 
incrementally. And I'd like to thank the committee for their 
support in allowing us to do that.
    As Dr. Satcher mentioned earlier, the full annual costs of 
implementation of that plan we have estimated to be $125 
million a year. And appropriations to date have brought us to 
$44 million, and we're hopeful that with the additional $15 
million we'll be almost halfway to the target.
    So we've been able to do a large number of things, and we 
can provide information on that, certainly, for the record.
    [The information follows:]

    Also attached is a recent article published in JAMA, 
January 24, 1996 entitled, ``Addressing Emerging Microbial 
Threats in the United States.''
    Offset Folios 214 to 216 Insert here



    Dr. Hughes. We've got a long way to go. We've made some 
progress, we've got some momentum. The recent experiences in 
this country and around the world tell us that these microbes 
are going to continue to challenge us. A particularly important 
area that we haven't mentioned very much is antimicrobial 
resistance, that is, drug resistance. That is a major global 
public health problem.
    So we're making progress, but we've still got a long way to 
go.
    Mr. Porter. And you will need increasing amounts of money?
    Dr. Hughes. Yes.
    Mr. Porter. I did kind of switch subjects on you, there.
    Dr. Hughes. They're very closely related.

                           vaccine excise tax

    Mr. Porter. Your budget proposes that we include 
appropriations bill language exempting your immunization 
programs from the vaccine excise tax for the year. My question 
is, have you checked with our friends at Ways and Means to see 
if they approve of us indirectly amending the tax code in our 
bill?
    Dr. Satcher. This I'm going to refer to Dennis. [Laughter.]
    Mr. Porter. Dennis, have you checked with them?
    Mr. Williams. We are talking with them. And we expect them 
to take action. What we're laying out here is the effect of 
what that would be in this budget if they did enact 
legislation.
    Mr. Porter. So you expect them to take the action and not 
to tell us to take it?
    Mr. Williams. Well, yes, we do.

                              food safety

    Mr. Porter. Okay. Your budget proposes to increase your 
food safety efforts by $10 million to a total of $14.5 million, 
Dr. Satcher. Is your agency the principal player in 
surveillance for outbreaks of food-borne pathogens? Your 
current spending of $14.5 million doesn't seem adequate for a 
comprehensive, nationwide program.
    Dr. Satcher. Let me say, and I'm going to ask Dr. Hughes to 
comment, too, but let me say that this food safety initiative 
is a very important initiative. And as you know, President 
Clinton has given it high priority. It is an initiative that 
involves not only CDC but FDA and the Department of 
Agriculture. So it's even an inter-departmental initiative. It 
has a lot to do with the role that Agriculture plays in 
inspecting food, and the role that FDA plays in inspecting some 
foods and also developing regulations in terms of how food is 
handled.
    However, the surveillance component of it is CDC's specific 
role. So all of the discussion having to do with rapid response 
to outbreaks and monitoring the food supply, that relates to 
CDC's role. And we are very much involved in that.
    Let me ask Dr. Hughes to give you the specifics.
    Dr. Hughes. Yes, thank you. We do consider this a very high 
priority, and we do work closely with FDA and USDA when these 
outbreaks occur. A good example, well, a couple of good 
examples from this past year, the Cyclospora outbreak 
associated with raspberries imported from Guatemala, that was 
mentioned earlier. And then more recently, the E. coli 0157:H7 
outbreak associated with the non-pasteurized apple juice 
product. That interestingly was recognized in Washington State, 
in fact in King County, in Seattle, which is where the 1993 
Jack-in-the-Box outbreak of E. coli 0157:H7 was recognized.
    In that county, and in the State of Washington, they have a 
particular interest in food-borne disease, and have put a lot 
of resources into that. We've been able to help them some with 
that.
    The very fact that those two multi-State outbreaks were 
recognized in a very timely way in King County I think is 
instructive. It makes you wonder, though, what's going on in 
the rest of the country where we haven't been able to assist in 
putting more emphasis on detection and response to food-borne 
disease. So, as with emerging infections generally, we've got a 
long way to go. But with food-borne disease and food safety, 
this $10 million would allow us to do some very specific things 
to make some progress.
    Dr. Satcher. We have, I guess five centers now, and what 
would happen with the $10 million?
    Dr. Hughes. Yes. We now have emerging infection programs in 
seven States. With that $10 million we would be able to expand 
to an eighth State and make sure that we have a food safety 
component there as well. We'll be able to do some things to 
strengthen laboratory capacity to facilitate sharing of 
laboratory data in a timely way when these multi-State 
outbreaks occur, and also to be able to assign some additional 
Epidemic Intelligence Service, or EIS officers, to States where 
they can focus also on food-borne disease.

                              food safety

    Mr. Porter. This is a follow-on on that question. Some 
industry officials have complained that some States incorrectly 
identify the sources of food-borne illness, fingering the wrong 
food product and causing needless concern and market 
disruption. Have you seen instances where State health 
departments misidentified sources of outbreaks?
    Dr. Hughes. Yes, and that actually was an issue with the 
Cyclospora outbreak. That was an outbreak that occurred in over 
20 States. We learned of 55 clusters of Cyclospora food-borne 
disease related to that outbreak. It turned out to be a 
contaminated raspberry product.
    There were announcements early on that maybe it was 
strawberries. It turns out that it's very complicated to sort 
these kinds of things out. I was at an Institute of Medicine 
meeting earlier this week and they served us lunch. And I 
couldn't help but notice the dessert that they served was a 
cream pastry. It had two strawberries, I think three 
raspberries, about six blueberries and one blackberry 
associated with it.
    And so when you're faced with one contaminated product, and 
you go and you see that it's the raspberries, which tend to be 
served often with other berries, it turned out to be very 
difficult to sort that out. And I think we did sort it out 
rapidly working with FDA and the State health departments. But 
early on, there was some miscommunication.
    Mr. Porter. Have you worked with health officials in Japan 
as they search for the source of E. coli bacteria that struck 
over 9,000 Japanese citizens?
    Dr. Hughes. I'm sorry, the question was, did we work with 
them?
    Mr. Porter. Did you work with them?
    Dr. Hughes. Yes, we did. We offered our assistance, and we 
sent a team that consisted of a couple of CDC people and a 
person from FDA to try to assist them in their epidemiologic 
and laboratory investigation.

                              tuberculosis

    Mr. Porter. Dr. Satcher, we've seen four consecutive years 
of decline in U.S. tuberculosis cases since the peak in1992. 
But with an increasing share of the TB cases in the U.S. attributed to 
foreign-born patients, will CDC's effort need to shift more to global 
control of TB in order to contain the problem in the U.S.?
    Dr. Satcher. I think the answer is yes, but also, I think 
we have been doing some things globally in terms of working 
with other countries, especially those countries where we have 
seen the largest number of cases coming into this country.
    Do you want to discuss this?
    Dr. Gayle. Well, the countries that account for most of our 
foreign-born tuberculosis cases include Vietnam and Mexico, 
primarily, are the two that contribute the most. And we've been 
working very closely with those countries, and helping to 
develop systems where we can get better data about people who 
are coming into the country who have been found to be TB 
positive and treated in those countries, but making sure that 
we have the appropriate follow-up, so in fact they can continue 
to be followed up. Some of those people become active cases 
again because of incomplete treatment and incomplete total 
follow-up.
    So we're working very closely with those governments to 
develop better systems for that sort of follow-up. It's an 
important area, though, because clearly, if we're going to have 
an impact on TB in this country, we're going to have to get 
more involved in working with the countries that contribute the 
most to our TB morbidity.
    Dr. Satcher. Let me just say that we just had a meeting 
with the Gore-Chenomyrdin agreement with the Russians last 
week. And the TB people from Russia, Dr. Priymak and his staff, 
visited CDC two days ago. And that's an example of where we're 
really trying to share knowledge and resources and strategies 
in a country that's having a major problem with tuberculosis. I 
believe that Vice President Gore and Secretary Shalala will be 
leaving tomorrow for South Africa, another country that's 
having major problems with tuberculosis.
    And the Gore-Mbeki agreement is one that we're still 
developing, but I can assure you that we will be working very 
closely with South Africa in terms of not just the problem in 
South Africa, but from a regional perspective in that part of 
Africa, in terms of how we can contribute, and also learn in 
terms of controlling this problem.
    I guess the two major interventions for us have been the 
directly observed therapy, but also some of our very important 
laboratory work, which allows us to rapidly identify various 
strains of tuberculosis and their resistance to various anti-
tuberculins.

                              tuberculosis

    Dr. Gayle. But this is an area where we desperately need 
better tools, vaccines, better preventive therapies, etc. And 
it's also an area where we have the experience where because 
cases were declining, we backed off of our commitment to 
tuberculosis, and saw a real upswing, reemergence of 
tuberculosis. And we hope that this will not be the case this 
time around. We really do need to maintain the infrastructure 
that has been built up to make sure that we really can continue 
to see the decreases over time. We have a tuberculosis 
elimination plan in place, and we really want to work towards 
the elimination of tuberculosis in this country.
    Mr. Porter. I might say, Dr. Satcher, that to me there is 
more at stake here even than joined efforts to eradicate 
diseases. Because when you work with the Russians or others, 
you're establishing this interchange, and these ties that I 
think can help perhaps the world live in peace in ways that we 
haven't pursued sufficiently in the past. I think that's a very 
important effort for you to do that all over the world.
    Dr. Satcher. And I know you visited China, and I must say 
the working relationships that we've had with the Chinese 
around neural tube defect, the polio eradication, influenza, 
and now behavioral risk factors, has really drawn us together 
very closely. We have a very good relationship.
    Mr. Porter. And they are very, not only very appreciative, 
but they bring it up all the time, we're working with you, this 
is a very good thing to do.
    Your budget justification described the identification of 
strain W, a form of TB that is resistant to eight different 
drugs normally effective in treatment. Do you feel your TB 
control and prevention program can contain these multi-drug 
resistant strains before they appear widely?
    Dr. Gayle. Yes. I think this is where the area of directly 
observed therapy and maintaining the tuberculosis 
infrastructure is clearly important. A lot of these strains 
evolve because people are incompletely treated, and that's why 
we moved to the whole program of directly observed therapy, 
where people are actually as, as the name says, directly 
observed when they're taking their treatment. And we're seeing 
that that is really making a big difference in the emergence of 
these resistant strains.
    It is inevitable that from time to time we're going to have 
those sort of strains like strain W, that we did not expect. 
But I think that the strategy of maintaining the infrastructure 
for this directly observed therapy is the right one, and the 
one that has really made a big, big difference in our overall 
rates of resistant TB.
    Mr. Porter. Thank you, Dr. Gayle.
    I have other questions for the record that I would like to 
submit.
    Dr. Satcher, let me say that you and your excellent team 
have answered our questions directly and candidly. We 
appreciate that very much. You're doing a wonderful job with 
CDC. And we think you need a little more money than the 
President is suggesting.
    Dr. Satcher. Thank you very much, Mr. Chairman. And we look 
forward to your visit to CDC, April 14th.
    Mr. Porter. We look forward to it, also. Thank you.
    The subcommittee will stand in recess until 2:00 p.m.
    [The following questions were submitted to be answered for 
the record:]
    Offset Folios 228 to 598/800 (453/1 included) Insert here



                                      Wednesday, February 12, 1997.

              HEALTH RESOURCES AND SERVICES ADMINISTRATION

                               WITNESSES

CIRO V. SUMAYA, ADMINISTRATOR
THOMAS G. MORFORD, ASSOCIATE ADMINISTRATOR FOR OPERATIONS AND 
    MANAGEMENT
MARILYN H. GASTON, DIRECTOR, BUREAU OF PRIMARY HEALTH CARE
PAUL M. SCHWAB, ACTING DIRECTOR, BUREAU OF HEALTH PROFESSIONS
AUDREY H. NORA, DIRECTOR, MATERNAL AND CHILD HEALTH BUREAU
WILLIAM H. ASPDEN, JR., ACTING DIRECTOR, BUREAU OF HEALTH RESOURCES 
    DEVELOPMENT
DENA PUSKIN, ACTING DIRECTOR, OFFICE OF RURAL HEALTH POLICY
JOSEPH F. O'NEILL, ASSOCIATE ADMINISTRATOR FOR AIDS
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, DEPARTMENT OF 
    HEALTH AND HUMAN SERVICES
    Mr. Porter. The subcommittee will come to order.
    This afternoon we continue with the Department of Health 
and Human Services with the Health Resources and Services 
Administration, and we're delighted to welcome Dr. Ciro Sumaya, 
the Administrator.
    Dr. Sumaya, we are glad to see you. Can you introduce the 
people who are at the table with you, and then proceed with 
your statement?

                       Introduction of Witnesses

    Dr. Sumaya. Certainly, Mr. Chairman and members of the 
committee.
    I am pleased to appear before you today to discuss the 
fiscal year 1998 budget requested for HRSA. I would like to 
introduce my colleagues from HRSA.
    To my immediate right is Dr. Audrey Nora, Director of the 
Maternal and Child Health Bureau;
    To her right, Mr. William Aspden, Jr., Acting Director, 
Bureau of Health Resources Development;
    Dr. Joseph O'Neill, Associate Administrator for AIDS;
    Mr. Dennis Williams, Deputy Assistant Secretary, Budget, 
Department of Health and Human Services;
    On my immediate left----
    Mr. Porter. Dennis gets introduced a lot, you know. 
[Laughter.]
    Dr. Sumaya [continuing]. Is Mr. Thomas Morford, Associate 
Administrator for Operations and Management;
    To his left, Mr. Paul Schwab, Acting Director, Bureau of 
Health Professions;
    Dr. Dena Puskin, Acting Director, Office of Rural Health 
Policy;
    And Dr. Marilyn Gaston, Director, Bureau of Primary Health 
Care.

