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



 
                 DEPARTMENTS OF LABOR, HEALTH AND HUMAN
               SERVICES, EDUCATION, AND RELATED AGENCIES
                        APPROPRIATIONS FOR 1999

========================================================================

                                HEARINGS

                                BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                       ONE HUNDRED FIFTH CONGRESS

                             SECOND 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        DAVID R. OBEY, Wisconsin
HENRY BONILLA, Texas             LOUIS STOKES, Ohio
ERNEST J. ISTOOK, Jr., Oklahoma  STENY H. HOYER, Maryland
DAN MILLER, Florida              NANCY PELOSI, California
JAY DICKEY, Arkansas             NITA M. LOWEY, New York
ROGER F. WICKER, Mississippi     ROSA L. DeLAURO, Connecticut
ANNE M. NORTHUP, Kentucky        

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, Carol Murphy, Michael K. Myers,
                and Francine Salvador, 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.......................  159
 Health Resources and Services Administration.....................  605
 Substance Abuse and Mental Health Services Administration........ 1089
                                ________

         Printed for the use of the Committee on Appropriations
                                ________

                     U.S. GOVERNMENT PRINTING OFFICE
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                       COMMITTEE ON APPROPRIATIONS                      

                   BOB LIVINGSTON, Louisiana, Chairman                  

JOSEPH M. McDADE, Pennsylvania         DAVID R. OBEY, Wisconsin            
C. W. BILL YOUNG, Florida              SIDNEY R. YATES, Illinois           
RALPH REGULA, Ohio                     LOUIS STOKES, Ohio                  
JERRY LEWIS, California                JOHN P. MURTHA, Pennsylvania        
JOHN EDWARD PORTER, Illinois           NORMAN D. DICKS, Washington         
HAROLD ROGERS, Kentucky                MARTIN OLAV SABO, Minnesota         
JOE SKEEN, New Mexico                  JULIAN C. DIXON, California         
FRANK R. WOLF, Virginia                VIC FAZIO, California               
TOM DeLAY, Texas                       W. G. (BILL) HEFNER, North Carolina 
JIM KOLBE, Arizona                     STENY H. HOYER, Maryland            
RON PACKARD, California                ALAN B. MOLLOHAN, West Virginia     
SONNY CALLAHAN, Alabama                MARCY KAPTUR, Ohio                  
JAMES T. WALSH, New York               DAVID E. SKAGGS, Colorado           
CHARLES H. TAYLOR, North Carolina      NANCY PELOSI, California            
DAVID L. HOBSON, Ohio                  PETER J. VISCLOSKY, Indiana         
ERNEST J. ISTOOK, Jr., Oklahoma        ESTEBAN EDWARD TORRES, California   
HENRY BONILLA, Texas                   NITA M. LOWEY, New York             
JOE KNOLLENBERG, Michigan              JOSE E. SERRANO, New York           
DAN MILLER, Florida                    ROSA L. DeLAURO, Connecticut        
JAY DICKEY, Arkansas                   JAMES P. MORAN, Virginia            
JACK KINGSTON, Georgia                 JOHN W. OLVER, Massachusetts        
MIKE PARKER, Mississippi               ED PASTOR, Arizona                  
RODNEY P. FRELINGHUYSEN, New Jersey    CARRIE P. MEEK, Florida             
ROGER F. WICKER, Mississippi           DAVID E. PRICE, North Carolina      
MICHAEL P. FORBES, New York            CHET EDWARDS, Texas                 
GEORGE R. NETHERCUTT, Jr., Washington  ROBERT E. (BUD) CRAMER, Jr., Alabama
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            

                 James W. Dyer, Clerk and Staff Director












[Pages 1 - 1623--The official Committee record contains additional material here.]





DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 1999

                              ----------                              

                                          Wednesday, March 4, 1998.

               AGENCY FOR HEALTH CARE POLICY AND RESEARCH

                               WITNESSES

JOHN M. EISENBERG, M.D., ADMINISTRATOR,
RITA KOCH, OFFICE OF MANAGEMENT, CHIEF, FINANCIAL MANAGEMENT STAFF
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET
    Mr. Porter. The subcommittee will come to order.
    Continuing our hearings on the Department of Health and 
Human Services, we are pleased to welcome Dr. John Eisenberg, 
the Administrator of the Agency for Health Care Policy and 
Research. Dr. Eisenberg, this is your first appearance, is it 
not, before our subcommittee?
    Dr. Eisenberg. It is, in this room.
    Mr. Porter. So, we definitely welcome you and hope you are 
challenged by your new job, which I imagine you are. Could you 
introduce Ms. Koch and then proceed with your testimony.
    Dr. Eisenberg. I would be happy to. I think you know Dennis 
Williams.

                          importance of ahcpr

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

                   ahcpr research and decisionmaking

    I would like to talk today about AHCPR briefly and then 
talk about our budget. As you know, AHCPR focuses on research 
that moves biomedical discoveries like the ones generated at 
the National Institutes of Health into medical practice.
    Our research bridges that gap between what our scientists 
know and what health care Americans receive. The decisions 
about health care in this country are very personal ones. Every 
one of us makes a personal decision but those decisions about 
health care are often made with help, maybe from a doctor or a 
nurse or a loved one, but they still remain very personal and 
individual decisions.
    What I want to emphasize today is that those decisions, 
those individual decisions, are made in the context of a very 
complex area, one of the most complex in modern life, the 
health care system. It is here that patients and clinicians 
usually do not have all the information that they need, 
sometimes do not have any of the information that they really 
need, to make the best choices among the alternatives that are 
available to them.

                     ahcpr's mission and customers

    Our mission, as I see it, is to provide science-based 
information so that we can help with those decisions, so that 
we can improve decisionmaking by all the decision makers in 
health care. Those are AHCPR's customers, the people who are 
making those decisions.
    They are patients, they are clinicians, they are health 
care system leaders, they are public policy makers in both the 
public and private sectors. They use this kind of information 
every single day to make decisions that have an impact on all 
levels in the health care industry, from an individual patient 
deciding on whether to have surgery, to the health plan 
deciding on what kind of new benefits it might offer. Our 
budget for Fiscal Year 1999 addresses these challenges that are 
faced by the agency's customers.

                           research findings

    Our research, as you know, is both conducted and sponsored 
by the agency and the vast majority of our funds go outside the 
agency to the best researchers in the country, people who 
compete for funds with grant applications and undergo peer 
review in the same way that NIH does.
    For example, one agency AHCPR-sponsored project found that 
we could cut the cost for antibiotics for people with pneumonia 
by two-thirds with no adverse effect on patient's health by a 
simple change in the way in which antibiotics are used. It is 
that kind of research that I think is so useful.
    And ironically, before I joined the agency, I was chairman 
of the Department of Medicine at Georgetown. And, so, my name 
is still listed on a number of managed care plans in 
Washington, in which I participated. I still get their mail. A 
few weeks ago, I got a brochure from four health plans in the 
Washington area who had put together an educational program for 
physicians. This brochure was about this very AHCPR research 
that showed how better care can cost less. And that, I thought, 
was very satisfying for an agency which generates research that 
we want to see translated into practice in the private sector.

                        translation of research

    A very important component of the research that we do on 
outcomes and on effectiveness is not only sponsoring that 
research, but also being sure that the research gets translated 
to clinicians and to patients for their decisions about 
treatment, and also gets translated to plans so that they can 
make decisions about what they are going to cover.
    One of our new programs deals with the evidence for what 
works and what does not work for a variety of different 
treatments and interventions.

                    evidence-based practice centers

    Last Fall we named 12 evidence-based practice centers 
located around the country and we assigned the first round of 
topics to those organizations. We are expecting reports from 
the EPCS within a few months.
    We expect the reports to be used by our partners. Each of 
those topics was nominated by either a public or a private 
sector organization who said, we need a public sector review of 
this material, an assessment of this material.
    These are organizations in health care and medical 
societies. They nominated the topics because of their needto 
develop quality improvement tools, practice recommendations and 
educational programs to improve health care.

                   colorectal cancer evidence report

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

                              partnerships

    We recognize that need to get this information, this 
research information, out to our customers. One of the ways we 
do this is through formal partnerships.

                    national guideline clearinghouse

    For example, we have a partnership with the American 
Medical Association and the American Association of Health 
Plans to establish a National Guideline Clearinghouse. The NGC 
will provide one-stop shopping to Americans about the best 
practices in clinical care.
    This is a clearinghouse that will be available on the 
Internet in the Fall. It will make existing practice guidelines 
developed by public and private sector organizations available 
to every doctor, every nurse, every patient, and every health 
plan who can use a computer.
    In addition to the research that we do on this level, the 
clinical level, to help doctors and nurses and patients make 
decisions, I think it is very important for us to remember that 
there are health plans, system leaders in health plans and 
health care organizations, who are making similar decisions and 
need similar kinds of information.

               consumer assessment of health plans survey

    For example, last month, Secretary Shalala released the 
AHCPR Consumer Assessment of Health Plans Survey. This survey 
will help not only consumers, but also employer benefits 
managers, and those who are making decisions for group 
purchasers about health plans, choose the plans that are most 
satisfactory to the people who are in them.
    I was very pleased when HCFA announced last week that it 
would use this survey, CAHPS, to survey Medicare beneficiaries. 
You, your staff, and all of us will soon have a chance to use 
CAHPS as well; the Office of Personnel Management announced 
that it will be using the survey, and we are looking forward to 
it spreading even further.
    Already several States and several private corporations are 
using CAHPS as a way of getting information to their people 
about the differences among the plans.

                 government performance and results act

    We have developed a budget request for this year, for 
Fiscal Year 1999, under the framework of the Government 
Performance and Results Act, GPRA.
    And let me say, that we have developed an internal 
evaluation strategy as well that will allow us to assess our 
progress in meeting the annual objectives so that we will know 
the impact of our research initiatives on the health care 
system. That is very important for our translation efforts.
    We are pleased that we met our Fiscal Year 1997 GPRA goal 
in improving the timeliness of data that we collect in our 
Medical Expenditure Panel Survey.
    The first release of this data for 1996 came out in April 
of 1997, a remarkably quick turn around for this kind of data 
and we have kept up that pace.

                        fiscal year 1999 request

    In Fiscal Year 1999, AHCPR requests a total of 
$171,435,000. That is an increase of $25,000,000 over the 
Fiscal Year 1998 Appropriation.
    The additional $25,000,000 will allow AHCPR to expand our 
emphasis on research to measure and improve quality, and to 
collaborate, as I have already mentioned, with other public 
sector agencies and the private sector to improve health care 
in this country.
    Our research is going to emphasize improving the quality of 
care for all Americans especially for those who are at the 
greatest need.
    For example, we will devote $5,000,000 to concentrate on 
the cost, quality and outcomes of care for people who have 
chronic diseases and disabilities. We will devote funds for 
research and demonstrations to improve the quality of care for 
children, as well as evaluations of the effectiveness of State 
and local approaches to implementing the CHIP legislation.
    We will support major new assessments of preventive 
services to provide information that will help all of the 
agencies customers that I enumerated earlier to make decisions 
about preventive services.
    In addition, the Food and Drug Administration Moderization 
and Accountability Act gave our agency a new responsibility to 
support two Centers for Education and Research in Therapeutics.
    These so-called CERTS will increase our knowledge about the 
new uses and risks of medical products through research, and 
will also help to prevent adverse effects of medical products 
and the consequences of those effects.

                               conclusion

    Mr. Chairman, approval of AHCPR's budget request for Fiscal 
Year 1999 will ensure that we continue to have unbiased, 
reliable information. It will allow us to provide more and 
better unbiased and reliable information on cost-effectiveness 
and effectiveness of treatments for specific conditions, as 
well as strategies that will help us to translate the best 
science into routine practice, into every day medical practice 
in this country.
    That will give us high quality care at an affordable cost. 
My colleagues and I will, obviously, be happy to answer any 
questions that you have.
    Thank you very much.
    [The prepared statement follows:]
    Offset Folios 11 to 24 Insert here



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

               initiative to improve health care quality

    Dr. Eisenberg, $15 million of the $25 million you are 
requesting as an increase in Fiscal Year 1999 is to support a 
Secretarial initiative to improve health care quality. We 
thought that was already what you were doing. Isn't this just 
the status quo in a different wrapping? Tell me how this is 
different from what you do now and what are the outcome 
measurements for this initiative?
    Dr. Eisenberg. The theme is similar, of course, to what we 
are currently doing because we are already devoted to trying to 
develop better ways of understanding and improving quality. 
What we want to do is to devote this agency to generating 
better quality measures, which are in great demand by this 
country, as well as to understand better what works and what 
does not work in trying to improve the quality of care that 
Americans get.
    Unfortunately, because of our budgetary constraints last 
year, Fiscal Year 1997, we were only able to award ten new 
grants. This year it looks as if we will be fortunate to be 
able to get to the 15th percentile on applications.
    There are a number of talented American investigators in 
this area who, I think, have a tremendous amount to contribute 
to what we know about quality and what we know about ways of 
measuring it and improving it. Our request is formulated to 
take advantage of the talent among the investigators in this 
country to apply the science to better quality of care.
    That is why we have asked for additional funding. Because 
of the passion that the Congress feels and the commitment that 
the Administration feels to improving quality of care research, 
we have asked for an additional $15 million in this area.
    Mr. Porter. So, you are just giving the request for an 
increase in funding a name because you are already doing the 
quality research in any case.
    Dr. Eisenberg. Well, we are doing some of it. What we have 
done by giving it a name is to transmit the message as clearly 
as we can that this is a high priority for the agency, and that 
this is the area in which additional funding would be 
dedicated.

                 national outcomes research conference

    Mr. Porter. All right. Your agency sponsored a national 
conference to chart the course for the next 10 years for 
investment in outcomes research. It was anticipated that the 
results of this conference would be published in the spring of 
this year. What is the status of the report and how will the 
information be used?

                  national outcomes conference report

    Dr. Eisenberg. Well, the report is being finished now. We 
had the conference in the fall. The report, what we call the 
``outcomes squared initiative'' or the outcomes of outcomes 
research, will be used in two ways. One way will be to help us 
target the areas in which we commit our resources to further 
research about outcomes and to understand where the research 
pays off the best. What kinds of outcomes research needs to be 
done?
    That could be the measurement of outcomes. For example, how 
individual patients value various outcomes. Or the content 
areas, those diseases in which they need to measure outcomes.
    But, in addition to that, one of the concerns that we all 
have is that this research be translated into improved health 
care. And, so, one of the other outputs of the outcomes 
initiative is to look at how we can take this research and get 
it translated into improved practices through education, 
through changes in health care organizations, through better 
information to patients, and through better information to 
physicians. I anticipate that the report will be ready within a 
couple of months.