                           Opening Statement

    HRSA's primary purpose is to preserve and protect the 
health of Americans who are too poor, too sick, too isolated, 
or who have special needs for sources of essential health care 
services that most of us take for granted.
    We work to open doors for hardworking individuals and 
families who are too rich for Medicaid, but too poor for 
private insurance. We serve rural communities and people in 
public housing, people with HIV and AIDS, and pregnant women 
and their children, including children with special health care 
needs.
    HRSA programs put primary health care services in their 
neighborhoods and help to train and place the physicians, 
nurses, and other professionals where they are most needed.
    HRSA programs assure that babies are born healthy, children 
are immunized, and adults receive the kind of ongoing 
preventive health care that keeps them productive at work when 
they are well, and out of expensive emergency rooms when they 
are sick. We are honored to be entrusted with such an important 
mission and justifiably proud of what we have achieved.
    But we are also concerned that the need for the kinds of 
systems of care and training programs that HRSA supports will 
only grow as more Americans find themselves outside the 
mainstream of our health care system.
    Managed care and Medicaid go hand-in-hand as States strive 
to control costs without sacrificing access, but these 
innovations still leave many uninsured, underinsured, disabled 
and chronically ill children, women, and men sitting on the 
sidelines. These people depend on HRSA's health care provider 
systems for access to the services and health professionals 
they need.
    Welfare reform promises to increase the pressure on States 
to care for their underserved citizens--again, care that in 
large measure has been provided through HRSA appropriations.
    Further, over 40 million Americans today have no health 
insurance, and we have a graph that you hopefully also have by 
you; if not, we have a poster here on the side. It shows you 
what's happening with the rate of uninsured. Over the next six 
years, the estimate is for an additional 4.5 million uninsured, 
which is a 9 percent increase. Just yesterday, CBO released 
very similar projections; as you know, this has been increasing 
for a number of years prior to the first year that we even have 
indicated here.
    Also, as you know, most of these are unemployed or in 
families in which there is an employed member, but are unable 
to afford the estimated $6,000 annual cost of basic health 
insurance for a family of four.
    Also, a growing number of them are children; 9.8 million, 
or 14 percent, of our Nation's youth have no insurance. For 
these children, for their families, and for millions of other 
Americans who are medically underserved, who are underinsured, 
live in isolated areas, have special health care needs, are 
infected with HIV, or for other reasons fall outside the reach 
of health care providers, HRSA programs are the ultimate 
services safety net.
    In fiscal year 1998, HRSA intends to weave together health 
care systems to form a safety net that is even tighter, with 
more and better preventive and primary care services that 
reduce hospitalization and prevent chronic disease and 
disability, and to help produce the right providers--the health 
professionals--for the right places.
    To accomplish this important work, HRSA requests a total of 
$3.3 billion and 1,523 direct full-time equivalent positions. 
The request reflects HRSA's commitment to the President's 
streamlining objectives and supports the diversity of 
operations necessary to meet the needs of our States, our 
communities, and our citizens.
    I will briefly summarize the budget request.
    The President's budget request maintains most HRSA programs 
at their fiscal year 1997 level. Included is a maternal and 
child health block grant to States which serves some 10 million 
women, infants, and youth every year, including children with 
special health care needs.
    To meet the increasing demands placed on HRSA Health 
Centers for the managed care industry, welfare reform, and the 
disproportionate increase of uninsured people utilizing these 
services, the request includes a modest increase of $8 million 
for Consolidated Health Centers.
    To assist communities experiencing the highest rates of HIV 
infection and AIDS and to help States make the newest life-
prolonging therapies available to those who otherwise would 
face barriers to receiving them, the request includes a $40 
million increase in Ryan White Comprehensive AIDS Resource 
Emergency, or CARE, programs.
    To help narrow the terrible disparity between the number of 
organs donated for transplant and people waiting for 
transplantation, the request includes a $1.6 million increase. 
These funds will be devoted to educational efforts to increase 
donation.
    The request calls for cuts in funding for HRSA's health 
professions training programs. Over the past 30 years these 
programs have helped to build our health care workforce. Their 
momentum will be maintained in HRSA programs with a focus on 
the most recalcitrant health professions problems, diversity 
and distribution.
    The request also decreases program management funding as 
HRSA continues the restructuring that already has reduced by 13 
percent program management FTEs.
    In conclusion, America has the finest, most technologically 
advanced medical system in the world. A prime example would be 
our investment in AIDS research that is producing therapies 
that were unimaginable a year ago. Infant mortality, also, has 
never been lower. These gains have been made in large part 
because the Federal Government made wise and strategic 
investments in the Nation's health, partnering with many 
groups--States and communities, private and public sectors, 
foundations, and many, many others.
    If we are to carry these gains forward, if we are to create 
a health care system that is as equitable as it is advanced, 
and create a medical home for all of our people, if we are to 
put effective new treatments and other research advances into 
the hands of those who need them, regardless of income, if we 
are to keep people out of costly emergency rooms and hospitals, 
if we are to lower our infant mortality rates to levels 
comparable with other industrialized nations, it will be 
because you have continued the wise investment of Federal 
dollars in the health of all Americans.
    The HRSA fiscal year 1998 budget is one such wise 
investment.
    If I can be more personal, Chairman Porter, I was glad to 
hear of your visit just a few days ago in Chicago, where you 
saw a lot of the HRSA programs in action, models that work, 
that come out of the Community Health Center system, and an 
award being given to the Chicago Health Corps in the context of 
a 330 Community Health Center which has a Healthy Start 
program, which has training programs dealing with academia and 
the AHEC program, which has Ryan White activities, which has 
maternal child health activities. You saw this, I think, in 
action.
    So, Mr. Chairman and members of the committee, I will be 
pleased to address any other questions or comments you may have 
on the specifics of this budget request.
    [The prepared statement follows:]
    Offset Folios 810 to 815 insert here



    Mr. Porter. Dr. Sumaya, thank you for your very fine 
statement. I will comment on that when I return; unfortunately, 
we have three votes, and the break will probably be at least 30 
minutes. I apologize for that, but there's nothing that I can 
do, so we will have to stand in recess for 30 minutes or 
longer, until I return.
    Dr. Sumaya. That's fine.
    [Recess.]

                          chicago health corps

    Mr. Porter. The subcommittee will come to order.
    Dr. Sumaya, I was going to tell you about my visit to the 
Chicago Health Corps and how impressed I was with what I saw 
and learned there. We had hoped that you would be able to join 
us; we understood that there were budgetary questions that had 
to be attended to, but I want you to know that you were very, 
very ably represented by Neil Sampson, who did a wonderful job 
for you. I think everybody learned how important is the 
leadership that HRSA is providing in this area.
    I think I will start with a question on this, though. My 
understanding is that there are only three areas in America 
that have this kind of program, and one is Chicago, and the 
others--Neil is here; he could probably tell me very quickly--
but I think it was Philadelphia and Pittsburgh. Those are the 
three?
    Mr. Sampson. Yes.
    Mr. Porter. If we are able to do this so well in Chicago, 
obviously there is a huge unmet need out there across the 
country, and the resources needed to replicate this program 
across the country would be really large. What are we going to 
do with the knowledge that we have here? Are we going to get 
private sector involvement? Are we going to spin off some other 
means of financing it? How are we going to do it?

                               unmet need

    Dr. Sumaya. Yes. Well, first of all, again, I am just 
extremely happy that you were able to make that trip and see a 
lot of things in action which are so important.
    I think you touched on the main issue, the unmet need that 
is there. We have, as the Chicago Health Corps shows as well as 
many of our other HRSA programs, very meritorious programs 
which are doing a good job, but the unmet need is very 
significant, and growing in many sectors. We have three 
specific sites with that type of health corps initiative. And 
as you know, this was really a pooling of some of the funds 
that we had from the maternal and child health area, the health 
professions arena, and the Community Health Centers. We worked, 
with some support--and then obviously got the assistance from 
the national AmeriCorps Program--and then tied that into some 
of the existing HRSA programs.
    What we would envision is, as we do with most of HRSA's 
programs, that they are catalytic, they are pilots, they are 
demonstrations, and we try to push them--push theenvelope--so 
that they leverage their activities. They find partnerships in the 
public and private sector and try to see how they can get 
institutionalized, and we try to support them as best we can in that 
process.

                              ahec program

    Mr. Porter. Okay. Now, my staff has developed a tough 
question in this area for you.
    You indicate that one of the continuing roles for health 
professions in your budget proposal is to address the problem 
of geographic distribution of providers, and your justification 
acknowledges that one of the roles of the AHEC program is to 
provide training for physicians who serve in rural or medically 
unserved urban areas.
    How, then, can you justify merging the AHEC program into a 
cluster which is smaller in size than the AHEC program alone is 
this year?
    Dr. Sumaya. So your question deals with the cluster----
    Mr. Porter. Well, my understanding is that the funding for 
the cluster which includes AHEC is less than AHEC itself is 
receiving in this fiscal year.
    Dr. Sumaya. Well, if I can approach it in two pieces, one 
of them is, why in a cluster-type approach? And then, why 
funding decreases as you are working on the cluster approach 
simultaneously?
    For the former, I would say that--and I've been an AHEC 
director in the past, and I think it's a very essential and 
important program--as we see how things are developing for the 
future, what is occurring outside in the various communities 
and regions and States is integrative health care systems. So 
what we are trying to do from the agency, working through our 
programs, including the AHEC, is, how can we integrate the AHEC 
with other similar type programs that have some common 
features, such as the interdisciplinary training program and 
the geriatric education centers. They have some common 
features, and what we're trying to do is make it a more 
synergistic type of approach in the enhanced AHEC. I think it 
gives it a much stronger type of systemic approach as we work 
with the various communities.
    Now, the dilemma, obviously, always deals with funding, and 
I share your concerns. Unfortunately, we are faced with a 
number of budgetary constraints and decisions that are very 
difficult to make, and so we approached the total health 
professions arena as to what are those priority areas that we 
think the marketplace cannot handle well, and let's try to move 
strongly in those areas. Those areas that we think the 
marketplace can handle, we will move less strongly in funding. 
The AHEC was one that we felt was a strong one, and needed to 
be boosted; perhaps not to the level of diversity, as you will 
see in the numbers that we've placed, but I think we gave it 
credible support. Obviously, we try to see how we leverage 
those activities with other programs that we have in the health 
professions training arena and other AHEC programs.
    Mr. Porter. Dr. Sumaya, I am going to yield to Mr. Bonilla 
in just a moment here. What is happening is that we have a full 
Appropriations Committee meeting next door; there will be, we 
think, a recorded vote there very shortly. I will have to 
leave, and perhaps Mr. Bonilla and I can spell each other then. 
And then, in about 30 minutes now, another cluster of votes on 
the House floor. So we will try to proceed as expeditiously as 
possible. Members may return here after the full Appropriations 
Committee; we don't know. We will try not to impede your 
schedule more than we already have.
    Dr. Sumaya. I fully understand.
    Mr. Porter. Mr. Bonilla?
    Mr. Bonilla. It's nice to see you again.
    Dr. Sumaya. Likewise, Mr. Bonilla.
    Mr. Bonilla. Have you spoken to our friend, Dr. Howe, 
lately?
    Dr. Sumaya. Actually, not too long ago, yes.
    Mr. Bonilla. He's still doing a great job down there in San 
Antonio.
    Dr. Sumaya. Exactly.

                          overall budget level

    Mr. Bonilla. I would like to start by talking about the 
overall budget, Dr. Sumaya. As you know I have always been very 
supportive of what HRSA has done. You serve so many 
disadvantaged areas, and there is a true need out there for 
additional funding. I have always been an advocate of that.
    Year after year I am running out of ways to express my 
sincere dissatisfaction for the low priority that the 
Administration is giving to HRSA. I know this is something that 
you struggle with, as well. HRSA's mission is to make essential 
primary care services accessible to the poor, to the uninsured, 
and populations severely underserved by the private health care 
system. You have seen those areas personally, I know, as have 
I. You are supposed to tend to the special health care needs of 
people with chronic health care problems, minorities, and those 
living along the U.S. border with Mexico; but you know that 
well, growing up in south Texas.
    How is HRSA supposed to do this, when the Administration 
plans to cut its budget by $82 million?
    Dr. Sumaya. Well, the $82 million is in the aggregate form. 
As you can see, some of our programs did receive some 
increases, and other ones did have some decreases. We had some 
that maintained a stable type of budget.
    What we would do with our array of programs, as we are 
doing within our organization, is seeing how we can assist the 
community better with our programs. We are trying to see what 
the common features are across all of our programs, and see how 
we can develop, even with less dollars in some cases, the same 
type of impact. What we don't have within our programs, we try 
to leverage with the public or the private sector in trying, 
again, to reach the impact that we would have had otherwise.
    Mr. Bonilla. Well, I don't know how else to say it than to 
reiterate again that it is very frustrating for people like 
me--and I can't speak for you--who see these needs out there in 
the community. We seem to have ideas that come out of the 
Administration to create new programs that don't even exist 
now, to create more entitlements and spending programs, yet the 
programs that are already in place, that are working and 
helping people, we can't seem to fund.
    So I am just mind-boggled sometimes to listen to the 
rhetoric and the choice to not give you what you need to do 
your job, to make your job easier and serve more people. Yet 
there seems to be a willingness to go for these ``pie in the 
sky'' programs in some cases that haven't even existed before, 
and somehow, a willingness to commit to funding something like 
that into the next millennium.
    So I just want to express that, and I think you know where 
I'm coming from.
    Dr. Sumaya. Yes, sir.
    Mr. Bonilla. I know you are on my side and I'm on yourside 
on this issue, and I know that you are somewhat restrained on what you 
can say.