                     use of ahcpr research findings

    Mr. Porter. This will, I think, help to pin down what you 
are talking about by perhaps your giving us some examples.
    Your agency has invested in 14 original Patient Outcomes 
Research Team (PORT) projects and 11 PORT II Projects. These 
projects have generated numerous findings. For example, the 
diabetes PORT has demonstrated that for Type II diabetes, 
insulin treatment is significantly more costly and not always 
more effective than oral agents.
    Like other PORT findings, the teams are working closely 
with professional organizations to get these results widely 
disseminated. Once these findings are made available, how do 
you know if, in fact, they are being used? And, in your 
response could you tell us first, if they are being used how do 
you measure the impact they are having, and second, if they are 
not being used, why they not being used?
    Dr. Eisenberg. Well, first, are the outcomes of these 
patient outcome research teams useful and what are the 
outcomes? Let me give you a few examples of some of the reports 
that have come out recently. The Patient Outcome Research Team 
at Johns Hopkins, which focused on cataract disease, developed 
a measure for understanding the impact of cataract disease on 
individuals who have cataracts. It has been described as the 
best method of understanding both who will likely benefit from 
cataract extraction, as well as understanding the outcome and 
what the contribution of those outcomes has been. That measure 
is already beginning to be used.
    The second example is an outcomes assessment that wasdone 
at the Massachusetts General Hospital on prostate disease, in which the 
outcomes of benign prostatic hypertrophy were evaluated. A videodisc 
was developed to help patients to understand their decisions. We have 
already seen the impact of this study for example, with the urology 
community picking up on that measure of outcomes such that that article 
has now become the most quoted article, I am told, in the urologic 
literature. This is a new measure of the outcomes of prostate disease.
    And we also understand that this videodisc, which is a way 
of translating the outcomes to patients so that it can help 
with their decision making, is being adopted by individuals who 
want to help their patients understand what the options are for 
them with prostate disease.

                 measuring the use of research findings

    Mr. Porter. But you are not actually measuring who is using 
it. You are saying it is out there, we put it out and we hear 
people are using it or talking about it, at least. How do you 
know if it is actually being used?
    Dr. Eisenberg. Well, we have asked the investigators in 
each of those Patient Outcome Research Teams to monitor the 
degree to which their work is getting disseminated and is being 
used by people in the community. And so far, that is the best 
way that we have of tracking that, other than watching some 
findings become commercial products, which some of them have, 
of course, as they appear to have value to those who would like 
to translate them and make a commercial product out of some of 
those findings.
    But the process is really using the investigators because 
they are the ones who are most likely to understand the way in 
which this is being disseminated.
    Mr. Porter. See, this is the point at which we really want 
to provide some focus because in the past, and not necessarily 
applying to this agency, the measurement might be how many 
ports did you do how many reports were generated? Well, it does 
not matter how many reports are out there if nobody ever reads 
them or does anything with them. Right?
    Dr. Eisenberg. Right.

                      research's impact on people

    Mr. Porter. What we really want to get at is not how many 
reports have been done, but how many people's lives are being 
bettered by what has been accomplished. In other words, is it 
being used, is it being followed, is it actually being given to 
patients?
    Dr. Eisenberg. Well, let me respond to that in two ways, 
because I could not agree with you more. In the several months 
that I have been at the agency that has been one of my own 
personal campaigns. We need to tell the story, to understand 
the story about what this agency's products have meant, not 
only getting the research published, but also doing something 
with it.
    I keep reminding our researchers that when they have their 
articles accepted that is not the end of their obligation to 
the public sector. It is in some ways the beginning of their 
obligation to the public sector that they need to get that 
research translated into action.
    Mr. Porter. And you need to determine whether it has been.

                 partners and use of research findings

    Dr. Eisenberg. Yes. We need to determine whether it has 
been translated. I would go a step beyond that actually, and 
say that we are looking now to develop partners who promise us 
that the research, once we have funded it, will be used. So, 
that for example, with the Evidence-based Practice Centers, we 
have partners who have assured us that when the report comes 
out they will adopt and they will use the results. For example, 
the American Psychiatric Association and the Academy of 
Pediatrics, have said that when our report on attention deficit 
disorder comes out, they will use it.
    We are also going to have the report from the schizophrenia 
PORT come out within a few weeks, and we have a commitment from 
the psychiatric community that it will be used. My sense is 
that we cannot just let it get out into the published 
literature----
    Mr. Porter. I would go a step beyond that and if it is 
used, is it efficacious in directing at the disease or syndrome 
that we are attempting to do something about.
    Dr. Eisenberg. Right, right.
    Mr. Porter. In other words, what effect is it having on 
people? Not how many reports are out or how many people have 
read it or how many people are actually using it, but is it 
working?
    Dr. Eisenberg. Right.
    Mr. Porter. You need an evaluation all the way to the end.

                    national guideline clearinghouse

    Dr. Eisenberg. I agree with you.
    Mr. Porter. Okay. At last year's hearing, your predecessor, 
Dr. Gaus, testified that the agency would soon be signing a 
partnership agreement with the American Medical Association and 
the American Association of Health Plans to jointly sponsor a 
National Clearinghouse of Clinical Practice Guidelines.
    This clearinghouse is intended to provide an 
electronically-based catalog of every guideline in the country 
as well as a comparison of the guidelines. What is the status 
on this initiative?
    Dr. Eisenberg. It is going right on schedule, in fact, a 
little bit ahead of schedule. The National Guideline 
Clearinghouse has contracted with an organization that is 
expert in putting these Web Sites together and in gathering the 
information.
    We have had several meetings of a planning group, which 
includes the AAHP and the AMA, to design the site, to decide on 
what the criteria ought to be for entry into the site, and to 
be sure that we are following the schedule as it has been laid 
out and we are right on schedule. We expect that it will be 
available on the Internet in the Fall.

              use of the national guideline clearinghouse

    Mr. Porter. Again, how do we determine whether professional 
societies and other groups will actually use the site and are 
they willing to finance any portion of its cost?
    Dr. Eisenberg. Well, I am pleased to say that the AMA the 
AAHP have already begun to finance part of its cost. They are 
partners with us in this project. As for use, we have the usual 
way of measuring whether or not a Web Site is being used, of 
looking at hits. But that really does not tell us whether or 
not it has been translated into action.
    We have met with a variety of specialty societies as 
recently, in fact, as last week in Chicago, to talk with 
specialty societies about the National Guideline Clearinghouse. 
We are letting them know it is coming and have begun to talk 
with them about ways in which they can enable their members to 
use it most effectively.
    We started to anticipate the concern that you have, that we 
have as well, because we do not want this to just sit on the 
Web, we want it to get used. We will follow that up with 
measures of how satisfied people are with the Web, and what 
their impression is of how much they have been able to use it. 
We are lookingnow for ways in which we can look at its impact 
on actual practice patterns, as well.

                ngc and the national library of medicine

    Mr. Porter. How does this differ from what, say, the 
National Library of Medicine does?
    Dr. Eisenberg. It differs substantially in that our role as 
a research agency is to generate the evidence reports and then 
to put them on the Web. We bring the guidelines together in a 
way that evaluates the degree to which they meet certain 
standards of evidence, of being evidence-based, and then 
collaborate with other organizations to make them available.
    We have collaborated with the NLM because of their 
expertise in using Web Sites and getting informaiton to users. 
They have been enthusiastic about working with us in this area. 
But the content of the National Guideline Clearinghouse is an 
area in which we have, I think it is probably fair to say, 
unique expertise within the Federal Government. The Library of 
Medicine's expertise in using the Internet and using the Web 
dovetails nicely with ours. And, so, we are seeing it very much 
as a partnership where we bring the expertise, the content, and 
the medical practice area, and they contribute expertise in how 
the Web can be used.
    Let me just say in addition, that one can get into this Web 
Site through NLM's site. We wanted to be sure that no matter 
how people come into the Web that they had ease in getting into 
the National Guideline Clearinghouse's Web Site.

                   current availability of guidelines

    Mr. Porter. If I go down, as I did, to a Community Health 
Center in inner-city Chicago, they have sitting there a 
television set or a monitor that's hooked into the National 
Library of Medicine. Do they not have these practice guidelines 
already available?
    Dr. Eisenberg. They do not have the guidelines available. 
They only have access to a small sample of guidelines. You have 
to know how to go to the various sites for each of these 
guidelines.
    What the NGC will do that is different from what you just 
described is two things in particular. One is that the 
individual who wants to gain information about a particular 
problem that they, he or she faces, has to go to only one place 
on the Web, instead of having to be an expert and finding all 
of the different sites that they might have to find anywhere on 
the Web. That is one contribution.
    But I think the most important contribution is that--and 
this really gets to your previous question about what value-
added we bring to this--is that because of our expertise in 
evaluation of medical services and using the evidence-based 
approach, we are putting together a side-by-side analysis of 
the guidelines that are available. This analysis will show not 
only who put the guideline together and what the audience was, 
and who the patients were and how the study was done that 
generated the guideline; but also a side-by-side analysis that 
compares the content of the guidelines, so that if you wanted 
to know about a particular area, like colon cancer, you could 
do a side-by-side analysis of each of those and compare what 
every organization said about that particular question. You 
cannot get that by yourself.

                        duplication of research

    Mr. Porter. Well, we are going to have Dr. Lindberg here 
and I am going to ask him the same question because it seems to 
me there is a potential at least for some duplication there and 
if there is then we have got to make certain that one of you is 
doing what needs to be done and not both of you doing exactly 
the same thing.
    Dr. Eisenberg. Well, you are absolutely right. That is why 
Dr. Lindberg and I meet every month to talk about what our two 
agencies are doing.
    Mr. Porter. You know what his answer will be.
    Dr. Eisenberg. Well, we believe that we ought to cooperate 
and collaborate because we have a lot to learn from each other, 
I think.
    Mr. Porter. Mrs. Northup, let me apologize. The last time I 
looked over in that direction, you were not there. So, please, 
proceed.

                          patient satisfaction

    Mrs. Northup. I understand that you are doing the work we 
talked about last year of assessing different plans and the 
efficacy of them and the efficiency of them and patient 
satisfaction. I assume you are doing that for managed care 
firms?
    Dr. Eisenberg. Well, we are not doing it for managed care 
firms so much as about them.
    Mrs. Northup. Assess them.
    Dr. Eisenberg. Yes, yes.

                         consumer satisfaction

    Mrs. Northup. Well, I wonder if you know there are several 
consumer protection bills regarding HMOs that have been 
proposed in the Congress and in fact, the President has 
endorsed certain proposals, but I wonder if it does not make 
more sense to see what your research shows both in consumer 
satisfaction and price control before we begin enacting new 
legislation that affects these plans?
    Dr. Eisenberg. Well, I agree with you fully about the 
importance of being able to do those side-by-side comparisons. 
In fact, the Health Care Financing Administration has begun to 
use the CAHPS, the Consumer Assessment of Health Plans Survey. 
They announced this a couple of weeks ago. The Office of 
Personnel Management is also using CAHPS and a number of 
programs around the country, States and private organizations 
are using it, as well.
    What it offers us is a way of providing one of the things 
that many of the people who are concerned about consumer 
protection believe is the first step--that is more information, 
better information so that we can compare what people think 
about the different health plans.
    I am pleased to say that between the time we answered this 
question last year and now, that the CAHPS survey is available. 
The State of Maryland, the State of Washington and others 
already have booklets developed using CAHPS that allow people 
to make choices about their health plans.
    To the degree that CAHPS addresses one part of the consumer 
protection agenda, which is getting good information to people 
so that they can make choices, I think that it is a very 
important part of that agenda and your bringing them together, 
I think, is an important and correct way to link them.

                    consumer protection information

    Mrs. Northup. Of course, when we talk about in enacting 
anything like consumer protection information it is as though 
it is going to affect the private sector insurance market only. 
However, many of the Medicare and Medicaid plans, Medicaid in 
particular, in Kentucky, have gone to HMOs processes and any 
sort of legislation that we pass that would profoundly affect 
the price of those is also going to affect the Federal budget 
and our ability to access more health care for people who are 
in those programs. Would you agree?
    Dr. Eisenberg. Well, on the price, let me just say that the 
Consumer Assessment of Health Plans Survey deals more with 
satisfaction about the care that people receive than----
    Mrs. Northup. And outcomes?
    Dr. Eisenberg [continuing]. And the outcomes that they 
receive, their perception of the outcomes that they receive, of 
course, which is an important part of outcomes. It does not 
focus as much on the price issues. What it does is to say we 
can measure the price. What we have had trouble measuring in 
the past is satisfaction and outcomes. This is a step towards 
balancing the measure of price so that we do not choose on 
price alone, but so we can choose on price and quality.

                         consumer satisfaction

    Mrs. Northup. Actually I think if we looked at the HMOs 
plans that are under state jurisdiction and we sort of proposed 
consumer health or consumer protection mandates, it is very 
easy to see what it does to the price.
    Because the state plans have experienced what happens to 
the price. I think what is important for us to know before we 
do anything in Federal policy affecting any other policies is 
to find out whether, in fact, there is an outcome problem or a 
consumer satisfaction problem.
    And that is why I am eager to know what your study showed.
    Dr. Eisenberg. Well, that is obviously what this agency is 
all about--measuring those outcomes and trying to get that 
information to individuals. I would be happy to show you what 
the CAHPS survey shows. It is different, of course, State-by-
State because the plans do differ State-by-State.
    But what it looks like is sort of like what you are used to 
seeing when you buy a car. They have the various 
characteristics of the plan so that you can see how they do on 
the various aspects of delivery of care that are important to 
you.
    Some users report it in stars, some report it as those 
circles that have different quadrants built in. But I agree 
with you that it is a very important part of being sure that 
people can make choices among their plans.

                        coordination of research

    Mrs. Northup. The Office of the Inspector General I know is 
also doing this type of work. Are you all coordinating your 
results?
    Dr. Eisenberg. Not with the Office of the Inspector 
General. No, not with the Inspector General.
    Mrs. Northup. Well, I might suggest that, you know, if we 
have two agencies doing the same type of research it might be 
interesting to have some coordination, some idea.

                        congestive heart failure

    Let me ask you another question. Last year, this 
subcommittee included report language regarding congestive 
heart failure. I had specifically brought that up with my 
colleagues concerned about what we know as the ``stroke belt.''
    This particularly effects Kentucky. We have a lot of rural 
health service and the availability of, for example, cardiology 
specialists in rural health is limited. And the suggestion by 
this subcommittee was that we link a teaching hospital on 
practice, a hospital that has a practice dedicated to that 
service and rural health care providers with cardiologists in 
these centers, so that the most advanced practice would be 
available to rural communities without the increasing cost of 
somehow attracting those practices.
    I just wondered if you had been able to do any work related 
to this? I mean I know that you all have grants that support 
this type of work and I just wondered if you had concentrated 
any of that in the ``stroke belt''?

                          stroke belt research

    Dr. Eisenberg. A number of the projects that we are doing 
relate to the topic that you have raised. One of them is a 
project that is designed to evaluate the recurrence of stroke, 
ways in which we can prevent the recurrence of stroke through 
the appropriate use of anticoagulant drugs, and getting 
physicians to do what we know they should be doing in terms of 
reducing recurrence of stroke in that way.
    One of the major factors that leads to stroke is atrial 
fibrillation, irregular beat of one of the chambers of the 
heart. We have some projects that we funded in that area as 
well, which should reduce the incidence of stroke.
    We also have a guideline that the agency has produced in 
the past that looks at what should be done in the area of 
congestive heart failure.
    And I have had personal conversations with the American 
Heart Association and the American College of Cardiology about 
the need for us to collaborate with them to develop additional 
information that would be available to practitioners so that 
they can help to reduce the stroke.

                          demonstration study

    Mrs. Northup. I am hurrying because I have to chair the 
meeting across the hall. But I think I am specifically asking 
about something else.
    And that is the demonstration study or a grant that would 
be targeted to where we already have a high incidence and a 
under-served area.
    And about trying to put together expertise in a very 
efficient, effective way to communicate either by telephone or 
computer or whatever the most advanced medicine. I think what 
you are talking about is practice parameters, practice 
practices that are good medicine.
    What I think I am thinking of is that there are those 
patients that do not respond as you expect and so forth, and 
they are not in Louisville, Kentucky, they are in rural areas 
and general practitioners do not have the expertise to, even if 
they had followed what was in the guidebook, and trying to 
bring advanced medicine specific to the patient. I justwanted 
to bring that to your attention.