                           health professions

    I want to talk about health professions now because that 
is, as you know, another area that I've worked closely on. Dr. 
Howe and I have worked so hard in trying to get the appropriate 
funding level for some of these areas. We all need dental 
hygienists; we need nurses; it especially reaches into low-
income areas and minority communities. Yesterday I expressed my 
frustration to Secretary Shalala that the President has decided 
to cut health professions by $160 million.
    Again, as a native south Texan, I know you can understand 
firsthand the unique challenges in providing health care to the 
predominantly poor and minority population of that region, but 
apparently that message is not getting through. There are only 
three substantial cuts that the President has made in the HHS 
budget, and health professions top the list with the largest 
cut of $160 million.
    I would like to point out an example. In the process of 
trying to convince people that there is a need for these 
services and health professions, there is a constituent of mine 
by the name of Ventura Gonzalez who is the director of the 
health care center in Crystal City, Texas, and who helps a lot 
of migrant farm workers----
    Dr. Sumaya. Yes, I know Mr. Ventura.
    Mr. Bonilla. He has a dental office that remains closed 
because he can't find a dentist to staff it.
    To people like Mike Treveno in Laredo, whom you may know as 
well, who has been trying desperately to recruit doctors to 
serve the needs of the border region. He's had to resort to 
hiring foreign doctors and sponsoring them for citizenship in 
order for them to fill his patient needs.
    These are prime examples about how more support for health 
professions training programs could alleviate these shortages. 
However, in your budget justification you seem to equate the 
substantial increases in the supply of primary care physicians 
and allied health professionals with there being an adequate 
supply of providers who practice in medically-unserved and 
underserved areas. In some cases, when they are having to deal 
with these medical institutions along the border, with visas--
they are in my office all the time; asking can we extend the 
visa for the doctor? We need him; if he leaves, we're not going 
to have one, because they are foreign nationals--we need to 
have more American minorities applying for these positions so 
that they can work and return to their communities.
    So I am asking for your comment on the increases in the 
supply of primary care physicians and allied health care 
professionals, and how you equate that with there being an 
adequate supply of providers who practice in medically-
underserved and poor areas.

                     distribution of practitioners

    Dr. Sumaya. Well, again, I have to say this all in the 
context of some of the budgetary constraints that we have to 
face in having a balanced budget and having to look, then, at 
the priorities within a number of those issues, and the unmet 
needs that we know of in so many varying areas.
    What we have tried to do within the President's budget is 
try to analyze where the marketplace can handle some of the 
aspects of the health professions more appropriately, and where 
the Federal Government can provide--or needs to provide--
significant leadership and support. In those areas that we felt 
were not quite at the priority of some of the others, like 
minority and distribution, we are going to try to tackle those 
issues in a more strategic, in a narrower form, as best we can 
within our budgetary restraints.
    Mr. Bonilla. In saying that these positions are 
adequately--I'm using the word ``adequately''--provided for 
right now in these underserved areas, if we have an adequate 
supply, does that mean that you don't need additional funding 
for health professions?
    Dr. Sumaya. Well, in response to that question, I would 
look at some of the issues that are raised in the health 
professions, that may be packaged differently. When one says 
there is an adequate supply or oversupply of physicians, for 
example, that may not be an appropriate representation as 
opposed to what the data is showing at this point, which is 
that there may be too many specialists but there may not be 
enough primary care physicians. We know that there are major 
problems in distribution. There are major problems in 
diversity, with underrepresentation of many minorities in the 
health professions. There are problems with cultural competency 
practices. There are problems with knowing about preventive 
skills within the health professions. Likewise, if we look at 
nursing, public health, dentistry, all the allied health 
professions, we see that there are some emerging unmet needs 
that hopefully we can address to some extent and leverage what 
dollars we have put into these with other marketplaces and the 
public and private sectors to try to address some of these 
issues, as you well recognize.
    Mr. Bonilla. Whatever you can do to be helpful to me, Dr. 
Sumaya, I would appreciate it, because I do fight this battle 
every year, and I think you know that. As much as you can be on 
my side on this, I would appreciate it. Sometimes I know it is 
difficult, disagreeing with the boss, but I think you recognize 
the needs out there that I've seen and you've seen. We need to 
stay on track together on this if we're going to be successful 
in all of these operations that we're talking about funding.
    Dr. Sumaya. I am happy to be of assistance, Mr. Bonilla.

                   health professions shortage areas

    Mr. Bonilla. Mr. Chairman, do I have time remaining?
    Mr. Porter. About a minute.
    Mr. Bonilla. Just briefly, I would like to also state that 
many of my colleagues on this committee and in Congress 
understand the importance of all of these issues. After all, 
shortage areas exist in each State; in fact, there are over 
2,600 counties in this country which are health professional 
shortage areas, meaning that there is less than one primary 
care physician for every 3,500 persons in those regions.
    There was wide support last year in this subcommittee and 
in this committee and in the Congress to restore the 
President's cuts and significantly increase funding for these 
programs. We thought that we were sending a clear signal to the 
Administration that these programs are valued, because we had 
bipartisan support.
    I am wondering why you think, tied to what we've been 
talking about today, that the President has ignored this 
committee's message? Because we've been very aggressive in this 
area.
    Dr. Sumaya. Well, I believe some of that may be related to 
our need to look at all our budget lines very carefully and try 
to balance the budget, and looking at priorities, and perhaps 
not only working from within our programs in the budgets that 
we have, but really trying to leverage them as manyfold as we 
can with outside groups.
    Mr. Bonilla. Thank you, Dr. Sumaya.
    Mr. Porter. Thank you, Mr. Bonilla.

                impact of aids drug assistance programs

    Dr. Sumaya, there seems to be considerable tension in the 
AIDS community between those who think that resources should be 
directed to the drug assistance program, because it can keep 
patients healthy and limit their need for social services, on 
the one hand, and those who think there is still a strong need 
for continued support of social services.
    Do you believe that protease inhibitor drugs will 
eventually reduce the need for services such as hospices and 
in-patient medical care? And do you expect your budget to 
reduce funds in these Title I services in the outyears?
    Dr. Sumaya. That's rather a complex question. I think with 
the use of new treatment modalities, whether it is protease 
inhibitors or whatever else is to come, they in a sense prevent 
a number of other health problems, and may prolong life. But 
that in turn may lead to a number of social types of support 
systems because they will be living longer.
    It appears currently that the amount of in-patient care may 
be on the decrease as we have better management, but that's 
being supplanted by a greater amount of intense care in the 
out-patient arena. So we have to follow this very carefully.
    I think another dimension to this is seeing, as we have 
with treatment like protease inhibitors, that we need to see 
how they are utilized. It is important that we have some very 
critically-examined ways in having clinical guidelines, because 
as we develop new therapies we have to see how far we push the 
envelope on treatment, how early in the infection stage, how 
early in AIDS do we use that; and that may have, again, 
significant clinical as well as funding implications for the 
ADAP program. As you know, we have the targeted ADAP or drug 
assistance dollars in Title II, but we also have within the 
reauthorization a Title II that has flexibility to provide 
additional funds into drug therapy, if needed. Also we have 
Title I that can provide some additional support in that 
context. There are some activities at the departmental level 
that are looking at some of these research clinical guidelines 
to help us utilize these drugs for the best advantage, and we 
also have to take into account what's happening in the States, 
because they have significant authorities, the enrollment 
criteria for receiving drugs, etc.

                   difference between titles i and ii

    Mr. Porter. Well, all right. Except for the fact that Title 
I of Ryan White goes to the cities and Title II goes to the 
States, is the distinction between Titles I and II really an 
artificial one? And are there any activities that can be funded 
in one title, but not in the other?
    Dr. Sumaya. I would like to respond to that, and then have 
Dr. O'Neill respond as well.
    I don't think I would call them artificial distinctions. I 
would look at them as a sense of focus in the State and a sense 
of focus in the community, but knowing that there has to be 
complementary activity between I and II, and III and IV and V 
as well. And not only between Ryan White, but if I just take 
HRSA as an example, I have to make sure that our Community 
Health Centers are working very effectively with the AIDS 
community. I have to see that our maternal and child health 
programs are incorporated and understand the treatment and the 
management of AIDS patients. So I have to look across the whole 
agency.
    But more particularly between Title I and II, Dr. O'Neill?
    Dr. O'Neill. It has a great deal to do with the ability of 
programs to be sensitive to the communities that they are in. 
Most of the important decisions that are made about what is 
paid for and what is not paid for through these programs are 
really made through either the city planning councils or 
through the consortia in the States, which are community-
representative organizations. It's the philosophy that people 
who are living in the communities, living with HIV disease, 
have a better sense of what's going to work for them than 
somebody sitting in the Parklawn Building.
    So the biggest distinction between the programs are that 
Title II supports can cover a whole State, where the cities 
just focus on a smaller area.

                      earmark for the adap program

    Mr. Porter. Should we consider discontinuing the separate 
earmark for the ADAP program within Title II so that the States 
can have flexibility in allocating Title II resources to meet 
their particular needs?
    Dr. O'Neill. I think that the importance of the drug 
reimbursement activities is quite clear. It's amazing to think 
that it has only been a year, or a little bit more than that, 
that we've had these medications available. As a practicing 
physician myself, I see the tremendous benefit that comes to my 
patients from these drugs; it's really overwhelming.
    I think that it is important that these medications be made 
available, and I think there is a certain baseline of funding 
that needs to be clearly there for these medications. But 
beyond that, every State operates its ADAP program in a 
slightly different way, again, looking towards the different 
abilities and different needs in different communities. Because 
of that, the increase in the Title II program, for example, 
that we are requesting this year, is money that the States can 
decide on their own to either put into their drug program, or 
to use in other ways.
    It is really important and it is very clear to us--I work 
in the inner city of Baltimore with a predominantly, almost 
exclusively, indigent population--it is very clear to me that 
these people can benefit tremendously from these medications if 
they can get into care, if there's a system of care that can be 
there for them. So the social services become extremely 
important for access to a system of care that is capable of 
delivering these medications.
    Again, I think those kinds of decisions are best made on 
the local level.
    Mr. Porter. So the answer is yes, give them more 
flexibility?
    Dr. O'Neill. I think the answer that I would say is that 
what we have requested, the baseline of $167 million, is a 
baseline that provides a certain amount for each State, in 
addition to which the increases--we would want to see the 
flexibility in the increase over that.
    Mr. Porter. All right.

                       adap supplemental funding

    Let me ask the next two questions together because they go 
to the same issue, and then you can respond to them, or Dr. 
Sumaya.
    Is it correct that you have permitted States to draw down 
up to 25 percent of their 1997 ADAP grant in advance of when it 
would usually be available? How big a year-end shortfall do you 
expect as a result, and how do you propose to deal with it? 
That's one question.
    The second question is, some of the advocacy groups 
haveapproached the committee, saying that supplemental funds will be 
necessary for the ADAP program this year. Your budget does not contain 
a 1997 supplemental request. Have you concluded that the 1997 funding 
is adequate?
    Dr. Sumaya. Okay. Tying in, again, to your prior question 
to Dr. O'Neill, I think there is an importance to having a 
focused drug assistance program, for several reasons. One of 
them is the cost issue. The second one is, there is still an 
unknown arena of clinical usage in these drugs. And the third 
one is, you can still have flexibility to bring other funds 
into this arena, so you need the flexibility there.
    In the first question that you had, yes, there are three 
States where we had advanced some of these funds because they 
were having, obviously, some funding problems in having 
sufficient funds for this particular program.
    Where do we see the supplementals across the board in all 
our other States, for the rest of the year? I think it is still 
unclear, but there are so many contingencies on this. The point 
is, I think we have to monitor what's happening in each State, 
close monitoring of that, so that we know where we have to 
head. We do have flexibility in Title II to put more money into 
the ADAP program. We do have some flexibility with Title I to 
bring in more dollars into the drug program.
    So I think we have to see how that issue occurs. We have to 
see whether the departmental commission is going to tell us 
some clinical guidelines for the use of this drug. We have to 
see how the States are handling their criteria enrollment and 
the number of people that are utilizing it. Different States 
are coming on board with the use of one or the use of several 
of these protease inhibitors, so it's a moving target that we 
have to monitor carefully to see how the funding can keep pace 
appropriately with that.
    Mr. Porter. But you have no feeling--we're, what, five 
months into the fiscal year--you have no feeling yet as to 
whether you're going to have a shortfall or not, and whether 
you're going to need a supplemental or not?
    Dr. Sumaya. Let me have Dr. O'Neill answer that.
    Dr. O'Neill. I was going to speak to the issue of the three 
States that we gave the early funding to.
    Part of that process, in the application of that funding, 
was that we asked them to demonstrate to us how they planned on 
not having to come back earlier in the next year. In other 
words, they satisfied us that they had a plan in place which 
would prevent them from running out of money at the end of the 
year.

                    adap programs drug pricing caps

    Mr. Porter. Are all State ADAP programs taking advantage of 
the drug price caps available to them through the requirements 
of Section 340(b) of the Public Health Service Act? How much of 
a discount off of regular prices do they receive?
    Dr. Sumaya. We are working very actively with drug 
discounts for the ADAP program, as well as many other 
medications that are used by covered entities in this extremely 
important program that we hope goes on and on. Currently we 
have some figures that about 20 percent discount on these 
drugs--I don't have the specific ones, unless Dr. O'Neill has 
that--for protease inhibitor-type drugs. But we can try to get 
that type of information.
    [The information follows:]

                     State Adaps--Drug Pricing Caps

    The Federal purchasing program enacted in Section 602 of 
the Veteran's Health Care Act (``the 602 program'') and 
administered by Health Resource and Services Administration's 
Office of Drug Pricing provides State ADAPs with another 
alternative for obtaining the best possible price on drugs. 
This legislation requires that pharmaceutical manufacturers, as 
a condition for continued participation in the Medicaid rebate 
program, provide discounts on outpatient drugs to certain 
``covered entities,'' mostly Public Health Services grantees 
and some ``disproportionate share'' hospitals. Pharmaceutical 
prices available under the 602 program are significantly lower 
than both retail and wholesale prices. Discounts range from 20-
40 percent, depending on what price is being compared. Covered 
entities are also free to negotiate further discounts that are 
lower than the maximum allowable statutory price.
    As of December 31, 1996, a total of 19 States (35%) were 
certified under the 602 program and a number of health 
jurisdictions in California participated in the program. Also, 
an additional three States received 602 pricing although not 
certified for the program by utilizing specific cost-saving 
mechanisms. For example, Alabama established a closed-store 
pharmacy while Louisiana worked with its Office of Public 
Health Pharmacy for PHS pricing on eligible pharmaceuticals. In 
1997, HRSA's Division of HIV Services is working to ensure that 
all States will be enrolled or reenrolled in the 602 program.
    In addition to the 602 program, States utilize various 
other cost containment strategies to maximize cost savings for 
their ADAP programs. At the end of 1996, thirty-one States 
reported negotiating manufacturers' voluntary rebates; twenty-
two States reported negotiating pharmacy discounts; fifteen 
States reported receiving manufacturers' discounts; and twenty-
two States reported using multiple strategies to obtain the 
best price on drugs. Based on data reported by Title II 
grantees in their FY 1996 ADAP supplemental applications and 
updated as of October 1996, $16.69 million was available for 
State ADAP programs from all of these cost recovery strategies.

    Dr. Sumaya. We plan on having a prime vendor mechanism in 
about six to seven months, which we think can even make greater 
inroads and bring in a greater savings. Obviously, we will make 
sure that they are utilized effectively by all the groups, 
covered entities, dealing with the ADAP program.
    Mr. Porter. You have anticipated my next question, but I'm 
not sure you've told me whether all State ADAP programs are 
taking advantage of the drug price caps or not.
    Mr. Aspden. They are all required to, and they have to 
certify on their applications which program and how they are 
purchasing their drugs. They have assured us that all of them 
are participating and receiving significant discounts, in some 
instances greater than the Federal Office of Drug Pricing.
    Mr. Porter. Okay.

                   ryan white performance evaluations

    What performance evaluations have been conducted on the 
Ryan White programs? Do you have any data on hospitalization 
costs avoided, longer workforce productivity, private insurance 
status retained, or other relevant performance measures?
    Dr. Sumaya. I'll have Dr. O'Neill answer that.
    Dr. O'Neill. We have conducted a number of evaluation 
studies on the Ryan White program. It would probably be best 
for me to pull that information together and give it to you in 
a clear and succinct way.
    [The information follows:]

               Evaluation Studies of Ryan White Programs

    Hospitalization costs: During the 1990s the frequency of 
hospitalization and the length of hospital visits have 
decreased. Future analysis of national data sets will further 
document trends in medical service utilization.
    Longer workforce productivity: The introduction of protease 
inhibitors is too recent to measure longer workforce 
productivity. However, a New York State study points to a 
decline in deaths from HIV between 1995 and 1996. If this trend 
is found in other states, it should translate into increased 
workforce productivity as people live longer and healthier 
lives.
    Private insurance status: The HIV Cost and Services 
Utilization Survey (HCSUS) will provide the first national 
estimate of private insurance status of individuals living with 
HIV. Because it is a longitudinal study started in 1996 and 
ending in 1998, it will measure changes in insurance status. 
The 1993 estimates of savings from Title II private insurance 
continuation programs in four states (Florida, Hawaii, 
Minnesota, and Wisconsin) indicate that continuation of private 
insurance saves a state Medicaid program approximately $782 per 
client per month.
    Other measures: 1% evaluation studies, proposed for this 
fiscal year include the analysis of HCSUS and one other 
national data set for changes in ambulatory medical use, 
changes in hospitalization rates, and secondary infections. 
HRSA also will be publishing a book that reviews outcome 
measures for eight service areas of the CARE Act including 
primary care, case management, mental health, and IDU 
treatment.

    Dr. O'Neill. One of the big pieces, though, that we're 
dealing with is these new medications, which you raised a 
little bit earlier, which have really tremendously changed the 
picture, vis-a-vis the cost-effectiveness of these medications. 
So many of the studies that we have done in the past are no 
longer going to be applicable.
    Mr. Porter. We are having a roll call next door in the full 
committee, and we have three votes again. I'm very sorry, but 
we're going to have to stand in recess again, Dr. Sumaya, and I 
hope you will bear with us.
    Dr. Sumaya. That's fine. We'll be here.
    Mr. Porter. The subcommittee will stand in recess for 30 
minutes.
    [Recess.]
    Mr. Porter. The subcommittee will come to order.

                               hemophilia

    The Chair recognizes Mr. Miller of Florida.
    Mr. Miller. I apologize for all these conflicts; it's 
unfortunate.
    I have been interested in a couple of things in your 
program. One of them I brought up before, that I think we 
talked about last year, is hemophilia. It's an area that I have 
a special interest in.
    Could you just update me on where that stands, as far as 
any changes from last year? You are proposing flat-funding it, 
I believe, which is in effect a cut, but you only fund a 
limited number of the programs. CDC does most of the funding, I 
think, right?
    Dr. Sumaya. Yes. We've very intimately involved, and we 
have a good relationship, I think, with CDC on the hemophilia 
program, and they're well involved as one of the covered 
entities in the discount program, as well.
    Let me have Dr. Nora add some additional comments on that.
    Dr. Nora. We have 145 hemophilia centers. We have 10 
regional networks [Clerk's note.--Later corrected to ``12''.] 
that the 145 centers feed into, and 50 of the centers [Clerk's 
note.--Later corrected to ``34''] participate in the purchase 
of clotting factors directly from the manufacturer through the 
Drug Pricing Program. And that has been a terrific savings for 
those families with the high cost of clotting factor.
    Mr. Miller. You're flat-funding it. The treatment centers 
themselves under the SPRANS Program?
    Dr. Nora. That's correct.
    Mr. Miller. I'm confused. You do 12 programs that you--it's 
only $5.3 million, right?
    Dr. Nora. For hemophilia?
    Mr. Miller. Yes. Or is that----
    Dr. Nora. Yes.
    Mr. Miller. And that goes to 12 projects?
    Dr. Nora. Right.
    Mr. Miller. Are they site-specific projects? Or what kind 
of projects are they?
    Dr. Nora. They are regional-type projects which then deal 
with the various hemophilia treatment centers around in the 
communities.
    Mr. Miller. Why is part of it funded through you all, and 
most of it funded through CDC? Or do you know?
    Dr. Nora. Well, it is part of the Title V legislative 
authority for us to support the hemophilia treatment centers. 
The CDC component is primarily for surveillance and for 
tracking of complications of hemophilia. We have been working 
together very closely to try and provide access to the patients 
in the centers for the CDC component.
    Mr. Miller. I am very familiar with the treatment centers, 
for personal reasons, very familiar with them, and I think they 
have been excellent since they started back in the 1960s or 
1970s--1960s, I guess. But at any rate, this is only a small 
amount of money, I guess? Most of it is under CDC, I guess.

                    elimination of specific programs

    Let me ask you a question. Are you eliminating any 
programs? I know that in the budget last year, you proposed 
elimination of some programs. Are you eliminating anything in 
your budget this year, any specific programs?
    Dr. Sumaya. No, we're not zeroing anything out.
    Mr. Miller. No plans, even in the future, to zero anything 
out or consolidate?

                         program consolidations

    Dr. Sumaya. Well, there is a consolidation forum, or 
cluster forum, that we have within the health professions that 
is looking at various programs.
    Mr. Miller. That makes sense to me, the clustering. Why 
doesn't it proceed very well? I know there's opposition to it, 
but have you all fought very hard for that? It will get shot 
down, I think.
    Dr. Sumaya. Yes. Well, I think we've come forth with that 
on several occasions, and we try to put forth the merit that we 
think it provides greater flexibility to the communities and 
the regions that are vying for these particular grants. It 
provides a more systemic approach. It provides for a lot more 
partnering so that it can be institutionalized better, in 
particular in the health professions. We can look across 
curriculum training for the various health professions, across 
disciplines for training, etc. So we think it's something that 
could be much more effective than the way we are working now, 
but we also have to contend with some groups that believe that 
we have to have some more narrow looks, or perhaps some of 
these programs would be left out and the bigger ones would 
gobble up the smaller ones. So these types of notions are out 
there.
    But we believe that you can develop these, and perhaps one 
approach would be to do a staging or a phasing-in so that you 
can see how some of these work and that they are effective, and 
then you can look at it in the broader sense----
    Mr. Miller. Is that what you're proposing, a phasing-in or 
to try a testing or staging or a demonstration?
    Dr. Sumaya. What we proposed is the broader approach of 
going into a consolidated type of format, particularly in the 
health professions. But what we are currently working on is 
looking at some of these as demonstrations or pilots within 
current appropriations and trying to, again, show how these can 
be structured, how they can be effective.
    Mr. Miller. It seems like this makes some sense. Maybe a 
demonstration would be the direction to go. I know it's not a 
partisan issue here, but some people get very defensive about 
it.
    So that will be all for now, Mr. Chairman.
    I appreciate your support for the hemophilia program.
    Mr. Porter. Thank you, Mr. Miller.

                    title i, title ii, adap program

    Ms. Pelosi?
    Ms. Pelosi. Thank you very much, Mr. Chairman.
    Dr. Sumaya, welcome----
    Dr. Sumaya. Thank you.
    Ms. Pelosi [continuing]. After you've been here all this 
time, to you and your colleagues, and thank you for all of your 
good work.
    I just wanted to seek some clarification, following up on 
the Chairman's questions earlier, about Title I, Title II, and 
the ADAP program as well.
    First of all, on Title I versus Title II, correct me if my 
understanding is not correct, but Chairman was asking about if 
we go to Title II, what's the difference, etc. My understanding 
is that Title II, the way it is now, the money that would go 
to--for example, the State of Illinois, just to pick a State at 
random----
    [Laughter.]
    Ms. Pelosi. It would count the cases in Illinois, excluding 
Chicago, because that's an impact city. That would be a Title I 
city. Is that correct?
    Dr. Sumaya. I'll have Mr. Aspden answer that.
    Ms. Pelosi. Excuse me, within Title II.
    Mr. Aspden. Are you talking about the changes in the 
formulas under the reauthorization?
    Ms. Pelosi. No, I'm not talking about the reauthorization. 
I'm talking about targeted ADAP funds. If they were looking, 
for example, to Illinois, in order to determine for Title II 
purposes what the funding should be, they would count the 
number of cases in Illinois, excluding Chicago.
    Mr. Aspden. That's not the way the formula is calculated.
    Ms. Pelosi. Tell me how it works, then.
    Mr. Aspden. There are two separate formulas under Title II. 
There's a separate formula for the drug program, and there's a 
separate formula for the basic Title II program.
    Ms. Pelosi. Right, of Ryan White.
    Mr. Aspden. Ryan White. Under neither formula does it 
exclude cases in EMAs. I'm sure it doesn't. The count is 
different, okay, but it doesn't exclude cases in Chicago.
    Ms. Pelosi. Okay. That answers my question. Thank you.

                    ryan white increase distribution

    Your budget request includes an increase of $40 million for 
Ryan White care. This, I suppose, is in response to the 
opportunities created by the new combination drug therapies 
which have been referenced, which can reduce the level of 
virus, and we are all so hopeful about that.
    Could you tell me what HRSA's rationale is for the proposed 
distribution of the $40 million across the Titles for Ryan 
White?
    Dr. Sumaya. Well, the rationale for the distribution is 
always, as you know, a difficult and complex one. We have to 
take into account what are some of the emerging needs in these 
areas. One, we feel, obviously, is the drug assistance program 
housed, for the most part, in Title II. But we also see some 
major needs in the need for primary care and support services, 
as well, that keep emerging in greater need amongst the various 
populations.
    We also have to take into account what are the changing 
demographics of the HIV positive/AIDS population, and we see 
the great emergence of the adolescent group, a stronger 
emergence in children and women. And so we also have to see how 
these fit into the various titles.
    We are taking into account as well what is happening in the 
particular cities and what changes in numbers of new cases are 
occurring in the various cities, and trying to get a balance, 
as best we can, amongst these various groups. More recently, as 
you saw, our emphasis was in Title II, with $50 million. And 
although it wasn't targeted to the ADAP program, which was 
maintained, we have flexibility within Title II to enhance the 
ADAP program.
    We also had increased emphasis in Title III(b), again, 
because we see emerging needs in primary care and other support 
services related to that.
    Dr. O'Neill, any additions?
    Dr. O'Neill. No, I think it's been covered.

                       new standards of hiv care

    Ms. Pelosi. HRSA and NIH are currently working on 
developing new standards of care for HIV disease. It is my 
understanding that this will be available in mid-March, 
approximately.
    What plans does HRSA have to implement any recommendations 
from the committee, including the possibility of emergency 
supplemental budget requests for the remainder of 1997? I know 
our Chairman asked this question also, but in light of this 
standard of care report----
    Dr. Sumaya. Dr. O'Neill will answer that.
    Dr. O'Neill. The committee that you are referring to is 
actually under the leadership of HHS and Dr. Fauci and John Bartlett 
from Johns Hopkins in Baltimore----
    Ms. Pelosi. I know the city.
    Dr. O'Neill. Right, I know you do.
    Ms. Pelosi. Just to pick a city. [Laughter.]
    Dr. O'Neill. Just to pick a city at random.
    The committee--I believe that we will be coming up with our 
recommendations in mid-March, although it's not under my 
leadership or HRSA's leadership, but that's roughly the target 
that we're looking for.
    I think it is an absolutely critical piece of information 
that we need, because this is going to tell us what medications 
are appropriate and when they should be used. Once we have that 
information, it will be much easier for us to make projections 
and for local ADAP programs and State ADAP programs to make 
projections about what the needs are going to be, for example, 
for medications. I think once we see what these recommendations 
are, we're going to have to take a good, hard look at what our 
budget is and see what we need to do. We are absolutely 
committed to making effective treatment available to as many 
people as need it, and that's not only paying for the 
medications; that's also paying for the infrastructure to 
deliver these medications.
    Ms. Pelosi. Exactly.

                                  ADAP

    If I may, just on that point, Mr. Chairman?
    Last year the conference committee approved $100 million 
more for the purchase and the administering of the new drugs, 
and we had such a response in the community between those who 
wanted it all to be on drugs, and those who thought we should 
have gotten more into care. It's so clear, as you say, that 
it's not just the drugs but the primary care or whatever that 
goes with it to administer the drugs. So although the drugs 
show great promise and they are giving us great hope, it still 
doesn't diminish the need for the primary care that Ryan White 
provides.
    If the HIV disease becomes more of a chronic but manageable 
disease, how would the Ryan White program need to be adjusted 
to assure primary care, lab testing, and the availability of 
the new therapies? I think we could have a whole hearing on 
that question; not to raise my question to that level, but I 
would love to invite you to California, Mr. Chairman, so that 
our communities could speak to you on this issue, but since we 
have the great professional judgment that we have before us 
today, I would like to avail myself of it.
    Mr. Porter. Sure.
    Dr. Sumaya. I would like to comment on that, and then ask 
Dr. O'Neill to respond as well.
    In the latter question on the ADAP, again, you are raising 
such an important arena, and it's one that we have to follow 
very closely. I know that the Secretary in her comments 
yesterday also mentioned the need to monitor this very 
carefully, and then try to make any adjustments we need to 
make, depending on what the needs are as things unfold.
    On this latter question, I think as we look to new 
management therapies that will provide a new dimension to a 
disease that instead of being chronic, but not-too-distant 
death once you start developing symptomology, now to one that's 
going to be a very prolonged, chronic disease, one will have to 
look at the various support systems in this more prolonged 
staging of our patients. We have to see, again, what we need in 
the sense of additional therapies, additional primary care or 
specialty care depending on what new types of health problems 
emerge as one lives longer, and put that, again, in the context 
of the changing demographics that we see unfolding before us.
    So I think we're going to have that flexibility within our 
Ryan White titles. We're going to have flexibility in the way 
that States engage activities with communities, because we see 
that the needs will continue to be there.
    Dr. O'Neill?
    Dr. O'Neill. I think it's really important, when we think 
about the tremendous costs of these new medications, to think 
about the benefit that we get from them, as well. There was a 
study that was recently published in Pharmacal Economics by 
John Bartlett and Richard Moore from Johns Hopkins, looking at 
the comparative cost per life year gained; in other words, how 
much each additional year of life costs, using the triple 
combination therapy, and then looking at another series of 
commonly-done medical interventions--for example, screening 
mammography, renal hemodialysis, or coronary bypass surgery for 
50-year-old men and older. By their calculations, the cost of 
life year gained for triple therapy with AZT 3TC and Adenovir 
was $10,000 to $18,000 a year cost. Using that same mechanism, 
looking at both prostate-specific antigen or coronary bypass 
surgery, that cost was $113,000 a year. So the point is, this 
is cost-effective, particularly if you compare it to other 
commonly-done medical treatments.
    The impact on Ryan White programs is--again, we are very 
challenged to find efficiencies, with limited budgets; to help 
communities prioritize what's really important, and to 
understand what needs to be in place in order to have effective 
and comprehensive care systems capable of delivering these very 
complex treatments.
    Ms. Pelosi. Thank you, Dr. O'Neill.
    Thank you, Dr. Sumaya.
    Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Ms. Pelosi.