                              peer review

    If I could just ask you one more question. It is about your 
research and I know you are an outcome-based agency. And I just 
wondered if you use peer review on the studies that you have 
conducted and the importance of peer review?
    Dr. Eisenberg. Yes, we do. Peer review is a critical part 
of what we do. All of our grants are reviewed by experts from 
around the country in exactly the same way this is done at the 
NIH.
    Unfortunately, in Fiscal Year 1997 we were only able to 
fund down to about the 8th percentile.
    This year we are hoping we can do a little bit better than 
that. That is one of the reasons why we have asked for 
additional funding for this year--so that the peer review 
process can approve and fund some grants in the future.
    Mrs. Northup [presiding]. Thank you. I am sorry. We are 
adjourned until 10 o'clock tomorrow morning.
    Thank you very much for your testimony.
    [The following questions were submited to be answered for 
the record:]
    Offset Folios 44 to 173 Insert here



                                           Thursday, March 5, 1998.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

                               WITNESSES

DR. CLAIRE V. BROOME, M.D., ACTING DIRECTOR, CENTERS FOR DISEASE 
    CONTROL AND PREVENTION
WILLIAM GIMSON, DIRECTOR, FINANCIAL MANAGEMENT OFFICE, CENTERS FOR 
    DISEASE CONTROL AND PREVENTION
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, DEPARTMENT OF 
    HEALTH AND HUMAN SERVICES

                       Introduction of Witnesses

    Mr. Porter. The committee will come to order.
    We continue our hearings on the budget of the Department of 
Health and Human Services, and are pleased to welcome this 
morning Dr. Claire V. Broome, the Acting Director of the 
Centers for Disease Control and Prevention.
    Dr. Broome, we're very pleased to have you with us here 
today. We're sorry to have lost Dr. Satcher to higher pursuits, 
perhaps, within the Department, but I know he'll continue his 
interest in CDC from his new position.
    We appreciate your standing in today, pending the 
nomination of the new Director for CDC. And obviously, we on 
this committee appreciate very much the work that CDC does, and 
consider it a very high priority for our country.
    I'd also like to welcome Jay Dickey to our subcommittee 
today. Nice to have you here, Mr. Dickey. [Laughter.]
    Mr. Dickey. Thank you, sir.
    Mr. Porter. Dr. Broome, why don't you proceed with your 
statement, and then we'll have questions.

                           Opening Statement

    Dr. Broome. Thank you, Mr. Chairman and members of the 
committee.
    It's a real pleasure to be here with you today to speak 
with you in support of the President's budget request for the 
Centers for Disease Control and Prevention for fiscal year 1999 
in the amount of $2.45 billion. This represents an increase of 
$78.6 million, 3 percent over the fiscal year 1998 
appropriation.
    I also really want to thank you, Chairman Porter, and the 
subcommittee, for your ongoing support of the Nation's 
prevention agency.
    I'm confident that each of you here today would agree that 
prevention is vitally important to the health of this Nation. 
Although it's crucial to be able to treat and cure sick people 
who become injured or disabled, we would all prefer to remain 
healthy in the first place. Public health activities are 
essential to the health, well-being and productivity of this 
Nation.
    The fact is that as we approach the turn of the century, we 
could be doing more for the quality of the Nation's health. 
Millions of people are still dying prematurely or suffering 
unnecessarily from preventable disease, injury and disability.
    What I want to emphasize today is what I call the 
prevention gap. In many instances, we already know what works 
to prevent diseases and injuries. And yet, there's a disconnect 
between knowing and doing. We're not always putting our 
knowledge into practice.
    Let me give you some examples of CDC's prevention 
strategies that work, and to point out what we still need to 
discover to close the prevention gap. We know how to protect 
our older citizens from the suffering and untimely deaths 
associated with influenza. Influenza vaccine works. It works 
not only to prevent deaths, but to help seniors maintain 
healthy function and quality of life.
    Yet more than 18,000 died unnecessarily of flu-related 
causes last year. Over 40 percent of persons 65 and older, the 
fastest growing age group in this country, did not receive 
influenza vaccine in the past year. Even worse, more than 60 
percent of African-Americans went unprotected. That's a 
prevention gap.
    We also know how to protect our children and grandchildren 
from certain birth defects. Folic acid works. Each year, 4,000 
babies are born with the life-threatening birth defects spina 
bifida and anencephaly. We've known since 1991 that at least 
half of these cases can be prevented if women of child-bearing 
age consume adequate amounts of the vitamin folic acid. But 75 
percent of women of child-bearing age still do not get enough 
folic acid in their diet.
    We know how to help prevent today's healthy young people 
from becoming tomorrow's victims of heart disease and stroke. 
Cardiovascular disease is the leading killer for men and women 
and across all racial and ethnic groups. Cardiovascular disease 
is responsible for over 960,000 deaths each year.
    Physical activity and proper nutrition work. Research has 
shown that moderate physical activity and a healthy diet can 
help protect Americans of all ages, not only from heart attack 
and stroke, but also diabetes and even some cancers.
    Yet poor diet, coupled with lack of physical activity, 
remains the second leading preventable cause of death in this 
Nation.
    Having the basic scientific knowledge about effective 
preventive measures is only half the battle. Scientific 
findings are worth little if they sit on a shelf. We must put 
our scientific knowledge to work for people if the public's 
health is to improve.
    We believe that CDC is in a unique position to close the 
prevention gap. We have the ability to conduct prevention 
research to close the gap between knowing what works and 
knowing how to turn that scientific knowledge into effective 
programs.
    We also have the scientific ability to answer new questions 
about how to prevent disease, injury and disability. Then, very 
importantly, we have strong long-term collaborations with State 
and local health departments, health care institutions, other 
community organizations and private practitioners, the people 
on the front lines who can deliver prevention programs and 
practices directly to your communities.
    The President's budget request includes funding increases 
to CDC in five critical areas. These increases will help us 
move from knowing what works to putting that knowledge to work.
    Food safety. The President's budget includes a $5 million 
increase to support activities under the Food Safety 
Initiative. Each year, an estimated 6 to 33 million Americans 
develop a food-borne illness, and 9,000 persons die as a 
result. The annual cost attributed to food-borne illness is $5 
billion to $6 billion.
    This increase will enable CDC to expand the National Early 
Warning System for detecting food-borne illnesses, and enhance 
links between Federal and State laboratories with sophisticated 
computer technology so that we can identify organisms which may 
be causing food-borne disease in multiple different locations.
    We know how to increase the safety of America's food 
supply. With your help, we can act.
    Adolescent smoking and health. The President's budget 
includes a $46 million increase for our continuing struggle to 
keep the next generation of young people from starting to 
smoke. Smoking is the number one preventable cause of death in 
this country, resulting in 420,000 deaths each year.
    In addition to this preventable loss of life, medical costs 
were estimated to total $50 billion in 1993. Studies show that 
over 80 percent of adult smokers became regular smokers before 
the age of 18. Each day, to our national shame, over 3,000 
young people begin smoking.
    The budget increase will allow CDC to significantly 
increase grants to States for their smoking control programs. 
This will include all States, both the States that participated 
in the National Iinstitutes of Health (NIH) American Stop and 
the States Smoking Interventin Study (ASSIST) supported through 
CDC's Initiative to Mobilize for Prevention program. Results 
from these and control of tobacco use (IMPACT) programs have 
defined the type of anti-tobacco public health program that 
will help us reduce youth tobacco use, exposure to second hand 
smoke, and help adults stop smoking.
    We know ways to help protect young people from addiction to 
nicotine. With your help, we can act.
    Eliminating disparities. The President's budget includes a 
total of $80 million for the Department to support a major goal 
in his initiative on race. Of this amount, CDC would receive 
$55 million to address the President's ambitious goal to 
eliminate disparities in health status suffered by racial and 
ethnic minority populations by the year 2010.
    One target of the initiative is HIV/AIDS. It is appalling 
that the rate of AIDS is more than seven times higher for 
African-Americans than for white Americans. We need serious 
attention to improving our prevention programs to eliminate 
this disparity.
    Because of its experience in conducting prevention research 
and programs, CDC will play a major role in the President's 
race initiative. CDC will help conduct a series of research 
demonstration projects in communities to address six areas of 
identified health disparities. HIV infections, infant 
mortality, cancer, cardiovascular disease, diabetes and child 
and adult immunizations.
    We know we can accomplish this challenge, as shown by the 
significant gains in childhood immunization rates of minority 
children, where we have essentially eliminated health 
disparities. We know that we can reduce the extra burden of 
disease borne by minority populations. With your help, we can 
act.
    Emerging infectious diseases. The President's budget 
contains $79 million, an increase of $20 million, to help 
combat emerging infectious disease. You've only to listen to 
the nightly news to know that the Nation remains vulnerable to 
deadly infectious diseases. Terms such as hepatitis C, Ebola 
virus, avian flu, and antimicrobial resistance have become 
household words.
    Hepatitis C, only recently identified, accounts for 8,000 
to 10,000 deaths per year. And yet most of the 3.9 million 
Americans chronically infected with hepatitis C virus are 
unaware of their infections.
    The requested budget increase will be used to expand the 
Nation's emerging infectious disease early warning system in as 
many as three additional States, for a total of 33 States. 
These efforts will strengthen the surveillance network and 
capacity of State and local health departments to respond to 
infectious diseases by increasing the speed at which outbreaks 
can be detected, investigated and controlled.
    With your help, we can do it.
    Prevention research. While we have many proven prevention 
strategies, such as the ones that I've mentioned, and are 
implementing successful programs based on these, there's still 
much that we don't know. We need prevention research to bridge 
the prevention gap. We need research that can help transform 
findings from bench level research into prevention programs 
that reach people, and research that can tell us about the 
effectiveness and the cost effectiveness of those programs.
    The President's budget contains $25 million for a new 
prevention research program at CDC as part of the Research Fund 
for America. With this funding, CDC will support extramural 
research in academic health centers, such as schools of public 
health and medical schools, local and State health departments, 
and other community organizations.
    As illustrated by chart one, which is the only chart I'll 
be using in my presentation, we thought it would be helpful to 
look at the kinds of questions we feel prevention research is 
needed to answer. There are very pragmatic questions.
    How do we keep organisms such as cryptosporidia and E. coli 
from invading our water and food supply? What factors motivate 
workers and employers to adopt protective work practices? How 
is hepatitis C virus transmitted among adults with no history 
of injection drug use or blood transfusions?
    How can we use what we know about the health consequences 
of smoking, obesity and unsafe sex to help people choose 
healthy lifestyles? Can we prevent the chronic disease 
complications of infectious diseases, such as cervical cancer 
or ulcer disease, a fantastic new opportunity for prevention?
    We know that prevention research is needed both to discover 
new ways to prevent health problems and to help us move 
knowledge into practice. With your help, we will do it.
    Mr. Chairman, with your support for the President's budget 
request of $2,457,000,000 for CDC, you can help us close the 
prevention gap. CDC has the unique capacity to move from 
discovery to action. We can move research findings quickly to 
prevention programs located in communities throughout this 
country--programs that help people remain healthy.
    With your help, we will be able to move more prevention 
know-how into practice.
    Thank you for this opportunity to appear before the 
committee. I'll be happy to answer any questions you may have.
    Mr. Porter. Dr. Broome, that was an excellent statement, 
and you organized it very well, and covered a lot of ground in 
a very short time.
    ``With your help, we can do it'' may be fairly close to 
lobbying. [Laughter.]

            prevention efforts targeting children and youth

    But we got the message. [Laughter.]
    I want to begin by asking a question, because much of, all 
of what you really said, how do we put our knowledge into 
practice, how do we gain additional knowledge, which was the 
last part, but how do we put the knowledge that we have into 
practice, and what you're saying, of course, is that many of 
our problems, certainly not all, but many of our problems in 
our country are problems of lifestyle that, if we can get our 
people to exercise more, use proper diet, have safe sex, not 
use tobacco and drugs, that people are going to be a lot 
healthier and a lot of lives are going to be saved.
    In a free society, we can't make them do those things. We 
can narrow the use of tobacco in certain ways, we maybe can 
even outlaw that. But like drugs, even outlawing something 
doesn't necessarily change people's lifestyles, if they want to 
do it, they'll probably find a way to do it.
    Many people believe, and Dr. Ernst Wynder is certainly a 
leader in this area, that what we have to do is get to our kids 
at an early age in their lives with these kinds of messages, 
and attempt to change the kind of lifestyle that they may 
otherwise be led to engage in.
    I wonder if you can lay out for the committee, what efforts 
do we have that reach children specifically, and are they being 
effective at all?
    Dr. Broome. We agree with you and Dr. Wynder that this is a 
very important approach. That is why we have been very active 
in supporting comprehensive school health education programs, 
which attempt to educate young people, but also make them able 
to understand the risks and benefits, to understand the 
messages that they get from society that smoking is cool, and 
evaluate whether it's really cool to choose something that will 
have such far-reaching health consequences.
    We do have support for comprehensive school health 
education currently in 14 States, and we are working with all 
States in providing technical assistance on school health 
education programs.
    [Clerk's note.--The witness clarified that the correct 
number is 13 States.]
    We have also done very rigorous evaluations of the 
effectiveness of school health education programs, and have 
shown that these are effective in decreasing use of tobacco 
among seventh graders.
    I'd also like to make one more general comment. I think 
there is understandable skepticism about the difficulty of 
changing human behavior. Because we all know how hard that can 
be. That's why I think it's really important to look at our 
successes, and specifically in the area of tobacco use. Since 
Surgeon General Luther Terry's report came out, the United 
States has experienced a substantial decline in adult smoking, 
which is not seen in Europe or other countries where there has 
not been the same emphasis on the health impact of smoking.
    Similarly, we have seen a dramatic decline in motor vehicle 
fatalities. Some of that is highway engineering, some of that 
is State laws regarding seat belt use, some of that is changes 
in cars. But some of it is changes in personal behavior, in 
terms of seat belt utilization.
    So I think we do have some successful models.
    Mr. Porter. Excuse me, but a lot of that is related to 
drunk driving and the crackdown by States on drunk drivers 
across the country, I believe.
    Dr. Broome. I think that's correct, as well. It's again an 
example of how sustained, organized attention to educating 
people around these problems and thinking about creative 
solutions can be effective.