                Allocation of Health Professions Request

    Dr. Sumaya, you will be happy to know that I am going to 
ask you a few more questions, and when the bells next ring, we 
won't ask you to stay any longer than that.
    I want to go back to health professions for a moment. No 
one disputes the need to encourage minorities to join the 
health professions, but do you feel you've reached an 
appropriate balance when you hold the minority programs 
harmless, and allocate the $160 million cut to the other $200 
million of health professions programs?
    Dr. Sumaya. I think, again, in viewing these very, very 
difficult--I have to use the word agonizing--types of 
decisions, working within the constraints we had within the 
budget, we thought these were the best approaches we could take 
in trying to work from the Federal Government in those areas 
that the marketplace does not handle that effectively, and 
allow the marketplace to work more in what they're capable at, 
particularly in the training arenas of the various disciplines.
    We do intend to have some strategic, focused approaches in 
medicine and public health and in nursing that we hope we can 
leverage much more with the private sector in a number of these 
areas that we know still have a number of unmet needs.

                 Health Professions Staffing Reductions

    Mr. Porter. Why aren't you proposing any staffing 
reductions for health professions, if you're cutting the 
program by 55 percent?
    Dr. Sumaya. Actually, as we looked over our FTEs in the 
past few years, we had been proposing a clustered and 
consolidated approach, and we had some decreased FTEs that were tied to 
those consolidations. We didn't get the consolidation or the 
clustering, but we did get the reductions in the FTEs, so we feel that 
those have been handled before.

                             Healthy Start

    Mr. Porter. Now, you plan to use about one-third of the 
funds requested for Healthy Start to continue the original 22 
grantees, and two-thirds to support new projects. What is your 
long-term plan for Healthy Start? Have you altogether abandoned 
the concept of a time-limited demonstration?
    Dr. Sumaya. I would like to respond to that, and have Dr. 
Nora respond, as well.
    I think what we see before us is that we do this on a year-
by-year basis, and one of the underpinnings is that infant 
mortality rates are still a major problem for our country. We 
have data that show that over 300 communities in the U.S. have 
over one and a half times the average infant mortality rate. So 
we're trying to work as best we can through the Healthy Start 
program, and bringing in those 22--or up to 22--programs that 
we had in the past, see if we can have them serve as peers or 
mentors to an additional up to 30 new programs that we would 
like to have scattered around the country. We see that the 
unmet need, again, is great; hopefully, this will make a major 
dent, and we will continue to spread the information that we 
get from these particular programs to other communities that we 
still are not able to engage in our program.

                     Healthy Start/Mch Block Grant

    Mr. Porter. Press reports in January indicated that you 
were considering merging the Healthy Start program into the 
larger maternal and child health block grant. If the reports 
are true, why was the proposal ultimately rejected?
    Dr. Sumaya. I would like to have Dr. Nora answer that, 
please.
    Dr. Nora. There was some concern about targeting the 300 
communities that have more than one and a half times the 
average infant mortality rate of the country. It was decided 
that it was better to be able to put the money directly into 
those targeted communities.

                           Abstinence Program

    Mr. Porter. Let me ask two quick questions on abstinence 
grants, and then I am going to have to go vote and we will 
recess.
    Since States are required to overmatch the Federal grants 
available under the new abstinence grant program under welfare 
reform, do you expect all of them to participate? That's one 
question, do you expect all the States to participate?
    Secondly, the welfare bill is rather vague on the purposes 
for which the abstinence grants may be used. Do you think this 
new program is substantially different from the Adolescent 
Family Life Program, which is also supported by HHS?
    Dr. Sumaya. We do expect all the States to come in with 
their matching piece to this, and we are working to the letter 
of the law in the Abstinence Program. We have some guidance 
efforts that we have been working on from HRSA through the 
department, and I think also in concert with the committee, to 
make that move within the next few months.
    Dr. Nora.
    Dr. Nora. We have had numerous questions from the States 
about whether or not they should or could decline the money. 
Those kinds of questions have eased off, and we are no longer 
having them, so we do anticipate that all States will apply.
    The matching that is required is the same as for Title V, 
three State dollars for every four Federal dollars. The 
Abstinence Program is very clearly outlined in the legislation 
that was passed, and we will be relying on that legislative 
definition in our implementation of the program.
    Mr. Porter. Dr. Sumaya, let me thank you and your very able 
staff for both your patience and your good answers to our 
questions. We appreciate it very much, and we do apologize 
because of all of these votes.
    Thank you all very much.
    The subcommittee stands in recess until 10:00 a.m. 
tomorrow.
    [The following questions were submitted to be answered for 
the record:]
    Offset Folios 855 to 1155 Insert here



                                      Wednesday, February 12, 1997.

       SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

                               WITNESSES

NELBA CHAVEZ, ADMINISTRATOR
BERNARD S. ARONS, M.D., DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES
DARYL W. KADE, DIRECTOR OF FINANCIAL MANAGEMENT, OFFICE OF PROGRAM 
    SERVICES
DAVID J. MACTAS, DIRECTOR, CENTER FOR SUBSTANCE ABUSE TREATMENT
DONALD GOLDSTONE, M.D., DIRECTOR, OFFICE OF APPLIED STUDIES
STEPHANIA J. O'NEILL, M.A., ACTING DIRECTOR, CENTER FOR SUBSTANCE ABUSE 
    PREVENTION
DENNIS WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, DEPARTMENT OF 
    HEALTH AND HUMAN SERVICES
    Mr. Bonilla [assuming chair]. Good morning. The 
subcommittee will come to order.
    Chairman Porter, who of course normally chairs the 
subcommittee, is trying to juggle a hearing right now with 
Secretary of State Madeleine Albright. And he will not be here 
for at least the first portion of this hearing. My name is 
Henry Bonilla, a Member from Texas. And I will be chairing this 
portion of the subcommittee hearing.
    We'd like to welcome Dr. Chavez this morning. We'll be 
delighted to hear your testimony at this time.

                           Opening Statement

    Dr. Chavez. Thank you, Mr. Chairman and members of the 
subcommittee, thank you for the opportunity to present the 1998 
budget request for the Substance Abuse and Mental Health 
Services Administration. Our request for $2.2 billion for 1998 
is an increase of 1\1/2\ percent over the 1997 enacted level.
    I think you will find that in developing our budget, we 
have taken into consideration the evolving role of the Federal 
Government, emerging health trends, fiscal responsibility, and 
the need for SAMHSA to focus on results and program 
performance, an area I know you have a great interest in.
    Our programs touch the lives of some of our Nation's most 
vulnerable populations and have a tremendous impact on the 
Nation's service systems. For example, early findings from 
SAMHSA's Access to Community Care and Effective Services and 
Supports program, show that homeless people with mental illness 
who received services through this program showed a 70-percent 
reduction in the actual days of homelessness, and a 36-percent 
increase in the number of days worked.
    Just last fall, we released the findings from the National 
Treatment Improvement Evaluation Study. This five-year study of 
more than 5,000 people that entered addiction treatment 
programs funded by SAMHSA demonstrated an overall 50 percent 
reduction in the use of illicit substance a year after 
treatment.
    The study also noted large reductions in criminal behavior 
and an increase in gainful employment. When it is done right, 
we know addiction treatment and mental health services are 
effective. They improve lives and save resources across a broad 
spectrum of public sector programs.
    However, almost half of the 3.5 million people in serious 
need do not receive treatment for drug dependence. And it is a 
national tragedy that two-thirds of young people in need of 
mental health services are not receiving help. Without help, 
these problems can lead to school failure, alcohol and other 
drug use, family discord, violence, crime, and even suicide.
    To help improve services to children, SAMHSA launched a 
Starting Early-Starting Smart collaborative effort. I say 
collaborative because SAMHSA is working with the Casey Family 
Program and the Department of Education in order to bring to 
bear all of the resources available in selected communities to 
provide coordinated systems of quality care for children and 
their families from birth to age seven.
    SAMHSA initiated the Starting Early-Starting Smart program 
because so many social and economic factors impact children's 
mental health and their potential for substance abuse. I 
clearly see this collaboration as the beginning of a much-
needed effort to improve the lives of children and ultimately 
as the first defense in preventing drug abuse. Preventing and 
reducing drug abuse in the country is going to require a long-
term commitment of leadership, new ideas and resources. And our 
past work has shown, we cannot focus on just one drug alone. 
Each new generation of youth needs to be immunized against all 
forms of substance abuse, from methamphetamine to marijuana and 
from alcohol to tobacco. And today's social trends make this 
generation of youth even more vulnerable.
    The proponents of legalization are better organized than 
ever before. Kids report drugs are easily obtained, and the 
perception of harm of drug use is on the decline among youth. 
And for the first time ever, we're facing a generation of 
youth, many of whose well-educated parents tried marijuana in 
their own youth without any perceived negative consequences. 
This single factor alone makes the problem unique and very 
difficult, because these parents don't know how to tell their 
own children not to use marijuana, or don't think it's bad that 
their kids use marijuana.
    The good news is that public and private sector investments 
in science-based research have developed substance abuse 
prevention strategies that work. For example, Project Star, 
developed by the University of California, demonstrated a 30-
percent reduction in marijuana use, a 25-percent reduction in 
cigarette use, and a 20-percent reduction in alcohol among 
students who began the program in junior high and whose results 
were measured in their senior year of high school.
    Obviously, parents and other caring adults, peers, school 
and other youth serving institutions and the media play 
influential roles in reducing youth substance abuse. And 
Federal, State, and local governments can help by fostering a 
supportive environment, and providing parents with the tools 
they need, and with strategic investments.
    In FY 1997, SAMHSA initiated a new approach toward youth 
substance abuse prevention that takes advantage of the unique 
role of the Federal government. In FY 1998, we are proposing to 
expand on this year's work and increase SAMHSA's support to $98 
million in order to build a sustained initiative. Approximately 
$63 million will be dedicated to State Incentive Grants and to 
developing a regional approach to providing state of the art 
prevention knowledge and technical assistance for implementing 
effective programs. The State Incentive Grants will call upon 
governors to develop comprehensive State-wide strategies that 
identify and take advantage of all available funding streams 
dedicated to reducing youth substance abuse.
    To measure outcomes, SAMHSA is dedicating approximately $28 
million to develop State level estimates using SAMHSA's 
National Household Survey on Drug Abuse. The Household Survey 
now provides data for making national estimates on the 
prevalence of substance abuse in the population age 12 and 
older, as well as information on behavior attitudes and the 
household environment. This new investment will enable us to 
make State level estimates in these same areas with a focus on 
youth. These State estimates will give governors and us 
information about where efforts are succeeding and where 
improvement is needed.
    Clearly, there is a need for continued Federal leadership 
and outcome measurement in other areas of substance abuse 
prevention, addiction treatment, and mental health services. In 
particular, SAMHSA's new Knowledge Development and Application 
program is designed to ask and develop questions or answers to 
critical questions of immediate concern to providers and policy 
makers, and to ensure that what is learned is used to improve 
policies and techniques in State systems, community services 
and individual practice.
    SAMHSA intends to devote more than half of the new 1998 
Knowledge Development and Application funds to ensure that new 
and current knowledge is actually used in ways that improve 
services and save money. The FY 1998 budget request proposes 
$137 million to fund new competitive Knowledge Development and 
Application grants. Another tactic available for implementing 
new funding is SAMHSA's Block Grant program. Our 1998 request 
proposes to modify these block grants into Performance 
Partnership Block Grants. We are already working with some 
States on private projects to identify performance measures, 
develop data reporting systems, and establish a sound base for 
outcome oriented Federal-state partnerships.
    In conclusion, over the years, our work has demonstrated 
that substance abuse prevention, addiction treatment and mental 
health services can be highly effective. Yet, just like 
interventions for heart disease, cancer and diabetes, these 
services can and must be improved. SAMHSA's Knowledge 
Development and Application program is the Federal tool 
specifically designed to make progress and improve services in 
our Nation's communities. And it is very clear that continuous 
Federal leadership in this area is needed, because each new 
generation of American youth will present us with new 
challenges. Each new scientific breakthrough will provide us 
new options. And each new option will need to be translated to 
everyday real life practice.
    If we are to maintain our gains and improve the quality and 
availability of prevention, early intervention, treatment and 
rehabilitative services for substance abuse and mental illness, 
including those individuals who suffer from co-occurring 
disorders. I am both optimistic and enthusiastic about what the 
future holds for our ability to address some of the Nation's 
most costly and devastating problems. The directions we have 
outlined for SAMHSA's future positions the Agency to best meet 
the challenges.
    I thank you for the opportunity to present the 1998 budget 
request for SAMHSA. We will be pleased to answer any questions 
you may have.
    [The prepared statement follows:]
    Offset Folios 1165 to 1168 insert here



                       Introduction of Witnesses

    Dr. Chavez. I would like to introduce the staff members who 
are with me today. To my far right is Dennis Williams, from 
Budget for HHS.
    Mr. Bonilla. That's Dennis' permanent chair.
    Dr. Chavez. Yes, I remember last year I kept calling him 
Bill, and I apologize. [Laughter.]
    David Mactas, Director of the Center for Substance Abuse 
Treatment, and Daryl Kade, Director of the Division of 
Financial Management, SAMHSA.
    To my far left is Dr. Goldstone, Director of the Office of 
Applied Studies, Stephania O'Neill, the interim Director of the 
Center for Substance Abuse Prevention. I believe most of you 
know that Dr. Johnson retired in December after 30 years of 
government service. And Dr. Arons, the Director of the center 
for Mental Health Service. Thank you.
    Mr. Bonilla. Thank you, and welcome to everyone.