                 use of mass media for health education

    Mr. Porter. Okay, but let me ask a question. It seems to me 
that education programs in schools are fine. But the medium 
that really reaches young people in our country and reaches all 
people in our country is the medium of television. And let me 
ask you a question about how CDC usestelevision and radio to 
get messages out on public health. Do you have to pay for those?
    Dr. Broome. We really have not had the budget capacity to 
support paid media advertising. However, we do think----
    Mr. Porter. So who does it? Because there are public 
service statements made on radio and occasionally on TV, coming 
from CDC. Is that the stations absorbing the cost? Is it the Ad 
Council? Who does these things?
    Dr. Broome. Let me make two points. One is that for 
example, in the tobacco area, we see advertising as part of a 
comprehensive campaign to educate the public, and particularly 
teenagers, about the risks of tobacco.
    We have a clearinghouse where we obtain media announcements 
developed in California, Arizona and Massachusetts with funding 
from their excise tax. And we make those very professionally 
produced and tested messages available to anybody who would 
like to use them. So we do provide a distribution service, if 
you will.
    We also do rely on donated public service announcement 
time.
    Mr. Porter. But we don't buy any time anywhere?
    Dr. Broome. My understanding is that to date, CDC has not 
purchased media counter-advertising. This would be part of our 
initiative for controlling youth tobacco smoking.
    Mr. Porter. See, I believe, and I know a lot of my 
colleagues don't believe this, but I believe that the people 
who use our public airways and are licensed to do so have a 
responsibility to the public, and the least they can do for us 
is carry these announcements, if necessary, on a mandatory 
basis, so that we can reach people with a message on a medium 
that they are attuned to.
    It seems to me that we do not do a very good job of 
combining your responsibility with the responsibility of our 
television and radio stations to help you get your message out 
to people, particularly to our young people. I think we have to 
have an initiative in that area, and I know some people say, 
``well, you know, maybe we'll have to pay for all that time''. 
But it seems to me there ought to be a way of working it out 
with the networks and the media representatives to help you get 
this message out.
    Influenza, you talked about, 40 percent I think you said of 
our seniors who would be at risk are not vaccinated. Is that 
right?
    Dr. Broome. Yes.
    Mr. Porter. That's incredible in a country like this. If 
you can prevent illness and death, people I think would, and 
reach people with the message that these things are available, 
I think we're doing a very bad job of getting from where we are 
in our knowledge base to getting people even information that 
they need to make a wise choice in respect to health issues, 
and particularly getting a message to our children.
    Dr. Broome. I can only agree with you. Although if you 
would permit me to make two other points. One is, in addition 
to advertising, there's a very innovative strategy for use of 
the media which we would like to explore further.
    Jay Winston at Harvard has worked with Hollywood producers 
to introduce messages about the importance of a designated 
driver into the actual content of TV shows. And therefore, it 
doesn't look as much like, here's an ad preaching to you. It 
looks like part of the standard norms. And we think this can be 
a very powerful approach to getting public health messages 
across. We are looking at that with other areas.
    Mr. Porter. Somehow we need a whole initiative, and I don't 
know whether it's Dr. Wynder's initiative, or one that would be 
brought forward by this Administration, but I think we need an 
initiative to reach young people in this country, and get at 
least their generation on the right track. I think we would 
save billions of dollars in health care costs over the long 
term and have a lot happier and healthier population if we did 
it.
    Mr. Bonilla.
    Mr. Bonilla. Thank you, Chairman.
    Welcome, Dr. Broome. It's a little unusual to not see Dr. 
Satcher sitting there. I've worked with him for so many years 
now on so many projects on the good work you're doing at CDC. 
Bill's almost extended family in our office, I think we've done 
so much work with him over the years.

                       race and health initiative

    I want to say first of all that not just as a Congressman, 
but as a citizen of this country, I'm proud of what the CDC has 
done historically, and hope that the work can continue. On this 
subcommittee, we've had strong bipartisan support for what you 
do.
    I want to start out, however, on cautioning CDC on delving 
into areas that might stretch the dollars even thinner than 
what you're already facing. We want to make sure the dollars 
that go to CDC go for legitimate medical research and disease 
prevention and continue the success stories. We read stories 
about flu hunters that have combed the globe and are 
oftentimes, with support with everyone at CDC.
    But when I hear initiatives like you outlined in your 
opening testimony about a race initiative, I'm concerned about 
that. Because CDC already does a lot of good work in 
economically depressed areas. I'm concerned that the 
Administration and others are split on this opinion, but I 
believe this is a great degree of bogus effort.
    I can cite for hours if necessary good prevention programs 
that already exist in Hispanic and African-American 
communities. Mr. Stokes and I have worked on this aggressively 
on this committee. But I want to just be careful that it's not 
part of a political effort just to pander to minorities in this 
country that has little substance.
    So let's be proud of what CDC is already doing and continue 
that, but be careful of political agendas that are occurring at 
a higher level. And I don't know if you want to respond to that 
or just accept that as a statement.
    Dr. Broome. Well, Mr. Bonilla, thank you for your comments 
and support of CDC. We really appreciate that.
    I would like to say that the eliminating disparities 
initiative that Health and Human Services is proposing has very 
specific target goals, to have impact on health in minority 
communities. And yes, it very much builds on what we already 
are doing.
    But I see it as an accountability, a way of saying, it is 
unacceptable to have higher rates of disease in minority 
communities than in the community as a whole. And we need to 
challenge ourselves to eliminate those disparities.
    Mr. Bonilla. Well, my contention, again, is that CDC is 
already doing this. So this new race initiative is just again a 
bogus effort to try to pander politically to minority groups in 
this country.
    And let me tell you, I can speak from those neighborhoods. 
My Congressional district is almost 70 percent minority, when 
you combine my Hispanic and African-American populations. There 
are a lot of good programs going on down there, either directly 
related or indirectly related to CDC, because we have some 
outstanding medical research facilities in that area as well.

                        diabetes control program

    Related to that, last year we discussed the implementation 
of CDC's diabetes control program. And as you know, Texas has 
applied for a diabetes control grant to serve the more than 
850,000 Texans suffering from diabetes.
    On page 86 of your budget justification, you state that 
about 14 to 15 States will be supported this year at the 
comprehensive level in their development of diabetes control 
programs. How many grants have been awarded so far?
    Dr. Broome. The expertise of the chronic disease center 
informs me that we have some funding for all States to have at 
least core capacity in diabetes. Five States will be funded for 
comprehensive diabetes control and prevention programs.
    Mr. Bonilla. Doctor, when do you expect the grant awarding 
process to be completed?
    Dr. Broome. For this year, the grants will be completed 
near the end of the fiscal year, so that would be September.
    Mr. Bonilla. I understand that CDC and NIH, the Joint 
Diabetes Education Program, is now underway. Would you 
elaborate on the current status of this project?
    Dr. Broome. We are very enthusiastic about this joint 
effort with NIH to have a national diabetes education project, 
which mirrors the kind of success that has been had with 
education projects in other chronic disease areas. We have been 
jointly funding this, and it is well underway.

                        prevention effectiveness

    Mr. Bonilla. I want to get into another area that you 
talked about. We all agree that prevention is so critical in 
this day and age. In fact, it's mind-boggling to me that with 
all the warnings about smoking, with all the warnings about 
diabetes prevention, with all the warnings about obesity, that 
people still choose to ignore this. If you teach a person 
something 10 times, 20 times, 30 times, over and over, do we 
reach a point where we're wasting our effort, where we're 
wasting money?
    In this day and age, with the media exposure we have to 
public service advertisements and the things that doctors, 
everyone who sees a doctor gets the advice from the authority 
face to face. And I'm just flabbergasted that more people in 
this country are not listening to what we're telling them. 
Every cigarette pack has a warning sign on it. In Texas, we 
have a law now that minors face if they buy cigarettes 
illegally. And I support that.
    But I'm concerned now, again, that some of these 
initiatives like the additional anti-smoking initiatives are 
just throwing money away, again, for a politically correct 
agenda that really isn't going to make a difference.
    Dr. Broome. I think that there's a lot of difference 
between putting information out and having an effective 
prevention program. I'd like to point out several ways in which 
we think we can make a difference.
    Let's take the example of physical activity. And I think we 
all are very aware of the couch potato image that unfortunately 
is all too prevalent in this country. The Surgeon General's 
first report on physical activity put together a lot of 
scientific information about the risks.
    But the most important step forward was informing people 
that they didn't have to go out and run marathons in order to 
get the benefits of physical activity. Moderate physical 
activity also provides substantial health benefits. And that 
moderate activity can be very much part of your daily lives, 
taking the stairs instead of the elevator, walking the dog a 
little more actively.
    And we're trying to follow up on that report with messages 
that are appropriate for different groups. For example, 
arthritis sufferers can very much benefit from moderate 
activity. We have a randomized controlled trial of the 
arthritis self-help course in which we've shown a decrease in 
doctor visits and a decrease in pain with a comprehensive self-
help education course which teaches arthritis sufferers what 
they can do to make their arthritis more manageable.
    So I think we have some sort of specific instances where 
doing a better job of identifying the right messages, of 
working with groups, can produce benefits from that knowledge.
    Mr. Bonilla. I know I'm out of time now, but just as a 
closing comment, again, related to what we're talking about, 
I'm picturing now someone that I know back in San Antonio who 
has, is a single person, has no children, lots of time, and 
understands clearly what some of the negative impacts are of, 
number one, smoking, which this person does, and lack of 
exercise, which this person is guilty of not doing.
    Yet, in spite of being educated over and over and over 
again, she's now getting into her 40s, and still would rather 
be the couch potato.
    So I wonder, at some point, what do you say, give up on 
that person, there is nothing you can do. Can you spend that 
dollar instead to develop a great vaccine for something else? 
It's a tough choice, but to put it into something else.
    I don't expect you to respond to that, because I'm out of 
time. [Laughter.]
    Mr. Porter. Thank you, Mr. Bonilla.
    I want to advise members of the subcommittee that we're 
proceeding under the eight minute rule, and also that we are 
following the rule of the subcommittee that those who are here 
at the beginning of our hearing will be recognized first, and 
then those who arrive during the course of the hearing will be 
recognized in the order of arrival.
    The problem I have is that all the people who were here at 
the beginning are Republicans, and all the people that arrived 
late are the Democrats. [Laughter.]
    Mr. Porter. So I guess perhaps--it's not usually that way. 
It's not usually that way, but let me say, maybe by enforcing 
the rule we'll change lifestyle here, and----
    [Laughter.]
    Mr. Porter. Mr. Dickey.
    Mr. Dickey. Thank you, Mr. Chairman.

                          prevention research

    Hi, Dr. Broome. I've got an interest in prevention, and I 
note in your statement that we have only 1 percent of $1 
trillion in our U.S. health care budget to spend on prevention. 
I'd like to talk about it in terms of it being an investment. 
And if I'm going to make an investment in something, I'd like 
to know if there's a return.
    Can you tell me just generally, not specifically about 
anything, if we as a Nation double our investment in 
prevention, what type of return will we get?
    Dr. Broome. Well, I will avoid going into columns 
ofnumbers. But I would answer that we have two categories. First of 
all, we think it is very important to answer that question, to look at 
what is the cost effectiveness of our prevention activities. And in 
fact, we have a group which provides expert consultation to all of our 
programs in order to assess the cost effectiveness of those programs.
    Prevention interventions, you could broadly divide into two 
groups. One actually saves money. For every dollar that we 
spend on immunizations, the country saves money. Between $6 and 
$20 per dollar spent. So that's a pretty good investment, I 
think anybody would agree.
    There are other cost saving interventions, such as diabetes 
education for prevention of blindness and kidney disease, and 
treatment of chlamydia infection to prevent infertility and 
pelvic inflammatory disease. Those have been shown, with good 
documentation, to save money for every dollar invested.
    But I think it's a mistake to hold prevention to a higher 
standard than medical care. We don't ask, does heart surgery 
save money? We say, this person needs heart surgery, and we're 
willing to invest, as a society, the money in that heart 
surgery.
    I would argue that prevention is a good investment, that 
people, I think, are willing to spend money to have a healthy 
life, to prevent the occurrence of that heart attack. What we 
are trying to do is provide the information about how much do 
you have to invest to get a year of healthy life for the 
different kinds of prevention interventions. And they compare 
very favorably to many health care interventions.
    Mr. Dickey. Mr. Bonilla, my colleague, was saying people 
know what they should do, and still don't do it. Now, I'm still 
looking at this thing from an investment standpoint. Whether or 
not we can spend the money to inform is one thing, and but it 
seems that we should then somehow encourage and give incentives 
to change behavior.
    What we need to hear, or what I need to hear is, if we do 
that, can you say, looking at the whole picture, that we will 
in fact win the battle, or at least make some gains?
    Dr. Broome. Well, this is an excellent example of why we 
feel prevention research is so important, that we don't want to 
just keep telling people over and over and over in ways that do 
not result in a change in improvement in health. And let me 
give you an example in the injury area of how we've looked at 
different ways of trying to change behavior. In this case, use 
of bicycle helmets.
    We have, first we supported the research that showed 
bicycle helmets are 85 percent effective in decreasing head 
injuries due to bicycle accidents. But then we said, well, it's 
not so easy to get kids to wear bike helmets. How can we 
encourage them to really use these helmets?
    And first we looked at education programs, at giving away 
bike helmets, to make no cost to actually having the helmet. 
But we also looked at the impact of States and localities who 
chose to pass legislation requiring bike helmet usage in 
children.
    The State of Oregon did a very effective research project 
showing that not only did helmet usage go up after the State 
passed a bike helmet child use law, but head injuries went 
down. So we think it's important to look at the range of 
different ways we could use.
    Mr. Dickey. Let's talk about obesity. You mentioned diet 
and exercise. Now, I don't want you to make any personal 
references to me in this answer, if you don't mind. [Laughter.]
    But there are numerous things, numerous diseases that you 
avoid by not having obesity in your life.
    Now, how can we give incentives for people who know, 
speaking from personal experience, who know it's wrong to be 
obese? What type of incentives can we give to get people to 
lose weight, to lose fat content?
    Dr. Broome. We think the most effective strategies to 
reduce obesity are in fact the improved diet and physical 
activity, that those two strategies together have been, 
although it is a very difficult problem, it can be effective in 
reducing obesity.
    The issue of how to effectively have people understand that 
and implement it is very difficult.
    Mr. Dickey. Understanding is one thing. I'm not asking how 
we should inform.
    Dr. Broome. Exactly.
    Mr. Dickey. How do we give incentives to change behavior? 
How can we as a government give incentives? How can we as a 
Nation give incentives? Do you have any thoughts on that?
    Dr. Broome. I think that this is an area which we really 
only recently had substantial funding for. And we've actually 
reorganized in the chronic disease center to put an emphasis on 
this. So I guess my answer would be, we don't have the answers. 
We do think this is a high priority area where we'll be looking 
at what works. If you could ask us next year, we hope we'll 
have some answers.