                            synar amendment

    Dr. Chavez, thank you for your testimony. I'd like to begin 
and talk about the Synar Amendment that was passed in Congress 
in 1992, a year before I got here, and for many of us like me 
who were not here, I'd like to just briefly describe the law. 
The Synar Amendment requires States that receive Federal funds 
for prevention and treatment of substance abuse to have in 
place and enforce laws prohibiting the sale and distribution of 
tobacco to minors. States are further required to conduct 
random, unannounced inspections to ensure compliance with this 
law.
    In 1996, several years after the law was passed, HHS 
finally issued regulations implementing the law. States are 
required to meet certain goals or lose their substance abuse 
block grants. In addition, States are required to show progress 
toward meeting a target rate of illegal sales to minors of less 
than 20 percent as shown by inspections. This legislation has 
received widespread support, and I believe it represents sound 
public policy. There's not a member of Congress that you'll 
find anywhere who supports smoking among young people in this 
country.
    To get a better understanding of this program, I'd like to 
ask you the following questions. And before doing so, I'd like 
to say that if these answers must be provided by letter, I 
would just appreciate a response to the subcommittee before we 
begin our consideration for the next fiscal year's budget of 
1998.
    First of all, Dr. Chavez, is it true that SAMHSA requires 
each State to submit an annual report describing the States' 
activities to curb tobacco use among minors, and the success 
the State has achieved in order to receive its share of the 
$1.8 billion from SAMHSA's block grants.
    Dr. Chavez. Congressman Bonilla, the Synar Amendment, asyou 
indicated, focuses reducing sales of tobacco to minors. One of the 
things that has happened is that all the States now have a law which 
prohibits sales to minors. One of the requirements that has been 
imposed on the States has been the inspection of outlets. This is part 
of their reporting requirement when they submit their Block Grants 
application.
    One of the things that I would like to point out, and then 
I'm going to have Ms. O'Neill expand on is the examples of the 
States that have reduced their sales to minors. In California, 
for example, they went from a 52 percent violation rate to 29 
percent in two years. South Dakota went from 84 percent to 31 
percent in two years. And Minnesota went from 67 percent to 30 
percent in two years.
    The States have embarked on enforcing this law, and the 
success the States have been able to achieve in the previous 
year. So we do have that, and we will submit additional 
information on the Synar Amendment.
    [The information follows:]
    Offset Folios 1172 to 1174 Insert here



    Mr. Bonilla. Thank you. I have an additional question about 
the laws passed by States. I want just an elaboration on 
exactly what they cover.
    In order to receive these grants, most States pass laws 
prohibiting the sale and distributing of tobacco products to 
persons under the age of 18, as well as enforce the law in a 
stringent manner to reduce tobacco use among minors, and 
annually conduct random inspections of retail stores to ensure 
compliance? Must they pass laws covering these three areas?
    Dr. Chavez. Yes States will----
    Mr. Bonilla. Ms. O'Neill is nodding. I don't know if that's 
a simple yes or what.
    Dr. Chavez. Congressman Bonilla, let me respond to that. 
States are required, in their first applicable fiscal year and 
all subsequent fiscal years, to have in place a law prohibiting 
the sale or distribution of tobacco products to minors. So the 
answer to your question is yes.
    All States were in compliance with this requirement as of 
fiscal year 1995. The Department allows the States the 
flexibility to determine which strategies are most appropriate 
for meeting the compliance standards and enforcement 
requirements of the regulations.
    Mr. Bonilla. I have a final question that has a couple of 
parts to it regarding this issue. Beginning this year, States 
were required to negotiate with HHS on an interim performance 
target for each fiscal year that will move States in the 
direction of a goal of reducing youth sales to less than 20 
percent as we've discussed here this morning.
    How were these targets developed, is the first part of my 
question, who negotiated these targets with the States? Are 
these targets now in place for all the States that were 
required to negotiate these targets, and have these targets 
been made available to the public?
    Dr. Chavez. All States will be required to meet the 20 
percent by the year 2002. In relation to how these targets were 
negotiated, it is my understanding that this came through a 
process that focused on the Healthy People 2000. However, there 
are probably some other issues that were involved in this, and 
we will get that information to you.
    Mr. Bonilla. I appreciate that very much, Dr. Chavez.
    I'd now like to yield to Mr. Stokes. And Mr. Stokes, I know 
that your voice is not quite what it normally is. And I'd like 
to ask if you'd like to use the microphone to question this 
morning, or would you like to submit your questions in writing.
    Mr. Stokes. I'll submit them for the record.
    Mr. Bonilla. Very good, Mr. Stokes. Thank you very much.
    Mr. Wicker?

            federal spending on drug prevention & treatment

    Mr. Wicker. Thank you, Mr. Chairman.
    Dr. Chavez, it is wonderful to have you here today. You 
certainly have a very important and difficult task in our 
Government, and I appreciate your efforts.
    I have available information about a General Accounting 
Office study last year, which found that no Federal agency 
maintained information regarding total Federal spending on drug 
prevention and treatment activities. In addition, the GAO 
projected $15.4 billion for fiscal year 1996 Federal spending 
for substance abuse treatment, prevention and supply 
interdiction.
    I'm curious to know if your agency has taken any actions to 
streamline any of these programs, and to address the question 
of overlap. And I note that the committee in its report last 
year commented on the dearth of comprehensive information on 
such activities across the entire Federal Government.
    Dr. Chavez. Congressman Wicker, thank you very much. It's 
good to see you again this year, and I will turn this question 
over to Daryl Kade, who is the Director of Budget.
    Ms. Kade. We have a very close relationship with ONDCP, 
since we're the lead agency for treatment. Our entire budgets 
is scored as drug-related.
    There may be instances in the supply side agencies where 
not all of their budgets are scored. But ours have not only 
been scored entirely for drugs, but we break it down by 
prevention and treatment, and by the goals and the strategy. 
We're basically covered by goal one and goal three.
    So the finding with regard to accounting for drug dollars 
really doesn't apply to us. We are totally accounted for.
    In terms of overlap, two years ago, we consolidated many of 
our programs into three KDAs for each of the centers, knowledge 
development and application. And in doing so, we really 
reconfigured the mission of the agency and applied that to our 
programs, both the old demonstration programs as well as the 
block grants.
    So in terms of overlap, we are the lead agency in 
treatment. We have been streamlining our programs. It was 
evident in the 1996 budget. That's where the major changes 
occurred and we've carried that through in 1997 and 1998.
    We've also streamlined our administrative operations as 
well, and we submitted a reorganization plan to the Congress 
last April and published it in the Federal Register. So I don't 
know the particulars of the GAO report, but I think in this 
case, SAMHSA is squeaky clean.
    Mr. Wicker. Well, perhaps we could submit that report to 
the agency for formal comment in writing.
    Ms. O'Neill. Sure.

                       prevention success stories

    Mr. Wicker. And I would simply reiterate that the committee 
expressed concern about overlap Government-wide.
    My only other question is in the area of prevention, we 
have devoted a great deal of resources. Can you give us your 
best success story? What can we go back to tell our town 
meetings the Government has done that's worked terrifically to 
prevent drug use?
    Dr. Chavez. Congressman Wicker, I will have Ms. O'Neill 
respond to that.
    Ms. O'Neill. I'm very happy you asked that question. I have 
some very good news to relate, I believe.
    As you know, CSAP has been for the last 10 years doing 
demonstration programs, evaluating strategies, interventions, 
models for different targeted populations in this country. And 
on a parallel track, NIDA for NIH has been doing research.
    After a decade now, 10 years, and that isn't really such a 
terribly long time in this kind of endeavor, we really are able 
now at this time to talk about successful prevention, 
interventions, successful practice, and that we do know the 
kinds of things that make good programming.
    We can give you specific examples of certain programs with 
percentages. And if you want me to cite a couple of those now, 
I can, or I can forward some of those for the record. But there 
are many specific examples of programs. Would you want me to do 
that now?
    Mr. Wicker. I really would.
    Ms. O'Neill. Okay.
    Mr. Wicker. We've got a room full of citizens here, and 
you've got my attention.
    Ms. O'Neill. Okay. In some of the programs under the Boys 
and Girls Clubs of America that CSAP has sponsored by are 
showing multiple outcomes. One of the biggest outcomes being a 
22 percent decreased drug activity, folks in that program; 25 
percent less crack present in the communities that have that 
program. We basically found that marijuana use and alcohol use 
in another program called the Child Development Project 
basically reduced alcohol, underage alcohol use by 7 percent.
    One of the ones that I'm particularly excited about is a 
school-based prevention program which reported that 92 percent 
of the children going through this program, improved their 
academic performance. Now, I know I don't have to explain to 
anyone the importance of succeeding in school as a protective 
factor against the use of substances. It's just absolutely been 
correlated by the research and by our demonstration program.
    In the community partnerships one of the successful 
outcomes, and let me look, I had a couple, some of the things 
that I think speaks to success, are the statistics about 
closing down crack houses, being sure that the sale and the 
availability of drugs in these community partnership 
communities has decreased. What I think is extremely 
significant is that 60 percent, 60 percent of those 
partnerships remain today, even though the Federal funding has 
ceased.
    And I think that's a testimonial to say, we like what we're 
getting and this works for us in reducing substance abuse.
    I think we're in a very exciting time, because we do know, 
and we have learned a lot in this area.
    Mr. Wicker. Do you have any information about faith or 
church-based programs?
    Ms. O'Neill. Yes. There are some of our programs 
associated, especially with high risk youth, that has been 
significant. I don't have it right on hand, but I can get some 
of that to you.
    Mr. Wicker. If you could, it would be most interesting. And 
if you have any comparison about the relative success----
    Ms. O'Neill. Let me add something that perhaps you're not 
aware that we're doing right now, which I think may answer what 
you're talking about. We know that we have had a great number 
of these youth programs. And in 1995, we decided to do an 
extremely extensive, rigorous cross-site evaluation of those 
programs. We are in the process of doing that right now.
    What's really significant about this is, again, it is an 
extremely strenuous evaluation design, and we will be looking 
at 6,000 children who have participated in these programs. And 
we will be comparing them with at least 4,000 who did not 
participate in these kinds of programs. The different services, 
interventions, community involvement, like faith communities, 
will be looked at. And what we're going to be able to do is to 
say, what is it, what has worked best there, and what are the 
ingredients. We will have preliminary data on this in 1997, 
September of 1997.
    And the other piece of this I think is extremely important. 
The following of these children for two years after they're no 
longer receiving any services. This is also something we've 
never really done to this extent before, and that's going to 
give us some very important information.
    [The information follows:]

      Drug Abuse Prevention Programs Involving the Faith Community

    CSAP has provided substance abuse prevention technical 
assistance to over 20 different mainstream faith denominations 
and supports numerous projects involving the Faith Community in 
substance abuse prevention efforts. Because of the close nature 
of their involvement in the community, churches are frequently 
ideal sponsors of substance abuse prevention programs.
    One community partnership prevention program in 
Tallahassee, FL, supports a network of six churches in their 
development of a county-wide initiative to implement a drug 
prevention and educational program. Areas of focus include: 
mentorship, intra-church coordination, youth for excellence, 
parent education, school enrichment, male/family emphasis, and 
summer/after school program.
    The Creating Lasting Connections project in Louisville 
involves families in five church communities identified as 
being at high-risk for substance abuse, and program staff. 
These urban, suburban and rural families participate in an 8- 
to 10-week program which includes family-oriented social 
activities, drug information and education, and training to 
improve parenting and family management skills. Evaluation of 
the program found short-term and sustained decreases in the 
frequency of youth alcohol and drug use when parents were 
actively involved in the program; significant short-term 
reductions in parents' alcohol use; and improved family 
relationships. In 1996, this program was selected as an 
Exemplary Substance Abuse Prevention Project and was included 
in the YouthNet of the International Youth Foundations enabling 
world wide replication in Faith Communities.