                        measuring health status

    Mr. Dickey. Okay, let me do this. Name me some measurable 
items of good health. I'm probably saying it wrong. That you 
can actually measure without going into the hospital and being 
admitted to measure your blood pressure for example.
    Dr. Broome. Blood pressure, you can take a history of 
physical activity, of use of immunizations----
    Mr. Dickey. Physical activity is subjective, though, isn't 
it? It's the report of the patient?
    Dr. Broome. Right.
    Mr. Dickey. Okay, now, let's talk about things that are 
objective, if we can.
    Dr. Broome. Weight.
    Mr. Dickey. Weight. Thank you.
    Dr. Broome. Weight and height, which tell you together what 
the body mass index is.
    Mr. Dickey. Cholesterol.
    Dr. Broome. Well, cholesterol takes a lab measurement, but 
that's certainly one of----
    Mr. Dickey. It is objective, and that's not a real big 
cost, is it?
    Dr. Broome. No, and we think that's an important part of 
preventive health services.
    Mr. Dickey. And what other items could we measure 
objectively without a great cost? Is there anything else?
    Dr. Broome. Dr. Gayle wants me to be sure and mention 
sexually transmitted diseases, which we can measure 
objectively.
    Mr. Dickey. No comment. [Laughter.]
    Dr. Broome. And I would argue that in fact, self-reporting, 
although not perfect, has been shown to be reasonably reliable. 
People, there's sort of a fudge factor, but you can----
    Mr. Dickey. That's the problem. Well, is my time up? I'll 
come back later. Thank you.
    Mr. Porter. Thank you, Mr. Dickey. Mr. Stokes, by reason of 
his being ranking on VA-HUD, has requested an exemption and is 
recognized next.
    Mr. Stokes.
    Mr. Stokes. Thank you, Mr. Chairman. For the record, that 
subcommittee starts at 9:00 o'clock in the morning. Therefore, 
I could not be here at 10:00. Otherwise I'd beat all those 
Republicans here. [Laughter.]

                       race and health initiative

    Dr. Broome, let me start with the question that was posed 
to you by Mr. Bonilla. And, I'm sorry Mr. Bonilla's not here 
now, because I think he asked a very important question. I 
think it's one we should address appropriately, and you're the 
appropriate person to address it.
    I've been sitting on this subcommittee for more than 20 
years. For more than 20 years, I have had to, year after year, 
probe about the disparity between minority health and majority 
health in this country.
    In 1985, the Department of Health, Education and Welfare, 
under Secretary Heckler, issued a report that said that there 
are 85 thousand excess deaths in the minority community, and 
cited six specific areas: heart attack, stroke, cardiovascular 
disease, suicide, homicide, and I believe diabetes was the 
other where we have these excess deaths.
    Ten years, later in 1995, there was a ten year update. That 
report found that the country still had a serious health 
disparity between minorities and white Americans. The 
President's initiative, as I understand it, is designed to 
seriously attack this problem where African-Americans die seven 
years earlier than white Americans, in every category of 
disease from cancer, to cardiovascular diseases including heart 
attack and stroke. There's a very serious disparity between 
white Americans and black Americans. And the President is 
trying to attack these problems frontally with these types of 
initiatives.
    Now, I see in your budget you address this. Would you 
explain for Mr. Bonilla's sake, for my sake, and for the 
Nation's sake why the President is doing this, and why this is 
not pandering. This is a President trying to be sensitive and 
responsive to the kind of disparity I've addressed.
    Dr. Broome. Well, I think this goes back to something that 
we as an agency really believe that what gets measured gets 
done. And I think the difference is that we now have specific 
targets, both for the year 2000 and the year 2010, for 
decreasing and then eliminating the different, increased 
burdens of disease seen in minority populations.
    As Mr. Bonilla noted, we already have a number of programs 
which address the disproportionate health impact in minority 
communities. And we have made progress, but not enough, as you 
point out. This is something that has been known for a long 
time.
    We believe that having these very specific targets will 
help us work with our own programs and with our partners to 
measure our progress and to make those goals. So we feel that 
this really is raising this to a different level.
    And I don't know, I assume you are familiar with the Year 
2000 goals for the Nation. It's another example of having goal 
setting. We haven't met all of those. But by focusing attention 
on those programs, we have made progress. And we have 
influenced how our partners and State and local health 
departments and community organizations measure what they are 
doing.
    The Year 2010 goals are under preparation. There will be no 
different goals for different ethnic and minority populations 
in the Year 2010 objectives. We will have a single objective 
for the country.
    Mr. Stokes. A few moments ago, Ms. Pelosi, who sits next to 
me, showed me your chart.
    Dr. Broome. We have a big one.
    Mr. Stokes. Can we refer to it for a moment?
    She was pointing out to me the disparity in terms of the 
AIDS case rate in persons 13 years of age, which is shown on 
this chart, where you can see the red block, which is marked 
white, and next to it the yellow block. I understand that in 
the next hour, seven Americans will become infected with AIDS. 
Three of the seven will be African-Americans. Is that correct?
    Dr. Broome. That's right.
    Mr. Stokes. Talk about that chart a moment, so we can 
understand what the President's trying to do here.
    Dr. Broome. Okay. The occurrence of AIDS in African-
Americans is seven times the rate in white Americans. And we 
consider this an indication of an urgent health crisis.
    The prevention programs, there are two particular areas of 
activity that we're focusing on. One is prevention of new 
infections in the first place. And this obviously is a primary 
goal of CDC AIDS prevention activities.
    In the minority community, we have targeted prevention 
activities toward minority communities in several ways. Most 
fundamentally, we use the community planning process, which 
tries to have local areas identify their priority groups and 
how they should be approached in terms of preventing AIDS.
    In addition to that, we have directly supported 94 
community-based organizations to address minority AIDS and HIV 
issues. In addition to that, as has been noted in previous 
budget increases, it's very important for us to address the 
prevention of HIV/AIDS in populations who use drugs 
intravenously. And this has affected minority communities 
disproportionately.
    We feel that it's very important, because of the increased 
rates of HIV/AIDS in minority communities, that we be sure our 
prevention programs are reaching those populations and having 
an effect.
    The other major issue for minority communities is being 
sure that they have access to treatment. As you all know, we've 
had a very encouraging decline in AIDS deaths nationally. 
However, that decrease has been much more striking in white 
groups than it has been in minority populations, such as 
African-Americans. We're very interested in working with our 
colleagues in the health care area to be sure that treatment 
access is also addressed.
    Mr. Stokes. But, would you say from your chart that AIDS 
has reached what we would describe as a disaster area in the 
United States as it relates to African-Americans?
    Dr. Broome. I think that it is a very serious crisis for 
the African-American community. Our surveillance data have 
identified this, and we are actively working with African-
American organizations to address it.
    Mr. Stokes. My time has expired. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Stokes.
    Mrs. Northup.

                                tobacco

    Mrs. Northup. Thank you, Doctor. I'd just like to respond, 
if I may, sort of in a statement form for a coupleof minutes 
about some of the things that were discussed previously. And in 
emphasizing how important I think your education programs are.
    I think changing behavior is enormously difficult. I think 
every single person can think of resolutions, to go to bed 
earlier, to lose weight, to exercise every day. And you do it 
incrementally--two steps forward, one step backwards.
    I think it's very hard to measure change over three months 
as opposed to over three years. Do you, over three years, learn 
to eat less fat? Do you, over three years, start eating more 
vegetables? And those are the kinds of changes that humans can 
accomplish in the long term? But it's very difficult in a day 
to day basis.
    But I do think that education is very clearly effective. 
Overall, we know that the more health education a person gets, 
generally they adhere to better health processes. It slowly 
makes a dent into our subconscious. Anybody who is a mom or a 
dad and tries to help a child change a habit knows that you 
don't wake up one morning and give your child a one page 
explanation about why they should start studying or be more 
organized. You help them every day for years become a more 
organized person.
    And that's why I think CDC's general effort to educate and 
target is so very important. I'd like to specifically apply 
that to tobacco.
    We can say that everybody knows that it's not good to 
smoke. And if you go into probably any classroom where you have 
7 or 8 year olds, you will see every child raise their hand and 
say they're not going to smoke. We're so involved in the class 
of 2000's effort to have a smoke-free class of 2000. Every 
seventh grader was so proud to be a part of that class.
    Yet if you go to the graduating classes, the class of 2000 
that are now sophomores, you find an enormous number of those 
children that smoke. So even though they get the information on 
health effects, they are also subject to $10 million of 
advertisements every day in this country, every day, $10 
million of advertising, connecting being popular, being cute, 
being successful, being liked by everyone, related to smoking.
    And when you become 11 years old, knowing that your mom and 
dad think you're great isn't your only objective. [Laughter.]
    It was the most heartbreaking thing I learned when my 
oldest became 11. And when they're 12, they want to know in 
seventh grade, of course my mom thinks I'm handsome, does the 
kid that sits next to me in class think I'm neat. And the first 
time they show up at a mixer, they think, how am I ever going 
to stand out as a person? The shortcut of having a cigarette 
with their peers is something that is innate in them because of 
the years of advertising that exist in this country.
    That is why it is so important that we have an effective 
counter-advertising strategy.
    Now, Mr. Chairman, I have to tell you I disagree, I don't 
know why the TV stations should bear the cost. I don't know why 
the tobacco companies shouldn't bear that cost. If they're the 
ones that have created this atmosphere that smoking is so neat, 
and they say they don't want 13 year olds to smoke, then why 
don't they also fund the program to effectively target 13 year 
olds.
    Mr. Porter. Okay, I agree with that. [Laughter.]
    Mrs. Northup. I just had to get that in. [Laughter.]
    And I'd like to point out that it's not public service 
announcements. The neatest ad I ever saw was the one in 
California where it shows on a park bench two 13 year olds 
starting to kiss, getting closer and closer, and at the very 
last minute, the little girl says, ``Yuck, your breath smells 
like smoke.'' [Laughter.]
    And you know, that message gets to kids in a way that a 
public service announcement doesn't.
    So I just want to really encourage you to continue your 
efforts with the States that have incurred this cost themselves 
and to make it available to help direct public policy in that 
direction.
    You pointed out that adult smoking has declined. I think 
it's true, it's because of education. But you did not mention 
youth smoking, and the last time I saw, that was going up. Is 
it still going up?
    Dr. Broome. This is something that is of great, great 
concern to us. Youth smoking has increased. That increase 
tracks along very well with increasing advertising and 
promotional activities on the part of the tobacco companies.
    The only somewhat hopeful sign is that in the States, 
California, Massachusetts and Arizona, that have had very well-
funded, extensive tobacco prevention programs, the rate of 
increase is substantially less. It's not good enough. We want 
to prevent youth smoking. But it does appear that comprehensive 
tobacco prevention programs can be effective.
    I couldn't do a better job of describing what those 
prevention programs might look like than you already have. I 
would just add two additional points. Those media campaigns 
don't just emerge. They need to be part of a well-designed 
health communication strategy which tests the message, which 
sees whether it's having the desired impact and alters the 
campaigns as needed. The materials that we are distributing 
have been through that kind of process.
    Secondly, we're very optimistic about a campaign called 
Media Smart, where we try to educate teenagers about how they 
are essentially being manipulated and fooled by commercial 
advertising. Teenagers don't like to be fooled or to look 
stupid.
    We think there is some opportunity to make them smarter 
targets of advertising, and better able to discern what the 
companies are really trying to do.
    Mrs. Northup. Well, I'd like to also point out that we have 
heard so much from the people that have come before us this 
week in support of the Administration's position on the tobacco 
settlement that offsetting the tobacco companies advertising 
could be done cooperatively. That is by them agreeing not to do 
so much advertising, which has been so effective.
    But we cannot do that by law. That has to be a cooperative 
effort that was part of a negotiated settlement.
    Now, we all know, and they know, that we have to change 
that settlement. It doesn't have the support base it needs. But 
one of the ways of changing the atmosphere and the way kids 
think is by having them not bombarded, and by also quite 
frankly, having the tobacco companies have to incur a bigger 
penalty if youth smoking keeps going up.
    And if we don't have some sort of negotiated settlement 
that includes a cooperative agreement to reduce advertising and 
to share in the burden if youth access goes up, we aregoing to 
find ourselves doing one thing and having very smart companies that 
haven't bought in find another way through the cracks. I'd really like 
to encourage the Administration to, rather than just sign on a 
unilateral bill, to put together a bill that has the cooperative 
effort, different maybe, but cooperative effort of what was proposed. 
Because we cannot negotiate that through 435 members of Congress.
    Dr. Broome. You made an absolutely crucial point, and that 
is our ability to monitor what's going on. CDC, particularly 
the National Center for Health Statistics, has developed in 
consultation with experts in the academic community a very 
specific proposal for how we could do effective monitoring of 
youth smoking, of youth starting to smoke. So we would know 
what effect our programs are having.
    Mrs. Northup. Okay.
    Mr. Porter. Thank you, Mrs. Northup.
    Mr. Miller.
    Mr. Miller. Welcome, Dr. Broome.

                       race and health initiative

    Before coming to Congress a number of years ago, I was a 
professor at Georgia State University in Atlanta. I taught 
statistics. My first lecture in statistics was always how to 
lie with statistics. It's an interesting lecture I used to do, 
because it was entertaining and it shows how you can prove any 
point using statistics.
    There's no question there is a statistical disparity 
between blacks and whites, on, for example, AIDS. But is that 
really the best statistical measure? What about income, 
education, families? What do the statistics really show? what 
is the real cause?
    So answer that question, if it's income, then we should 
target all low-income people.
    Dr. Broome. Well, I love to get these kinds of questions, 
because my background is actually as an epidemiologist. What I 
ask people all the time is have they separated out the effects 
of income, of particular geographic locations, or other 
variables?
    In this instance, and I think it's also important to point 
out that we use race as a variable which can be a marker for 
many different and complex risk factors. Being clear about what 
the particular problem is lets us tailor an intervention to 
that particular area. Having said that, when you look at 
income, there still is an increased risk among minority 
populations for HIV/AIDS.
    There is also, and again, the issue of how to address that, 
you have to look at some of the different risk groups. Some of 
that is heterosexual transmission, some of that is transmission 
related to intravenous drug use. Some of that is transmission 
related to poverty. That means that it's not uniquely African-
American or Hispanic. But we do need to look at the particular 
circumstances in a particular population.
    That's again why community planning has been so important 
in trying to design prevention strategies that are appropriate 
for individual communities.
    Mr. Miller. I always have a concern about creating new 
programs, because I think we have too many programs in the 
Government right now. Are there not better variables than just 
race on these issues? Is that really the best variable to work 
with? What would be the best variable, for example, in AIDS?
    Dr. Broome. We look at it in many different ways. One of 
the most traditional has been the particular risk groups and 
means of transmission. That's where you divide sexually 
transmitted, transmitted in the early days by blood 
transfusions, transmitted by intravenous drug use. And those 
are important ways of looking at it, because they suggest 
what's the appropriate prevention strategy.
    But it's also important for us to understand the 
epidemiology which may be quite different. For example, in 
rural communities and in urban communities. There really isn't 
a one size fits all solution.

                      hemophilia and blood safety

    Mr. Miller. We can talk some more about the issue of what 
is the best variable, and whether are we are just creating 
programs. But in my limited amount of time, let me switch to 
another subject. An area that I personally had an interest in 
over the past years, and I've brought it up with Dr. Satcher at 
hearings, is the issue of blood safety, of our blood system.
    I have a special interest in hemophilia. In last year's 
report language, the committee encouraged CDC to enhance its 
support of a comprehensive blood safety surveillance and 
patient outreach effort to address the hemophilia product 
safety concerns, to ensure that these resources were available 
for broad implementation of this important public safety 
program. Additional funding was provided for this program in 
the conference agreement.
    It is my understanding these funds have been allocated, but 
that a first-time internal charge for administrative costs was 
assessed at the same time, essentially leaving the effort at 
status quo. Could you tell me more about the administrative 
assessment and why the hematological unit has been charged with 
this assessment for the first time?
    Dr. Broome. Let me see if I can get the name of the bill 
right. The Federal Financial Accounting Improvement Act of 1996 
required us to look at how we assess costs for our different 
activities, including grants and cooperative agreements. So we 
have had an outside consultant look at our accounting practices 
and recommend how the very real costs for administering grants 
are allocated.
    And the recommendation identified that historically, for 
various reasons, CDC had not been charging overhead on grants 
and cooperative agreements. This was judged quite inappropriate 
from correct accounting practices terms. The recommendation was 
that CDC should be charging 1.97 percent overhead on grants and 
cooperative agreements.
    So not surprisingly, programs count on every dollar, and 
they would like to see that all dollars go directly into 
programs.
    Mr. Miller. Are we making any progress in this particular 
area?
    Dr. Broome. We are, actually. I would much rather focus on 
what we have been accomplishing. We have supported surveillance 
in federally funded treatment centers for hemophilia, and we're 
seeing decreased mortality in individuals enrolled in those 
treatment centers. We also are improving our ability to do 
surveillance on the blood supply for a range of organisms that 
might be risk factors. And the hemophilia population has been 
very collaborative and very anxious that we have effective and 
improved surveillance systems.
    I think it's worth emphasizing that the blood supply in the 
United States is exceedingly safe. And we have learned from the 
kind of emerging infection crisis that AIDS caused with the 
blood supply and the hepatitis B and hepatitis C concernsto 
rapidly identify new threats, to get the screening tools which will let 
us keep infectious blood out of the blood supply system.
    But we can't--this is a human product, so it's hard to 
guarantee absolute safety. But we have developed new diagnostic 
tools. We're looking very hard at Creutzfeld-Jakob disease to 
see whether there's any indication that this could pose a risk. 
We're looking at new tools for Chagas disease, for example.
    So I do think we are working very hard to be sure that we 
have the safest blood supply possible.
    Mr. Miller. Do you need any more resources to implement 
this safety program? I know everything needs resources, but is 
there something special?
    Dr. Broome. We have certainly used some of the emerging 
infections resources to address the blood safety issue, and 
also the support for the hemophilia program has been very key 
in monitoring the safety of the blood program. There's always 
more we could do. But we consider this a very high priority.
    Mr. Miller. Thank you, Dr. Broome. As I said, I look 
forward to getting some more information about the 
justification for statistically, that we're just not doing it 
for political purposes, but there is a real statistical 
validity to this method of creating new programs.
    Dr. Broome. We'd be delighted to get you all the cross-
tabulations.
    [The information follows:]
    Offset Folios 219 to 221 Insert here