              youth substance abuse prevention initiative

    Dr. Chavez. Congressman Wicker, may I follow up on some of 
the issues that Ms. O'Neill has mentioned?
    Basically, one of the things that we are doing, and as Ms. 
O'Neill indicated, we will have many, or some results on cross-
site evaluations. There's a couple that I'd like to just report 
on, and then your question, I think, leads into our Youth 
Initiative, which is targeted specifically to some of the 
issues that you've raised.
    Ms. O'Neill already mentioned the national evaluation of 
the Community Partnership programs. Basically what this is 
doing is looking at 24 Community Partnerships and matching, and 
doing a comparison with 24 other matching communities to see 
the results and how effective those are. We do know at this 
point that of those funded, 60 percent have been continued by 
communities. A Community Partnership brings together people 
from all segments of the population into not only identifying 
what some of the issues are, but working towards solving some 
of those problems.
    The other one is the national evaluation of the Community 
Coalition Program. Its goal is to determine the effect of 
Community Coalitions on substance abuse as they relate to 
health and safety factors. This study will give the largest 
indicator data base of its kind in the United States, and will 
allow us to monitor the impact of this program throughout the 
country.
    Finally, let me just mention the other one that I think is 
really critical to look at some of our High Risk Programs that 
were funded in 1994 and 1995, and measure the effects of 45 
programs across the United States. What we are doing here is 
collecting standardized data of the prevention and behavioral 
outcomes from 6,000 youth in the program, and 4,000 in a 
comparison group. Preliminary results of these programs will be 
made available in September. We will be forwarding the 
information to you and other members of the Committee.
    Another area that I think is very important, as indicated 
earlier by Ms. O'Neill, there has been a lot of work that has 
been done in the past 10 years in the area of prevention. The 
field of prevention knows more now than it did 10 years ago. We 
have learned not only from the research that has been done, but 
also by the experiences that people have had throughout the 
country, as well as input and direction from the States and the 
leadership within the States.
    We do know that many of the things that are happening today 
are a result of changes in our environment, changes in our 
norms, etc. We also know that there is an upward swing in the 
use of marijuana among youth between the ages of 12 and 17. And 
many of these reasons, I know you're aware of, have a lot to do 
with the perception of harm. This has decreased, and the 
national and media attention to this area has diminished. I'm 
sure most of you are aware that through the internet, you can 
access how to roll a joint and how to grow marijuana, and how 
to order it through the mail.
    There has been more emphasis on crack and cocaine. We also 
have issues in terms of parents not being very comfortable or 
not really knowing how to talk to their children about the use 
of marijuana. The movement that we have seen in this country 
toward the legalization, the glamorization of this and the 
availability, it's cheap, it's available. Most kids will tell 
you that by the time they're 17 years old, close to 70 percent 
of them have been approached to buy marijuana and/or other 
drugs.
    Taking this information and much of the other information 
that we have available, what we're looking at is bringing 
together some of the best strategies we know that are out 
there. What is it that we know, how do you pull all of that 
together so that we have a four-pronged initiative for drug use 
among young people.
    What we're looking at is that we're focusing on what are 
some of the things, what are some of the strategies that we 
know are very effective in developing a menu with outcomes that 
States will be allowed to develop their own initiatives, 
however selecting from this menu of strategies that we know 
work, and then beginning to hold them accountable in 
partnership.
    The other piece of that which we're working very closely 
with ONDCP is looking at a focusing on the media and not just 
your usual media, but really involving young people from the 
ground up. The third component is the evaluation and looking at 
outcomes and data. And I'd like Ms. O'Neill or Dr. Goldstone to maybe 
touch on this a little bit more, and Mr. Mactas. Because I know that 
some of this is also very related.
    Mr. Bonilla. Dr. Chavez, if I could interrupt for one 
second. In the interest of allowing other members to ask 
questions, perhaps the additional information, could be 
submitted for the record if it's all right with Mr. Wicker.
    Mr. Wicker. Sure.
    Mr. Bonilla. Mr. Wicker would, and all of us would love to 
hear about that. We're just trying to get everyone's questions 
in this morning. I appreciate that.
    [The information follows:]
    Offset Folios 1190 to 1191 Insert here



    Mr. Bonilla. Ms. DeLauro?

                              managed care

    Ms. DeLauro. Good morning.
    Let me just ask a question about managed care. Because more 
and more Americans are being served via managed care what have 
been the effects of managed care on the patients afflicted by 
substance abuse and mental health problems? And have you had to 
adjust, or how have you had to adjust your knowledge 
development application grants to adapt to this changing health 
care landscape? What's happening to these populations of people 
with the whole onslaught of managed care?
    Dr. Chavez. Thank you, Congresswoman DeLauro. Let me begin 
to respond to your question, and then I will let the directors 
jump in, because I know they are wanting to jump in on this 
one.
    First of all, we know that as of today we have 140 million 
Americans that are covered by managed care in the area of 
substance abuse and mental health. We also know that there is 
great anxiety among consumers, providers, the States, and 
families, about the managed care movement and the impact that 
this has had on individuals who have persistent and serious 
mental problems, as well as serious and persistent drug 
problems.
    Some States have made an orderly transition into a managed 
care system, and some States are still having some difficulty. 
Some of the problems that we are experiencing, we, the American 
people, in relation to this population, is the issue, and I'm 
going to briefly just cover these and then let Dr. Arons and 
Mr. Mactas participate, issues in terms of access. Access in 
terms of the kinds of appropriate rates of penetration for 
mental health and substance abuse services, particularly the 
big question here is, how can minorities and ethnic groups be 
assured access to culturally specific programs that target this 
particular population, populations that are seriously mentally 
ill and have serious drug abuse problems.
    The other issues are the quality, and really looking at how 
we can assure that good quality is maintained, and that it 
allows enough creativity so that because of the constraints or 
cost, the impacts that this has in terms of quality of care, 
and then the issue of performance monitoring outcomes, consumer 
rights, these are also issues in terms of consumer rights, 
grievances. Many of these areas that we have been very, very 
concerned about, SAMHSA has taken a very strong leadership role 
in this area, in that we have developed several, we're 
consolidating a lot of the information and we've been able to 
provide consultation and work with the States very carefully in 
providing information in the managed care area, as well as 
beginning to identify what are some of the needs that States 
have.
    I'll ask Dr. Arons to talk a little bit about what is being 
done specifically in the area of mental health consumer report 
cards.
    Dr. Arons. I think this is an excellent example of the 
Center for Mental Health Services, and why we exist as part of 
the Federal Government. We can have the best information, the 
best research to have the best medications about interventions 
for mental illness, we can have psychotherapeutic 
interventions, and yet here we have an example with managed 
care of a change in the system of care that comes along and 
suddenly makes all that we know difficult to get to the people 
who need it.
    So part of what we do at the Center for Mental Health 
Services is try to develop the knowledge, make it available to 
individuals and to communities and States throughout the 
country, so that we can best gear the system and improve the 
system to assure quality of care for all those who need it and 
thereby improving the lives of all Americans, but especially 
those with mental illness and their families.
    In the area of managed care, we have a number of knowledge 
development and application activities going on, trying to get 
the best information about what is working, how to assure the 
quality and so forth. For example, we have a program in 
Pittsburgh which is looking at children covered under Medicaid 
who are being served either in managed care or in a fee for 
service system. And looking at what happens to those children. 
And we're already, we try to see what we're finding very early 
in these studies, so that we don't wait until they're finished 
at the end. It's already clear that those individuals with 
mental illness end up leaving the managed care program for the 
fee for service program fairly quickly. And we're looking at 
why that would be the case.
    We also have a number of other projects across SAMHSA. We 
have 15-5 in the area of mental illness evaluating existing 
managed care programs and looking at a variety of clinical 
outcomes, as well as outcomes that are relevant to the 
community.

                    managed care vs. fee for service

    Ms. DeLauro. Just in terms of the fee for service--if I may 
follow up on that. Is that then, that cost goes up for folks 
who, as you said, move quickly into managed care from fee for 
service. The cost for the care is increased?
    Dr. Arons. Historically, fee for service systems have been 
more expensive than managed care. But these days it's very hard 
to find any kind of health care, including our own through the 
Federal Government, that's not managed in some way. We are 
collecting very accurate cost data. We think that managed care 
has the potential to follow up on the kinds of systems of care 
that we developed in ourlegacy programs, the Community Support 
Program, and give comprehensive services to individuals with mental 
illness or children with serious emotional disturbances. It should be 
possible to do that and still provide good quality care.
    Ms. DeLauro. I'm concerned in this area, because I think, 
as we've seen in other areas--let me step back a second and say 
that I worked very hard four years ago to try to see that we 
bring down the cost of health care and that didn't work. So 
let's try to take some different approaches.
    On the other hand, what I'm concerned about as well as the 
cost cutting aspects of managed care where we are immediately, 
immediately seeing what I call abuses. First, there were the 
drive-through childbirths. Wow we're seeing drive-through 
mastectomies. So we need to address these abuses now, to send 
the appropriate signals to managed care that say that the 
bottom line is just not the only health care standard. We've 
got to be looking at what happens to these populations of 
people, particularly in the area of mental health, where we 
already know that folks suffer not only from stigma, but also 
are discriminated against in terms of their ability to get 
insurance and everything else, and then what is happening here 
with these populations of folks, and are we going to find a 
much larger problem than we are currently dealing with, the 
cost of which then is even graver.
    So I'm particularly interested that we follow this in some 
way that makes sense for people.
    Dr. Arons. Just one brief response, Congresswoman DeLauro, 
to your statement is that we have looked very carefully at the 
appropriate role for the Federal agency to carefully use the 
funds that are available to us. One of the things we think is 
most important is providing individuals, communities, and 
families the tools they need to judge whether a particular 
managed care company or a particular State program is good for 
them. We've put a lot of effort into developing what we call a 
report card, a consumer-driven, family-driven report card, so 
that communities can use it to judge their own systems.
    Ms. DeLauro. Mr. Chairman, do I have time for another 
question, or is my time up?
    Mr. Bonilla. You have additional minutes remaining.

           mental health performance partnership block grant

    Ms. DeLauro. Oh, thank you.
    I just wanted to pursue the mental health area for a 
moment. The performance partnership block grant in mental 
health has been straightlined for the last couple of years. 
Costs, however, have not been stagnant. What are the States 
losing by not receiving any increases in this area? And let me 
ask my second question on this, which is about children's 
mental health services, which received an increase last year of 
about $10 million. It's a lot less this time around.
    Why is this and where are we in terms of children's mental 
health services?
    Dr. Arons. Let me answer each question separately, because 
these are two different programs. The Performance Partnership 
Block Grant for mental health, community mental health, as you 
mentioned, has been approximately the same for the last several 
years. This program gives the States flexibility and some 
leverage to promote community systems of mental health care. 
We've been very pleased with its successes. Even with a 
straight line budget, we've been able to see some important 
successes in States moving towards community based care and 
improving their systems of care. States use this in a variety 
of ways, because it is from their point of a view a little bit 
more flexible than some of the other funds they may have within 
their State.
    For example, some States use these funds for targeting 
services to children with emotional disturbances. In other 
States, we've seen the funds used to supplement providers in 
rural areas, and to try to attract providers to rural areas 
where there are no mental health specialists.
    In the children's area, the Children's Mental Health 
Services Program, has been a very successful approach to trying 
to spur communities on. We currently have 22 grants in 
communities that are putting into place comprehensive community 
based family focused systems of care for children. We have a 
request for more proposals this year with the additional funds 
that were appropriated in FY 97, we expect to fund another 
seven to nine grants.
    One last point we're collecting information from this 
program and making that available to communities throughout the 
country through our Knowledge Exchange Network. Through our 800 
number and worldwide web site we are making this information 
available so all communities can improve the system of care for 
their children. Where we know that information that has been 
discovered through research is not getting to the children and 
families who need it.
    Ms. DeLauro. Are those sites through schools, or are they 
at different locations?
    Dr. Arons. These are comprehensive programs that try to 
bring in schools, the juvenile justice system, the child 
welfare system, all child related services that exist in a 
community.
    Ms. DeLauro. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Bonilla. Thank you, Ms. DeLauro.
    Mrs. Northup?

                      synar amendment regulations

    Mrs. Northup. Dr. Chavez and Ms. O'Neill, I'd like to 
return to the Synar Amendment. I asked about it yesterday, I 
asked the Secretary of HHS about it. And to be honest, I felt 
like there was a real lack of information, almost an awareness. 
There were a couple of lines that were read back to me from a 
report.
    But the Synar Amendment, in my opinion, is the way to 
reduce youth access to tobacco. And the Cabinet was very slow 
in promulgating the regulations. I think they were maybe a year 
and a half or two years longer than they were supposed to be, 
which pushed every single State back. The Secretary said every 
State was now in compliance. They were only in compliance 
insofar as they now have a baseline.
    None of the actual progress has even begun, because of the 
slowness in involving this agency with the Synar regulation. 
And in my opinion, this is what's created the demand or even 
the interest in FDA regulation. I'm not somebody that believes 
FDA is the best way. In fact, all past progress in keeping 
youth from purchasing tobacco is because of what is done in the 
community where the child purchases cigarettes. They either 
become engaged in that or they don't.
    And nothing we can do up here makes that more likely to 
occur, unless every State and every community becomes engaged 
in it. It requires States to engage in a discussion thathasn't 
gone on before in many of the States. Many of the States actually 
passed a law that complied with Synar, but really won't produce the 
results. And they know this, and they realize now they're going to have 
to go back and say, for example, pass a law that attacks the question 
of vending machines and attacks other questions of compliance.
    I like the idea that Synar does not prescribe to States 
whether they get involved in licensing or not. Our problem is 
not what their law is. It's just whether or not they achieve 
the results of decreasing youth access.
    My feeling is because FDA has been put now in this process, 
that this agency has largely become disinterested in Synar. You 
almost don't hear it discussed at the State level any more. The 
fact that you all have not been very aggressive in what the 
baselines are, in negotiating what the target rates are for 
each year, I mean the fact is, they almost feel as though maybe 
those funds are no longer in danger, it has decreased a lot of 
the impetus that was there when Synar was first passed.
    Dr. Chavez. Congresswoman Northup, thank you very much for 
your comments and question.
    When the Synar, when the regulations were finally 
established, it is my understanding that there were over 3,000 
comments from throughout the United States that had to be 
incorporated into the regulations. The States are held 
accountable if they don't comply with the piece that we're 
responsible for, which is the monitoring of drug patterns, 
sorry, tobacco samples in terms of tobacco use.
    The 20 percent, as I indicated earlier, that has to be 
reached by all the States by the year 2002, is part of the 
Healthy People goals and objectives that were established.
    Mrs. Northup. I'm very familiar with the program. I've 
worked very closely with it in Kentucky. My objection is with 
your administration of Synar. First of all, I thought that the 
law was very clear about what target, I mean, it's a 
mathematical formula. Whatever Kentucky was last year, figure 
out the formula, crank out those numbers, and you know what 
their target is this year.
    But I don't believe that the Department has very 
aggressively established what their process is going to be and 
how it will hold States accountable for reaching those targets. 
You know, there have been delays every step of the way. And I 
don't believe it was just the comment section part of the 
process that held it up. It's been held up from the very onset.
    And we might have different results and maybe not the need 
for FDA intervention that we have today. In fact, I tell you 
that the Secretary pointed to the lack of progress as the 
reason we needed FDA. And the only reason there's a lack of 
progress is because your Department has never implemented Synar 
along any sort of the time frames that were a part of that 
bill.
    Ms. O'Neill. Congresswoman Northup, I think that you were 
right about the final rules implementing the Synar Amendment 
being released in mid-year. And that resulted in some delays. 
And we would agree with that. Also that SAMHSA had a tremendous 
amount of work to establish the new system, in reviewing, 
approving, negotiating the States' current and future tobacco 
enforcement efforts.
    CSAP has the Synar regulation work to do. And I've been 
acting director for one month, and have met probably 10 times 
with our lead person working on Synar. Since January of 1996, 
he's informed me that the States are making tremendous progress 
in complying with the sampling and the inspection requirements. 
However, some of the applications were not received as soon as 
we would have liked them from the States. Some of it involved 
working with the States and helping them through that process. 
All of those applications are in now. We are really very clear 
with the States from the Department and from SAMHSA, that 
abiding by the Synar law with the possible consequences of 
block grant reduction, is for real.
    Mrs. Northup. Possible consequences?
    Ms. O'Neill. No, the consequences, sorry.

                             synar baseline

    Mrs. Northup. When would you expect States to be in 
compliance? If the Synar baseline was established, was it in 
the middle of 1995 every State was supposed to have a baseline?
    Ms. O'Neill. Well, what's happened because of the delay in 
getting, my understanding of this now, again, is that there was 
some flexibility and leeway for the States to begin to make 
sure that the random inspections were complete in order to 
establish the baseline. Most are already established, and that 
serves as the first step in enforcement.
    Mrs. Northup. Right.
    Ms. O'Neill. And that needed to be done. And that had been 
delayed. That had been delayed.
    Mrs. Northup. Well, I think that all those baselines now 
are almost a year old. So the second round should be coming in 
the next six months. So would you expect in the next six months 
to start informing States that their block grants are in 
jeopardy if they don't resolve their youth access to tobacco 
problem?
    Dr. Chavez. Congresswoman, earlier in the year we had two 
States that were not in compliance. They were notified, we 
worked with them, they are now in compliance. Notification is 
very clear that x number of months, you are not in compliance, 
then your block grant will be reduced by the Secretary.
    We also submitted to the Secretary if these couple of 
States were not in compliance information so that she could 
directly speak with the governors in terms of what the 
consequences were going to be. So we have every State now, as 
of today.
    Mrs. Northup. But they're only in compliance in that 
they've established their baseline.
    Ms. O'Neill. That's correct.
    Mrs. Northup. Okay. So 12 months after they establish their 
baseline, they have to come in with the next test. And for many 
of those, that's momentarily.
    Dr. Chavez. And that is momentarily, you are correct, and 
that is in process right now in relation to the States that are 
submitting their application for block grant.
    Mrs. Northup. Okay.
    Dr. Chavez. And may I please add something else. We are 
working very closely and very carefully with the States, only 
the States, but also the State associations, in helping States 
come into compliance, monitor this and make sure that tobacco 
use by minors is reduced.
    Mrs. Northup. I'm still having a little bit of trouble. If 
a particular State established a baseline 12 months ago, then 
they are now ready to give us what their first year results 
are. Have any of them given us a second year? Have any States 
provided us the next round of what their results are?
    Dr. Chavez. I will submit that information.
    [The information follows:]

    Each State is responsible for establishing a baseline 
violation rate as part of its Block Grant application, and for 
negotiating yearly targets as it progresses toward the ultimate 
goal of a maximum violation rate of 20 percent. The first 
required reporting of State baseline violation rates (i.e., the 
rate at which outlets in the State are likely to sell tobacco 
products to minors under the age of 18, using a statistically 
valid sample) is as part of the FY 1997 Block Grant 
application. This application reported on tobacco activities 
conducted in FY 1996. To date, SAMHSA has received 40 
applications from the States and jurisdictions, with reported 
violation rates as high as 73 percent (Louisiana) and as low as 
7 percent (Florida).

    Mrs. Northup. And my second question is, if they have not 
made the mathematical improvement that they were supposed to, 
are you going to carry out the prohibitions or the limitations 
on the money that were a part of the Synar amendment?
    Dr. Chavez. Congresswoman, the answer to your question is 
yes.
    Mrs. Northup. I guess I've used up all my time. I had a 
couple of questions.
    Mr. Bonilla. Thank you, Mrs. Northup.
    Thank you, Dr. Chavez, and your associates, for being here 
today. We appreciate your testimony very much.
    Mr. Porter regrets again not being able to be here today, 
and he will be submitting extensive questions on outcomes and 
results for people. So you can expect that to arrive shortly.
    Dr. Chavez. Congressman Bonilla, I'd like to thank you and 
the other members of the Committee on behalf of SAMHSA. Thank 
you so much.
    Mr. Bonilla. Thank you.
    [The following questions were submitted to be answered for 
the record:]
    Offset Folios 1209 to 1426/1700 Insert Here





                           W I T N E S S E S

                               __________
                                                                   Page
Arons, B. S......................................................   867
Aspden, W. H., Jr................................................   537
Chavez, Nelba....................................................   867
Gaston, M. H.....................................................   537
Gaus, C. R.......................................................     1
Gayle, Helene....................................................   119
Gimson, W. H.....................................................   119
Goldstone, Donald................................................   867
Hughes, J. M.....................................................   119
Kade, D. W.......................................................   867
Koch, R. M.......................................................     1
Mactas, D. J.....................................................   867
Marks, J. S......................................................   119
Morford, T. G....................................................   537
Nora, A. H.......................................................   537
O'Neill, J. F....................................................   537
O'Neill, S. J....................................................   867
Puskin, Dena.....................................................   537
Rosenberg, M. L..................................................   119
Satcher, David...................................................   119
Schwab, P. M.....................................................   537
Simpson, Lisa....................................................     1
Sumaya, C. V.....................................................   537
Williams, D. P.........................................1, 119, 537, 867


                               I N D E X

                              ----------                              

               Agency for Health Care Policy and Research

                                                                   Page
Academic Health Centers..........................................    19
AHCPR Administrator..............................................    15
Budget Request...................................................     8
Changing Practice Patterns.......................................    17
Clinical Practice Guidelines:
    AIDS Guidelines..............................................    19
    Modification of Guidelines...................................    17
    Phasing Out of Guidelines....................................    28
Consumer Assessment of Health Plans.......................3, 28, 36, 37
Consumers Decision making, Helping...............................     8
Customers........................................................     2
Customers and Partnerships.......................................  2, 5
Diabetes Research................................................    24
Evidence-based Practice:
    Comparison with Clinical Practice Guidelines.................34, 38
    Initiative...................................................  2, 7
    Evidence-based Practice Centers (EPCs).......................    15
    Private Sector Support.......................................    38
    State Contributions..........................................    31
    Topic Selection..............................................38, 39
Government Performance and Results Act (GPRA)....................    10
Health Care Outcomes and Quality Budget..........................    22
HIV Cost and Services Utilizations Study (HCSUS).................    19
Information Dissemination........................................    39
Introduction of Witnesses........................................     1
Investment in the Future.........................................     2
Low Back Pain:
    Research.....................................................    26
    Increased Funding............................................    27
Managed Care, Research in........................................    40
Medicaid Coverage for Blood Glucose Monitoring...................    25
Medical Expenditure Panel Survey (MEPS):
    Annual Cost..................................................    21
    Data Release................................................. 3, 35
    FTEs Required................................................    32
    Funding Sources..............................................    32
    Medicaid and Medicare........................................    32
    Minority Population Data.....................................    40
    Priority.....................................................    10
    Savings......................................................    16
Medical Malpractice Reform.......................................    31
Minority Health Services Research, Agenda for....................    41
National Guideline Clearinghouse (NGC)...........................    34
National Institutes of Health, Coordination with.................    33
One Percent Evaluation Funds.....................................    18
Opening Statement................................................     1
Orthopedic Research..............................................    25
Peer Reviewed Research...........................................    35
Primary Care Research............................................    24
Quality and Cost Effectiveness Initiative........................     3
Quality Measurement Network (QMNet)..............................23, 31
Reprogramming Request............................................    16
Research Centers in Minority Populations.........................23, 39
Research Priorities, Development of..............................    33
Technology Assessment............................................    17
User Fees........................................................    18

                      Centers for Disease Control

Asthma...........................................................   191
Biomonitoring....................................................   289
Birth Defects..................................................203, 259
Block Grant......................................................   287
Block Grant/Rape Prevention......................................   184
Blood Safety.....................................................   255
Breast and Cervical Cancer.....................................123, 315
CDC Budget.......................................................   286
Children's Health................................................   259
Chlamydia........................................................   309
CFIDS............................................................   189
Chronic Diseases.................................................   170
Chronic Pulmonary Hemorrhage.....................................   300
Congressional Justification......................................   375
Cooperative Agreements...........................................   318
Crime Victim Study...............................................   185
Diabetes.............................................122, 202, 281, 307
Environmental Health.............................................   288
Ergonomics...........................................205, 224, 225, 229
    Administrative Law...........................................   230
    Analysis of Ergonomics Data/Research.......................207, 223
    Concerns Related to Research Analysis........................   217
    Conclusions..................................................   221
    Economic Impact and Regulatory Flexibility Analysis..........   225
    Ergonomics Research........................................213, 216
    Evaluation of Ergonomics Studies.............................   211
    OSHA Compliance..............................................   231
    Specific Studies on Ergonomics........................204, 214, 219
    Work Factors Related to Ergonomics...........................   206
Folic Acid.....................................................260, 290
Gulf War Syndrome................................................   179
Hemophilia.....................................................192, 256
Hepatitis B......................................................   183
HIV/AIDS..................................................122, 164, 280
    Communities of Color.........................................   320
    Grants.......................................................   194
    Investment...................................................   343
Immunization...................................................168, 303
    Polio Vaccination..........................................189, 372
    Vaccines for Children......................................167, 200
    Vaccine Stockpile............................................   187
Infectious Diseases............................................169, 291
    Emerging and Re-emerging...................................121, 304
    Foodborne Illness..........................................121, 169
    H. Pylori....................................................   182
Infrastructure...................................................   184
Injury Control:
    Firearms.....................................................   181
    Firearm-Related Research...................................192, 257
    Traumatic Brain Injury.......................................   181
Introduction of Witnesses........................................   119
Junk Science.....................................................   283
Laboratories.....................................................   293
Lead Poisoning Prevention........................................   313
Mine Safety and Health..........................................77, 186
Minority and Women's Health......................................   314
Morgantown.......................................................   178
Musculoskeletal Disorders........................................   228
National Health and Nutrition Examination Survey (NHANES)........   123
NIOSH..........................................................295, 296
Occupational Safety and Health.................................123, 282
    ANSI Z-365 Committee.........................................   239
    Criteria to Select Target Industries.......................233, 234
    Data Collection Initiative.................................232, 238
    Information Access and Privacy Issues........................   236
    Report on Health Effects.....................................   208
Office of the Director...........................................   192
Opening Statement..............................................120, 125
Pelvic Inflammatory Diseases.....................................   279
Prevention Investment............................................   298
Psychosocial Factors and MSD Occurrence........................209, 210
Respiratory Syncytial Virus......................................   285
Sexually Transmitted Diseases....................................   121
Surveys..........................................................   191
Teen Pregnancy/Infant Health.....................................   183
Tobacco........................................................122, 261
Tuberculosis.....................................................   175
Violence.........................................................   298
Year 2000 Health Objectives......................................   174

              Health Resources and Services Administration

Abstinence Program...............................................   563
ADAP.............................................................   561
ADAP Supplemental Funding........................................   554
ADAP Program Drug Pricing Caps...................................   555
AHEC Program.....................................................   548
Allocation of Health Professions Request.........................   562
Chicago--Health Corps............................................   547
Difference between Titles I and II...............................   553
Distribution of Practitioners....................................   551
Earmark for the ADAP Program.....................................   553
Elimination of Specific Programs.................................   558
HEAL Program.....................................................   461
Health Professions...............................................   550
Health Professions Shortage Areas................................   551
Health Professions Staffing Reductions...........................   562
Healthy Start....................................................   563
Healthy Start/MCH Block Grant....................................   563
Hemophilia.......................................................   557
Impact of AIDS Drug Assistance Programs..........................   552
Introduction of Witnesses........................................   537
New Standards of HIV Care........................................   560
Opening Statement................................................   538
Overall Budget Level.............................................   549
Program Consolidations...........................................   558
Ryan White Increase Distribution.................................   559
Ryan White Performance Evaluations...............................   556
Title I, Title II, ADAP Program..................................   559
Unmet Need.......................................................   547

       Substance Abuse and Mental Health Services Administration

Agency Restructuring.............................................   899
Block Grant Legislation..........................................   900
Budget Estimates, Justification of...............................   966
Children's Mental Health Services Program.................908, 941, 944
Children with Serious Emotional Disturbance......................   943
Conference on Survivors of Torture...............................   919
Data Collection Initiative.....................................903, 962
Drug Abuse Prevention Programs Involving the Faith Community.....   883
Drug Use Among Youth and Adults..................................   960
Drug Free Workplaces.............................................   960
Evaluation of Mental Health and Substance Abuse Programs.........   897
Funding for Consultant Services..................................   913
Funding for Other Services.......................................   913
Funding for Substance Abuse Prevention and Treatment......880, 926, 955
Government Performance and Results Act(GPRA).....................   895
Health Benefits and Managed Care Providers.......................   964
High Risk Youth Public Housing Grants............................   912
HIV/AIDS Mental Health Programs..................................   953
Knowledge Development and Application Program (KDA)..............   913
KDA Program and State Involvement................................   922
Leadership to Address Issue of Drug Use..........................   956
Managed Care...................................................888, 889
Marijuana Use....................................................   934
Mental Health Services and Managed Care..........................   939
Mental Health's Legacy Program...................................   947
Mental Health Performance Partnership Block Grant/Children's 
  Mental Health..................................................   890
National Women's Resource Center.................................   948
Opening Statement................................................   867
Outcome Measures for Community-Based Mental Health Care..........   908
PATH and ACCESS Program..........................................   949
Prevention Success Stories.......................................   881
Program Effectiveness............................................   895
Public Campaigns on Dangers of Substance Abuse...................   956
Report Card on State Mental Health Services......................   907
Report on Managed Care...........................................   914
Saint Elizabeths Hospital........................................   910
Savings in Rent..................................................   912
Starting Early-Starting Smart Initiative.........................   955
State of Incentive Grant Program.................................   901
State of Mental Health Services and Managed Care.................   939
Substance Abuse Among Youth......................................   929
Substance Abuse Prevention.......................................   931
Substance Abuse Treatment for Women..............................   951
Supplemental Security and Disability Insurance Benefits..........   927
Synar:
    Amendment....................................................   875
    Baseline.....................................................   893
    Block Grant Application Reviews..............................   921
    Regulations..................................................   891
Use of Marijuana for Medical Purposes............................   935
Welfare Reform...................................................   927
Witnesses........................................................   875
Youth Substance Abuse Prevention Initiative...............883, 902, 936