    Mr. Miller. Not too much.
    Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Miller.
    Ms. Pelosi.
    Ms. Pelosi. Thank you very much, Mr. Chairman.
    And thank you for the eight minutes. I hope it's the same 
eight minutes that my Republican colleagues have used. 
[Laughter.]
    Dr. Broome, thank you for your excellent testimony. I join 
with our distinguished Chairman in commending you on that 
statement, but also for your excellent work.

                  hiv/aids prevention and surveillance

    As we all know, the charge of the CDC is promoting health, 
preventing disease, injury and premature death. So in the 
interest of promoting health, I think one of the issues before 
us that I hear my colleagues talking about is why do people not 
get the message. I think the answer is that we send mixed 
messages.
    For example, as I said yesterday, we tell children 
education is important, yet we send them to schools that are 
falling apart. If it's important, then let's make it important 
across the board.
    We talk about health and we look at this chart, yes, we can 
probably extrapolate from that chart that many of the people in 
the yellow column are poor. But as you honor your charge in 
promoting health, preventing disease, injury and premature 
death, and we try to send a message to people to change their 
behavior, whether it's tobacco, which was appropriately 
emphasized here, or whether its unsafe sex practices, etc., we 
should also send a message to the communities of America, rich, 
poor or otherwise, that promoting health is important, and that 
we make it a priority by giving access to everyone to quality 
health care.
    Until we do that, I think we're fooling ourselves. First of 
all, our message is a confused one. Health is important, but 
you can't afford to have it, or we can't make it accessible to 
you. And if you happen to be minority, then you will have all 
these increased instances of poor health as well as our 
distinguished colleague, Mr. Stokes, pointed out.
    He emphasized that, as you will recall, in our visit to the 
CDC when some of our colleagues came down there, and you 
welcomed us and gave us a report on what you were doing. That 
was very beneficial.
    But it was also very important for us, as far as Mr. Stokes 
was concerned, to convey in the area of HIV that our prevention 
efforts have to be much more specifically targeted. I 
appreciate your emphasis that you have made on community-based 
solutions. Certainly Dr. Helene Gayle is an expert in all of 
this, and I commend the CDC for the extremely important work on 
HIV prevention that you are doing.
    Today that work is crucial, as we've discussed. At least 
one more American is infected every 13 minutes. With every 
passing day, the newly infected person is more likely to be a 
woman, a young person, or a minority.
    CDC has been on the front lines in the battle against HIV. 
And given your effort, I was disappointed that CDC HIV 
prevention activities were flat funded in the Administration's 
budget.
    Mr. Chairman, with your leadership, and working with Mr. 
Obey, this committee has responded to the urgent need for more 
resources for care for people with HIV. That funding has made a 
tangible, real difference.
    But we must also prevent disease. That's the best dollar 
spent.
    So I would ask you, if you were able to find substantial 
additional funds over and above the Administration's request to 
help you respond to the epidemic, how would you use this 
additional funding to fight HIV?
    Dr. Broome. I couldn't agree with you more on the crucial 
importance of prevention. We still do not have a permanent cure 
for AIDS. So the best approach remains to prevent getting AIDS 
in the first place, getting HIV infection.
    I think it's worth emphasizing that, there issome attention 
to prevention of AIDS in the President's budget request, specifically 
in the demonstration projects for eliminating disparities in health. 
Five million dollars is specifically directed to AIDS prevention.
    In addition, we are hoping there will be an additional $10 
million specifically for syphilis elimination, which as you 
know, can have a dramatic benefit also in AIDS prevention, HIV 
infection prevention.
    So there are two specific areas which will very much be 
targeted toward eliminating disparities.
    In addition I think that there are a number of areas where 
there are new opportunities for improving our HIV prevention 
activities. As you know, we have a very good tool for markedly 
decreasing perinatal transmission. We want to be sure that 
every pregnant woman in this country gets counseled and tested.
    We are already seeing over 50 percent declines in infant 
HIV infection. This is wonderful news related to the use of 
AZT. We also feel we've got very good levels of AZT treatment 
of pregnant women. But we want to be sure that's available.
    Ms. Pelosi. Dr. Broome, I appreciate your response. And I 
want, before my Chairman leaves, not to neglect to say how 
pleased I am with other increases in funding that the 
Administration has put in the budget, for new ADAP drugs and 
Ryan White care and other priorities. It's just the prevention 
piece I was concerned about.
    And in the interest of time, if I might just ask you about 
something you've mentioned a couple of times in relationship to 
the answer you're giving now, and that is, you've talked about 
the community prevention planning process as a model of local 
decision making, which allows each community to respond to its 
particular prevention needs in this diverse and dynamic 
epidemic.
    As you know, we've had some concern about who's getting the 
grant money, especially in the minority community where the 
competition has been keen. Can you tell me about how the CDC 
helps community-planning groups get access to the latest 
science-based prevention research at CDC and NIH? Because we 
believe that the prevention must be science based. We believe, 
though, that has to be conveyed to these groups making 
application for grants.
    Dr. Broome. Well, we agree with you as well, and we're 
doing that in several different ways. One is through the use of 
high quality surveillance data. We need to know where the 
epidemic is going, so that we can be sure our prevention 
messages are reaching the groups at highest risk. This is one 
of the reasons why we are putting forward a major consultative 
effort to be sure that we are tracking HIV infection, rather 
than AIDS cases.
    With the new improved treatments, AIDS cases are markedly 
delayed and do not reflect where the epidemic is today. So we 
and our partners are generally agreed that HIV surveillance is 
an important tool.
    There certainly are still ongoing discussions about exactly 
how that surveillance should be conducted. But we will be 
developing a guidance for State health departments for 
comments.
    In addition, there is certainly specific technical 
assistance that's important both for community planning groups 
and for community-based organizations. We do provide support 
both within CDC and also specific technical assistance groups 
who have the latest research information and can make that 
available to community planning groups.
    Ms. Pelosi. Thank you, if I may, on another subject----
    Mr. Dickey [assuming chair]. Ms. Pelosi, I want you to know 
that you're proceeding only because I don't have enough nerve 
to keep you quiet. [Laughter.]
    Ms. Pelosi. Well, anything that works. [Laughter.]
    I'll be brief, Mr. Chairman.

                       breast and cervical cancer

    The Administration's budget would direct $145 million to 
maintain State-based programs as part of the National Breast 
Cancer and Cervical Cancer early detection program. Can you 
tell us about your successes there and what you see as the most 
crucial needs and best prevention methods, and opportunities in 
women's health?
    Dr. Broome. We think that this has been a very successful 
program, and we very much appreciate the support that it has 
received. Through 1997, we have screened over 1.3 million women 
for breast and cervical cancer. We have detected 23,000 early 
or pre-cancer lesions in the Pap tests. This kind of early 
detection directly saves lives. We believe cervical cancer 
should be a completely preventable disease.
    Now, in addition to the screening program, you can ask, 
well, why haven't we completely prevented cervical cancer 
deaths in this country. And that's why we think the cancer 
registry program is very important. What we're doing is looking 
at where cancers are occurring.
    The State of Rhode Island has done a very creative program 
which shows that in older women, the cancer deaths are 
occurring because they tend to see internists who don't think 
about doing Pap smears. So we can then tailor our screening 
programs to reach those women.
    Ms. Pelosi. I think they're doing them every five years or 
so for older women now.
    The tyrant, the clock, not our Chairman, beckons us, Dr. 
Broome. But I want to thank you again for your extraordinary 
work. Certainly, we miss Dr. Satcher, but he's still there, in 
a new position. But he made a valuable contribution to CDC, we 
all agree on that.
    I also want to commend the Clinton Administration for the 
demonstration projects to reduce health disparities in minority 
populations. I think that is a very, very important initiative, 
science-based, and that promoting your mandate at CDC in that 
context is the most appropriate approach for you to take. I 
commend the Administration and you for that.
    Thank you for your testimony and your answer.
    Mr. Dickey. Dr. Broome, I am certainly supportive of the 
Federal dollars----
    Ms. Pelosi. Are we having a second round?
    Mr. Dickey. No comment. [Laughter.]

                          prevention research

    I am certainly supportive of the Federal dollars that have 
been pouring into medical research. However, I am concerned 
that we might be investing too much in research and too little 
in the dissemination of facts to the general public.
    In your opinion, are we bringing in the research in a 
fashion the public can use it? And then, as a second question, 
or do you believe we are investing in prevention at a rate that 
adequately complements our investment in research?
    Dr. Broome. Well, given my scientific background, I 
dobelieve that additional research yields additional benefits. What we 
would argue is that it's crucial that the public gets the benefit of 
those research results, that it's complementary that we invest in 
turning research results into prevention programs.
    I think it's fair to say, when you look at the 1 percent of 
the $1 trillion dollar budget which is invested in prevention, 
that's not a reasonable proportion, given the value that I 
believe the public places on prevention.
    We've actually just seen a Harris poll in which 93 percent 
of persons contacted felt that it was very important that there 
were programs to prevent the impact of infectious disease. And 
the other 7 percent thought it was somewhat important. 
Similarly, 82 percent thought that it was very important to 
have programs which supported clean water, clean air and dealt 
with toxic substance health effects.
    So I think the public support is there for prevention 
programs.
    Mr. Dickey. What I'm saying is almost heresy, that we might 
have too much research, but I'm not saying that. What I'm 
saying is that if we don't let it out, if we're constantly 
letting our research just exist in the boot camp and we don't 
go out and actually go to war, it doesn't do a whole lot of 
good.
    Are you brave enough to really discuss that?
    Dr. Broome. Well, as a health agency, we've always tried to 
avoid military metaphors. [Laughter.]
    Mr. Dickey. Then let's talk about football. [Laughter.]
    Dr. Broome. But we feel that CDC is really in an excellent 
position to take the results of research and put them into 
practice. We have, as you know, we were very appreciative of 
your visiting. I think you saw the range of programs that we 
have. We have an incomparably trained intramural staff. We have 
outstanding partners in States and in the private organizations 
to really use the research findings today.
    We are, I think, really very good at taking something like, 
for example, the smoke detector findings and using them to 
protect people. In Oklahoma City, we found that installation of 
smoke detectors in the highest risk part of Oklahoma City 
decreased burn injuries, hospitalized burn injuries, by 80 
percent, while the rest of the city was going up 30 percent.
    We have taken the information and encouraged our injury 
prevention programs in other States to use that approach to 
decreasing burn injuries.
    Mr. Dickey. Excuse me, we're going to have to declare a 
recess. Obviously my colleagues don't care about my voting. 
[Laughter.]
    But one good thing is that this is not the second round. So 
no one knows about this if you won't tell them. [Laughter.]
    [Recess.]
    Mr. Porter [resuming chair]. The subcommittee will come to 
order.
    I'm going to ask a question until members of the 
subcommittee return.

                            needle exchange

    Dr. Broome, let me ask you about needle exchange and needle 
distribution. As you know, our appropriations act that was 
passed last year prohibits the use of funds for needle 
distribution projects, but permits the funding of needle 
exchange projects after March 31st, subject to certain findings 
by the Secretary and certain guidelines prescribed by the 
Secretary.
    The Administration has been involved in the needle exchange 
debate for several years. Legislation that permits such 
programs under the circumstances I just described was signed by 
the President five months ago.
    Nevertheless, we continue to get mixed messages from the 
Administration about its policy on this matter. Recently, 
General McCaffrey was quoted as indicating that such programs 
were perhaps not the right way to proceed in fighting illegal 
drugs.
    Does the Administration have a unified policy regarding 
needle exchange projects, and if so, what is it? If not, why, 
after all this time, does the Administration not have a unified 
policy on this important issue?
    Dr. Broome. I don't think that I'm expected to speak for 
the entire Administration. I do think it's important that we 
emphasize that there is an epidemic of HIV/AIDS among 
intravenous substance abusers in this country. And I think the 
Administration's position really was summarized in Secretary 
Shalala's February 1997 report to Congress, which concluded 
that needle exchange can be an effective component of a 
comprehensive strategy to prevent HIV and other blood-borne 
infectious diseases in communities that choose to include them.
    The Department is continuing to look at the issue, and has 
not yet concluded that the conditions set forth by Congress 
have been met.
    Mr. Williams. I think it is as you stated, the evidence is 
fairly strong that needle exchange programs have an effect on 
AIDS. That evidence is less clear with respect to drug use. So 
I think the Administration supports continued looking at needle 
exchange programs that are started by local communities to 
continue to gather evidence on this. But until that evidence is 
more conclusive, I think the Administration continues to 
support the two-prong test as it has existed before.
    Mr. Porter. Mr. Williams, I would direct the Administration 
to look at the program in Baltimore by Dr. Belinson. I think it 
has done very well in both respects, and might be the model.
    Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman.
    We're delighted to see you here, Dr. Broome, thank you 
very, very much for your testimony.

                          prevention research

    I was struck by this chart, investment in prevention. I 
understand while I was gone, my colleague Mr. Dickey made 
reference to the research budget. But I just wanted to comment 
that this is, total U.S. health care budget equals $1 trillion, 
1 percent equals prevention.
    And it just seems to me that I think that we who are asking 
the questions are incredibly self-serving and maybe somewhat 
disingenuous and insincere when we talk about spending 1 
percent of our health care budget on prevention and then we 
start to talk about how we are stopping children from smoking 
by what we're doing in terms of prevention.
    How are we stopping illness in a variety of directions, 
whether it's AIDS or whether it's any other area, that in many 
cases, when you think about it, we who do appropriate money and 
resources here, and then we stand here and sit here and say, 
why haven't you done all of this, why haven't you ended the 
AIDS epidemic, why haven't you stopped people, whyhaven't you 
changed your behavior with what you've done.
    Again, I've made the point, I think this is really the 
height of the wonderful Yiddish expression, which is chutzpa, 
that we don't provide the resources, the serious resources, to 
deal with prevention on the scale that we need to in order to 
truly try to make a difference.
    That being said, that being said and what I want to do, 
because you have done an unbelievable job at CDC, and I 
compliment you for what you have done. You have made a 
difference in the lives of people in this country. And in fact, 
it is, how do we prevent disease. What is that cutting edge of 
medical research that is going to allow us to do that.
    I want to hear something from you about, you know, what are 
the prevention programs that have been the most successful? How 
do you measure those results? What is your sense of what we 
could be doing, what we are and could be doing that is in 
effect going to help us save money in the long term? And can 
that be accomplished, in your mind? Can we get to the goal that 
we would like to get to, if we have the will to do this?
    Dr. Broome. Well, thank you very much for those comments. 
We do feel a real urgency in trying to apply the prevention 
tools that we have. Women should not be dying from cervical 
cancer in this country. Our senior citizens should not have the 
kind of burden from influenza and pneumonia that we could 
prevent with influenza vaccine.
    I think I tried to outline in my testimony only a few of 
the areas where we have interventions that work, and they're 
being used, but not as completely as they could and should be, 
whether that's influenza vaccine, getting the coverage up from 
60 percent to, as with childhood immunization, we've reached 90 
percent with the kind of substantial investment that has been 
made and the kinds of commitments on the part of all of our 
partners. We should be able to do the same with our seniors. 
Similarly, chlamydia is an excellent example, where we have 
shown by a very orderly approach, starting with the basic 
research randomized controlled trial, to show that detection 
and treatment of chlamydia works, and then implementing that in 
States as we've had the funding available.
    And we estimate that the impact on preventing infertility, 
the impact on preventing pelvic inflammatory disease, is very 
substantial and cost saving. So that we have, as feasible, 
expanded those programs.
    There's a number of other examples I can give, but we do 
agree with you that we have tools, and we would be very happy 
to use those nationwide.
    Ms. DeLauro. Well, just a final comment on that, and then 
I'll move to one or two other things. But I think that we truly 
do, if we are sincere about this effort, need to work with you. 
We've got to, in a world of limited resources, but we've got to 
identify where our priorities our, if we do know how to save 
people.
    And it isn't a question of geography when it comes to 
cervical cancer, is that where you've got a center, that 
determines your ability to survive. We need to take a hard 
look, if we are going to sit here and evaluate, and we're going 
to sit here and make pronouncements on whether you are a 
success or a failure at what you are doing to stop these, then 
I think we have got to, you know, step up to the plate here and 
sit with you and others of you and our colleagues in this 
committee in particular, and figure out where we don't have 
that sliver of a line we're talking about prevention of 
illnesses and diseases in which we truly know today we can make 
an impact.
    So I think that we have to have that as a goal for those of 
us who are here.

                                tobacco

    Let me just mention, because you've answered lost of the 
questions on the tobacco control, we have today with all the 
outreach, etc., 3,000 youngsters who are smoking every day, a 
third of whom will die from tobacco-related illnesses. This is 
once again another area, 420,000 people die every year from a 
tobacco-related illness. My God, if we had an outside force 
coming in and killing 420,000 of our people every year, we 
would determine this an external threat we couldn't live with, 
and we would figure out how to mobilize and go after it.
    This is in fact what some of us are trying to do in this 
area, particularly to start with our youngsters. So I applaud 
your efforts here and the outreach that you are making. I would 
love to have a conversation with you at some point about 
something that we have done in the Third Congressional District 
in Connecticut, which is called the Kick Butts Connecticut 
Campaign with middle school children and the use of the 
broadcast media, as our Chairman has talked about. But the use 
of the community and of getting kids to go, middle school 
children going into elementary schools and help prevent their 
peers from starting to smoke.

                             women's health

    I am interested in the WISEWOMAN project, which established 
three demonstration clinics through the breast and cervical 
cancer program to more fully meet the health care needs of 
high-risk populations. And in fact, we do have high-risk 
populations. I understand that you have some preliminary 
results from the project. I wonder if you would share them with 
the committee, and what would be gained by expanding that 
project.
    Dr. Broome. Okay. I'm delighted to report back to you on 
the results of the demonstration projects that the committee 
supported. This is an attempt to actually be very efficient in 
delivering our prevention activities by combining other 
prevention services with the breast and cervical cancer 
screening program.
    The Well-Integrated Screening and Evaluation for women in 
Massachusetts, Arizona, and North Carolina, or the WISEWOMAN 
program, has been implemented in three States. In addition to 
breast and cervical cancer screening, it provides high blood 
pressure checks, cholesterol checks, physical activity, diet, 
and smoking counselling. We have provided those services to 
over 4,000 women.
    I think one of the most interesting results is that we have 
identified 50 to 75 percent of the women screened who have 
increased blood pressure, which is a very direct risk factor 
for cardiovascular disease and stroke. We've been able to refer 
those for treatment.
    Ms. DeLauro. Quickly, do we have enough results here to 
understand that what we could do in terms of prevention, If we 
expanded this program? If we were in 50 States, what our 
benefit would be in terms of reducing the risk here?
    Dr. Broome. I don't have those numbers right at the tip of 
my fingers, but we would be very happy to get those for you.
    Because we do think we have some promising results.
    [The Information follows:]

                               Wisewoman

    In order to better understand the health benefits in many 
other populations, CDC needs to expand the WISEWOMAN program to 
target other populations such as Urban African-Americans, 
Western Native Americans, Cuban-Americans, and border 
populations. CDC would like to increase the number of States 
authorized to receive funds under the WISEWOMAN demonstration 
program from three to eight States. By expanding this program 
to five additional States, CDC will be able to develop valuable 
insights into the feasibility of and benefits of integrated 
preventive services and test other interventions, such as, the 
Arthritis Self-help Course.
    Health benefits of expanding the WISEWOMAN program are 
based on results from the three current demonstration projects:
    More than half of the uninsured and underinsured women who 
participate in the NBCCEDP WISEWOMAN sites have high blood 
pressure or high cholesterol and more than two-thirds are 
overweight.
    In Arizona among Hispanic populations, 1 of every 10 women 
have high blood glucose values.
    In North Carolina among white and African-American women, a 
simple counseling tool aimed at improving diet and physical 
activity was provided to participants. Their diet improved; 
physical activity increased, and cholesterol levels decreased 
on average by 4% within one year.
    In Massachusetts among an ethnically diverse group of 
women, who participated in an intensive intervention that 
provided community education and support, diet improved, 
activity increased, and the percentage of women with high 
cholesterol will likely decrease on average by more than 25% 
within one year.
    Results from the Massachusetts program show that WISEWOMAN 
participants had a higher return rate for annual mammograms 
than did nonparticipants (60% vs 31%).

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

                             teen pregnancy

    I co-chair a teen pregnancy prevention task force in this 
Congress, which is bipartisan, with Mike Castle. We've seen 
many of the studies, and we're trying to fund additional 
studies to show what works and what doesn't work. An 
interesting report which recently was released from Harvard 
shows that the PSAs frankly don't have that much impact. The 
story lines, the programs which our Chair referred to, do have 
impact.
    We continuously ask public television and other members of 
the media what we can do to get positive messages in the 
programs that the kids watch, or if they're positive messages, 
why won't they watch. How can our creative talents be put to 
work encouraging programming that kids will watch.
    An interesting statistic which I just heard this morning, 
is that most people in America get their health information 
from a program called ER. Now, that's amazing. I find that 
extraordinary.
    So I won't pursue this line of questioning, and I'd love to 
talk with you and have follow-up meetings. But how can we 
better get the media involved, get our creative talent 
involved, in creating messages through programs that the kids 
will watch, so we can impact this critical question, what do we 
do about the health consequences?
    We know the information, why can't we get it across, to 
even people like us, whether it's obesity, smoking, or alcohol 
use, etc?
    Briefly, before we go on to a couple other questions, I 
know you are doing a study on teen pregnancy. And we would like 
to have any information available or would you prefer waiting 
until the study is released? If you have anything to share with 
us on what works and what doesn't work, that would be very 
helpful.
    Dr. Broome. We do have 13 demonstration projects. At this 
point, I think it would be premature to provide results, but 
we'll be very happy to get those to you as soon as they're 
available.
    [The information follows:]

                   Teen Pregnancy Prevention Project

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

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

                    assisted reproductive technology

    Another area that I think is so important, I was delighted 
to see your report on assisted reproductive technology success 
rates. We all have friends or family members that have spent 
enormous amounts of money on fertility treatment, plus going 
through an agonizing period. It's so important for them to know 
what works and what doesn't work.
    I worry about charlatans, these people are spending, as I 
mentioned, enormous sums. Can you tell us something about this 
report, and frankly, since this report was released for 1995, 
where are you with the 1996 report? How are we progressing? Are 
there model standards on assisted reproduction laboratories?
    Thank you.
    Dr. Broome. We also agree that this is a subject of 
enormous concern to a number of our citizens. We worked 
together with the Society for Assisted Reproductive Technology, 
and also with a parent's group, with Resolve, to define what 
kind of report would be most helpful. One of the particular 
targets was to have something that was really consumer 
friendly, where people could read it, and have comparable data 
collected and reported in comparable ways from the whole range 
of clinics across the country.
    And we worked with focus groups to be sure we were 
communicating effectively. I do think we have been successful 
in providing a source of information for our citizens about 
what they can expect, what are the success rates with the 
different techniques, what kinds of variables. I'm sorry Mr. 
Miller isn't here, because in fact age is a crucial variable 
for determining the success.
    Overall, we found that about one in five couples can expect 
to have a successful live-born infant when they go through a 
program of assisted reproductive technology. The document also 
provides information on where clinics are, and what the success 
rates are.
    We are working on the 1996 report and hope to have that 
out, I believe later in the summer.
    The standards for clinics was another part of the bill. And 
we have worked, first of all, there currently are standards 
which have been developed by the professional society. And 
those are implemented.
    We have reviewed those and used our professional judgment 
as to whether the standards are appropriate, made some 
modifications, and we have developed a draft Federal Register 
notice for comment, which will outline the criteria, personal 
standards, professional issues, for a certification program.

                folic acid and birth defects prevention

    Mrs. Lowey. Another number I found shocking, as a mother 
and a grandmother, in your testimony you note that folic acid 
can prevent at least half the cases of serious birth defects, 
spina bifida, if women of child-bearing age had adequate 
amounts of folic acid in their diet.
    This is an amazing scientific fact. Yet, as you state, 
three-quarters, three out of four women of child-bearing age do 
not get enough folic acid in their diet.
    Now, I know, as a recent grandmother, when a woman becomes 
pregnant, she wants to know, what can I do, what should I do. 
How can we reverse this? Why aren't women getting this 
information? What are we doing and how can we do it better?
    Dr. Broome. One of the complications with folic acid is 
that the women actually need to be taking it very, very early 
in pregnancy, because that's when neural tube defects occur. 
And as you know, many pregnancies are unintended, and women are 
not aware that they're pregnant during those first weeks.
    That's why our approach has been to advocate that all women 
of child-bearing age who could become pregnant need to consume 
this amount of folic acid.
    Now, it turns out that getting it just through diet is not 
very easy. You'd have to be a real spinach fan to be sure that 
you were getting enough folic acid. The most practical way to 
get it is, well, there are two approaches. One is to take a 
dietary supplement, a vitamin pill. And most pills do have 
sufficient folic acid. So one of our messages has been to take 
a multi-vitamin containing folic acid every day. The other way 
has been through fortification of cereal products. And as you 
may recall, the FDA, this year is actually the implementation 
of the FDA's requirements that cereal grains be fortified with 
folic acid.
    Because of a fairly complex scientific discussion, which is 
still going on, the level of fortification is relatively low 
and will not assure that 100 percent of women reach the 
recommended level. The National Academy of Science is re-
examining this question and seeing whether changes in 
fortification might be appropriate. Because that would be the 
easiest way to be sure that women got this quantity of folic 
acid.
    There's also very exciting information coming out that 
folic acid may actually be very important in preventing 
cardiovascular disease. So this issue is not only relevant to 
pregnant women.
    Mrs. Lowey. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mrs. Lowey.
    Mr. Wicker.
    Mr. Wicker. Thank you, Mr. Chairman.
    Dr. Broome, let me join the members of the subcommittee in 
welcoming you here today, and thank you for going on past the 
noon hour, as obviously you will.
    When we're on the Floor of the House of Representatives, 
we're not supposed to talk about C-SPAN and television. I don't 
know what the rules are before the subcommittee, Mr. Chairman, 
but I'm glad to see C-SPAN here today.
    Mr. Wicker. We never have to put anybody under oath here in 
this subcommittee, and we probably won't do anything 
controversial today. Somebody may be watching this at 2:00 a.m. 
tomorrow. [Laughter.]
    But it is an excellent opportunity for us to showcase what 
I think we all believe, on both sides of the aisle, is a 
terrific Government agency. You've been in existence 50 years, 
51 now?
    Dr. Broome. Fifty-one now.
    Mr. Wicker. A half a century plus one. This subcommittee 
took a delegation to Atlanta to tour CDC just last year. We 
learned that in the 50-year history of CDC, we were the first 
Congressional delegation to go to Atlanta and see the very fine 
things you're doing there.
    I would just say to any of my colleagues, whether they're 
on the appropriations committee or not, that it would be worth 
their while to take a Monday off or a Friday or a weekend and 
go and see the very fine things that are going on there in CDC. 
I applaud you.
    Dr. Broome. Thank you.

                   cardiovascular disease prevention

    Mr. Wicker. Last year we set aside some funds specifically 
for cardiovascular problems. I noticed that in your testimony 
you mentioned approximately 70 percent of Americans die as a 
result of chronic diseases. And cardiovascular disease is the 
leading killer for men and women, and it crosses racial groups.
    You've been kind enough to provide us some information 
about our own home States. I notice in looking at the 
statistics that heart disease and cardiovascular problems are 
certainly the leading cause of death in Mississippi.
    Of this money that we set aside specifically last year for 
cardiovascular, how are you doing with that, and what are you 
using the money for to address this critical health issue?
    Dr. Broome. We have started to support States for 
prevention programs. We think that we do know some effective 
tools for preventing cardiovascular disease, and that 
supporting State health departments to develop effective 
cardiovascular disease prevention programs is the way to go.
    In addition to that, our division of nutrition and physical 
activity is continuing its work to understand how we can be 
more effective in preventing cardiovascular disease. As you 
know, there are a number of different risk factors which are 
responsible. Prominent ones include tobacco use, lack of 
physical activity, poor diet, particularly, consumption of 
foods which raise cholesterol.
    Intervening with those risk factors is important. We are 
trying to develop in States an effective approach which pulls 
together what we know and pulls together the many partners. 
There are a number of organizations which deal with tobacco 
prevention activities; there are a number which are interested 
in nutrition. Trying to get those pulled together 
comprehensively into programs to prevent cardiovascular disease 
is what we're interested in.
    This year, we'll be able to fund six to eight States with 
the money that was appropriated last year.
    Mr. Wicker. And that's the fiscal year 1998 funding?
    Dr. Broome. Right.
    Mr. Wicker. Now, you've asked for $5 million extra for the 
next fiscal year. Where will this take us?
    Dr. Broome. Well, we would be able to support, I believe, 
an additional three to four States with that increased funding.
    Mr. Wicker. I just wonder how much it's going to take, or 
what it's going to take to take a program like this nationwide. 
Have you had time to quantify that, or to look that far down 
the road?
    Dr. Broome. Well, I'd like to, we will certainly be able to 
provide you with a figure as to what that would require.
    [The information follows:]

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

    But I think this is also an area where we want to use what 
we learn from the initial States that we've funded as to 
whatworks best and what are the most effective components of a 
cardiovascular disease prevention program.
    We know the range of risk factors, but how can we be 
effective in changing those.
    Mr. Wicker. Well, I certainly want to encourage you on 
that. I want to thank the leadership down at CDC for working 
with us on this appropriations committee initiative.

                         fire injury prevention

    Let me ask you about another pilot project, demonstration 
project, that I know has saved lives in my own Congressional 
district. And that is with the injury prevention and control 
program in the area of fire-related deaths, particularly just 
the simple initiative of going into a county with high rates of 
fire deaths and educating the people, demonstrating and 
distributing smoke detectors.
    I know you've got the project going in Benton County, 
Mississippi. Do you know how many other counties we're using 
that in, and what we've been able to learn from that 
experience?
    Dr. Broome. The smoke detector program, I think, is a very 
good example of how we support research and then turn it into 
programs. As I mentioned, in the State of Oklahoma, was where 
the pilot research project was done, a formal research project 
that was peer reviewed and carried out under very rigorous 
research conditions. That showed that a targeted smoke detector 
distribution program, and being sure that the smoke detectors 
were installed and active, was effective in decreasing fire-
related injuries.
    That finding was then translated into programs in 
Mississippi and, I believe, four other States this year. We do 
think that this is a proven, effective program. We would like 
to see it added to injury prevention programs nationally.
    And it relies on, it's not just, it seems simple to say, 
well, you put up a smoke detector.
    Mr. Wicker. Right.
    Dr. Broome. The key aspects are, using our surveillance 
data to identify what are the particularly high-risk areas, 
where are those fire injuries occurring, so that you put your 
priority efforts into making the smoke detectors available in 
those areas.
    We are also trying to develop longer-acting batteries, so 
that we don't have to be as dependent on people remembering to 
change the batteries every year.
    Mr. Wicker. My Chairman obviously set the clock wrong. 
There's no way that eight minutes has elapsed. [Laughter.]
    Let me just say that in Benton County, Mississippi, in my 
district, we've gone from the highest death rate in the State 
to no fire-related deaths since this program came in. CDC is a 
good program, and it's a pleasure for me to work with the other 
members of this subcommittee on things like that that are 
saving lives and enhancing the quality of life.
    Dr. Broome. Thank you.
    Mr. Porter. Thank you, Mr. Wicker.
    Mr. Hoyer.
    Mr. Hoyer. Dr. Broome, I want to welcome you to the 
committee. I apologize for being late. As you know, some of the 
rest of us are also either ranking or chairs on other 
subcommittees. So we have to be there, try to do both of these.

                               pfiesteria

    I want to ask you three quick questions, if I can. 
Pfiesteria, as you know, is a very high concern in Maryland and 
North Carolina. We have put some additional resources into CDC 
on other objectives.
    Can you tell me where we stand on this, and update me on 
what you foresee the CDC will need for fiscal year 1999 to 
ensure that the public health response to Pfiesteria and like 
toxins is effective?
    Dr. Broome. Thank you, Mr. Hoyer.
    This is, Pfiesteria is a very good example of a new 
emerging health threat, where we have to first answer the 
question, how big a problem is this? Can we scientifically 
define what particular health problems are being seen, and 
then, can we figure out how that could be prevented?
    So the money that was appropriated last year, which I 
believe is $4.7 million, first of all, we did supplement that 
with CDC one-time funds from the Director's discretionary money 
of $2.3 million. So we have committed substantial resources to 
this activity.
    We're working with the States to define the magnitude of 
the problem. We had a large meeting to kick this off, and then 
we've had work group meetings with the States, the seven 
southeastern coastal States that have Pfiesteria identified.
    We'll be doing surveillance. First of all, we had to agree 
on what sorts of health effects we think are likely, which ones 
are we looking for. We got agreement on what we call a case 
definition.
    Then we established surveillance. We're trying to identify 
any cases of health effects that might be related to 
Pfiesteria, so that we can both count those cases, characterize 
them, and also do any testing of, for example, neuro-behavioral 
changes which might be related to Pfiesteria.
    We're also defining what we call exposure cohorts, groups 
of people such as watermen who are exposed to Pfiesteria in the 
course of their work. We will also be working with our State 
and academic partners to identify when they are potentially 
exposed to Pfiesteria, and to look at any changes in their 
health status related to that exposure.
    Another major issue is trying to have accurate 
environmental data, what is happening with the microorganism at 
the same time that there may be health effects in the groups of 
people who are occupationally exposed.
    We feel that these studies are moving forward very 
effectively, and we hope to have much better data on Pfiesteria 
and the potential health risks because of these studies. We 
certainly feel that it would be important to continue these 
activities, at least at this level, and if there is any 
evidence of increasing health effects or increasing 
distribution of the organism, additional funds might be needed. 
But certainly the $7 million would be an appropriate level for 
support.

                                syphilis

    Mr. Hoyer. Thank you, Doctor. CDC, and of course this 
committee, has been very concerned about STDs. In particular 
Doctor, we had report language in last year's bill concerning 
syphilis. We asked for a report to this committee by January 
1st outlining the additional investment necessary to eliminate 
syphilis.
    It is my understanding we do not have that report. Can you 
tell me its status, where it is and how soon we might 
contemplate its receipt?
    Dr. Broome. The report is in the review process. It is 
currently at OMB, and we hope that we will be able to deliver 
that report fairly soon.
    Mr. Hoyer. Doctor, what do you mean by fairly soon----
    [Laughter.]
    Mr. Hoyer. We use that term all the time ourselves. So it 
is important for us to explain it a little more.
    They want me on the Floor.
    Mr. Williams. I'm not sure exactly when it went to OMB. As 
far as I know, there's no particular reason to hold it up. We 
can get you a very specific date right away.
    Mr. Hoyer. And the reason I ask that, obviously I would 
like to have it, the Chairman is moving us along, all of the 
chairmen would like to mark up earlier than we have marked up, 
and therefore I'd like to have that information so we can use 
it for that.

                           health statistics

    One last question. The National Center for Health 
Statistics, can you tell me what level of funding you believe 
they need--you may not know this at this point in time, you may 
want to submit it for the record--to provide the American 
public with a complete and accurate health survey?
    Do they participate in this document?
    Dr. Broome. Yes
    Mr. Hoyer. I am sure all of us have found this very 
interesting. I've just leafed through it briefly. Obviously in 
Maryland, we have some particular challenges, cancer in 
particular, where we have a higher incidence than the national 
average.
    Can you tell me what level of resources are necessary, so 
that the statistical picture of where we stand is available to 
us?
    Dr. Broome. We'll be happy to provide you a more detailed 
response.
    [The information follows:]
    OFFSET FOLIOS 261 TO 262 INSERT HERE



    But I really appreciate your bringing this up. Because we 
feel that having accurate health statistics and health data is 
crucial to doing our job. We want to be held accountable of 
making a difference in health status, and that can only be 
measured if we have good, quality health information and data.
    There's one very particular area that we're concerned 
about, and that's the National Health And Nutrition Examination 
Survey, NHANES. This is really a national treasure. It 
represents a statistical sample of the United States, people 
who volunteer, they're selected randomly but then they agree to 
participate in a full examination, including providing a 
specimen of blood, and answer an extensive questionnaire about 
health-related issues.
    These NHANES data have let us show our successes in 
decreasing childhood lead poisoning. We have shown dramatic 
public health successes. At the same time, we've been able to 
identify areas that still have risk.
    We've been able to show how widely exposed our citizens are 
to secondhand tobacco smoke. We can take these specimens and 
measure cotinine, which is a metabolite of nicotine, in the 
specimens from participants. This shows us that over 85 percent 
of people in this country had detectably elevated levels, these 
are non-smokers, had detectably elevated levels in 1991 to 
1994.
    Now, I'm going into some detail because, well, for two 
reasons. First of all, we have requested funding to support the 
survey, we're starting a new round of this survey. And we do 
not have the appropriations support that's really necessary for 
conducting this extremely valuable survey. It's estimated that 
$3.6 million would be needed to assure a firm funding base for 
NHANES.
    I would also like to welcome committee or staff visits to 
the NHANES examination centers. I'm glad you like the book, but 
people tend to think of statistics as very dull and dry and 
they just happen. But understanding how central they are to 
what CDC does, and how central they are to improving the health 
of the Nation I think is very important for prevention.
    Mr. Hoyer. Doctor, thank you very much for that response. I 
would agree with you 100 percent. Whether they be economic, 
health, educational, the statistical analysis of how 
effectively we are responding to problems and how big those 
problems are is critically important to us making credible 
decisions.
    So I agree with you that we need to keep up our statistical 
capability of providing us, and the American people, American 
business, farmers, with statistics daily to be more effective 
in whatever we do.
    Thank you, Doctor. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Hoyer.
    Dr. Broome, those are the easy questions. Now we get to the 
GPRA questions and the administrative expense questions.

                 government performance and results act

    We're very serious about the implementation of the 
Government Performance and Results Act. We understand that 
every agency is grappling with the problem of developing 
performance goals and measures for ongoing programs. But it 
seems to me, given the requirements of the law, that any new 
program ought to include as an integral component a strong GPRA 
plan.
    Regarding the health disparities initiative, the budget 
justification does not list a single performance measure. For 
instance, regarding heart disease, page 182 of the 
justification indicates seven performance measures, not one of 
which relates to closing the gaps between black and white.
    Does CDC have any specific performance measures relating to 
closing health disparities, and if so, can you insert them in 
the record?
    Dr. Broome. We would be happy to do that. We have actually 
found the Government Performance and Results Act strategic 
planning to be very valuable. We have in fact been complimented 
on the CDC plan because of its reliance onoutcome measures 
showing the impact of our programs on changes in the health of the 
population in many of our areas.
    We've also, I think, identified good GPRA measures for our 
new initiatives. We will certainly, and my understanding is we 
have very clear targets in rates of the health conditions for 
the eliminating disparities initiative. But we will look again 
at that.
    Mr. Porter. Please put those in the record for me.
    Dr. Broome. Certainly.
    [Clerk's note.--The witness did not provide the requested 
information and clarified her oral testimony as follows: ``We 
will be happy to discuss our approach to developing performance 
measures for eliminating racial and ethnic disparities for the 
record.'' The information follows:]

              Performance Measures for the Race Initiative

    We are gratified that there is such an interest in CDC's 
individual performance measures and our plan. We found the 
planning process associated with GPRA to be very valuable, and 
we're pleased that OMB and various other experts on GPRA 
recognized our plan as being one of the best in the Government. 
There are three reasons why our plan was recognized as being 
good. First of all, we identified and used outcome measures 
wherever possible. Second, we have the data and existing 
systems to support our measures. And finally, we viewed our 
performance plan as a way in which we could ``tell our story.''
    When developing our agency-wide Performance Plan, we did 
not include specific measures for eliminating racial 
disparities in health status. We are currently working on the 
development of such agency-wide measures, and with the 
appropriations the President has recommended for the Community 
Demonstration Projects, we will continue to work with our 
partners to ensure that these measures are achievable and 
mutually acceptable.
    We believe that CDC's commitment to the reduction of health 
disparities among minorities is reflected throughout our 
programs. Early in the development of CDC's Performance Plan, 
performance measures from four sources were reviewed and 
considered for incorporation into the Plan. These sources 
included: Healthy People 2000 Midcourse Review and 1995 
Revisions, Healthy Communities 2000, proposed outcome measures 
for Performance Partnership Grants (PPGs), and draft Health 
Plan Employer Data and Information Set (HEDIS) 3.0 
Effectiveness of Care Measures. Based on our review of these 
existing measures, a concerted effort was made to include only 
the ``vital few'' in our final performance plan.
    Although specific measures to reduce disparities among 
particular minority groups are not specifically stated in the 
agency-wide plan, they are an integral part of the plans which 
exist at the program and Center levels within CDC. It is our 
intent to further develop (and make explicit) such agency-wide 
measures in our Performance Plan in the future and to share 
these with the Subcommittee.

    Mr. Porter. As you said a moment ago, I think you have some 
very good performance measures at CDC. I think you also have 
some very bad ones. I'm talking about whether you choose a good 
measure, not whether you pick the right target to reach by a 
certain time.
    In HIV/AIDS, you set the objective of reducing the number 
of AIDS cases related to injecting drug use by 15 percent from 
a base of 17,800. In STDs, you have an objective of reducing 
the prevalence of chlamydia among high-risk women under 25 from 
11.6 percent to less than 8 percent. In immunization, one goal 
is reducing the number of cases of pertussis from 7,796 to 
1,000.
    I don't know whether 1,000 is the right goal, but this is 
the type of measure that we are looking for, quantitative 
outcomes.
    On the other hand, in chronic disease, CDC lists seven 
performance measures for heart disease and health promotion, 
none of the type I just indicated. The agency proposes to 
establish coalitions, conduct educational activities, develop 
resources centers, and perform community outreach. These may be 
very important things to do, but they don't tell us whether we 
are achieving goals or reducing heart disease in certain 
populations or increasing the number of healthy Americans.
    Now, I understand there are difficulties in developing 
outcome measures for many activities. But I want to send a very 
strong message that we want you to adopt measures of the kind I 
described first, and we don't want you to adopt measures of the 
kind I described second.
    When do you plan to modify and update the GPRA plan, and 
will you include quantitative outcome measures in the fiscal 
year 2000 GPRA plan for all major activities at CDC?
    Dr. Broome. We actually, I think, just finished the final 
revision of our current GPRA plan. So I must confess, I haven't 
focused on when the next one will be due.
    [Clerk's note.--The witness clarified her oral testimony as 
follows: ``We will quickly be starting work on our fiscal year 
2000 plan which will build upon and enhance our fiscal year 
1999 performance plan.'']
    But we will absolutely take your concerns into account. And 
I agree with them. We definitely want to be measured by the 
impact on disease.
    We do, I think, also have to have appropriate process 
measures to be sure that we've got the right steps to get 
there. So we are trying to look at the right mix of both 
process and health outcome.
    Mr. Porter. All right. I'd like to look at one more example 
of what I consider to be a performance measure that is really 
off the mark. I'm singling out a specific example, but 
unfortunately, the justification contains many like it.
    In the area of violent crime, page 189 of the 
justification, CDC sets a goal of increasing the number of 
State and community based intimate partner and sexual assault 
projects from 7 to 31. Shouldn't we instead be looking atthe 
crime reports for communities that have projects to determine whether 
domestic violence is decreasing, so that we know whether the projects 
are having a significant, positive effect on people?
    Ultimately, we're not concerned with how many Government 
projects we can have. What we want to make sure of is that 
people aren't being abused. That's the kind of thing that I 
think you've got to focus on at CDC and make certain that we're 
not going in a direction that really doesn't affect the lives 
of people. Having projects is fine, but what it means to people 
is what we're really looking for.
    Dr. Broome. I agree with you. I do think some of the work 
we're doing in defining, trying to have accurate measurements 
of the level of, for example, domestic violence, not all of 
that ends up in the criminal justice system. So that we are, at 
this stage in our knowledge in this area, working to refine 
measurements, get general agreement on that, get data which 
will tell us where we are.
    That will help us in then using an outcome measurement and 
looking at the impact of our programs.
    Mr. Porter. Correct. I would caution that we shouldn't let 
the measurements that are easy drive the goals or the 
performance standards, just because the data is there. If we 
aren't using good performance standards in the first place, 
then the data may give us something that really isn't useful. 
What we need to do is find out where we want to go, and then we 
might have to develop whole new performance standards in order 
to determine whether we're getting there.

                          Administrative Costs

    Dr. Broome, we've had a very difficult time getting a 
handle on CDC's administrative costs. Let me give you an 
example. On page 9 of the fiscal year 1998 justification, you 
listed total administrative costs of $494 million for fiscal 
year 1997.
    This year's justification lists total administrative costs 
of $611 million for fiscal year 1998, a jump of $117 million, 
or over 20 percent in one year. Keep in mind that the entire 
appropriation for CDC was increased by less than $100 million 
between the two years.
    The fiscal year 1998 House Report directed CDC to limit any 
increase in administrative costs to 1 percent, consistent with 
the bill-wide policy on such costs. Can you explain why the 
budget justification reports such widely varying figures? Why 
doesn't the justification include some explanation of these 
figures?
    Dr. Broome. We would very much like to clarify that and 
give you a detailed explanation for the record. I am reasonably 
sure that it is a comparability issue. As I had explained 
earlier, we did have an external consultant review how we were 
classifying and paying for administrative costs, relative to, 
for example, grant support, cooperative agreement support and 
support for our intramural activities.
    And there also has been some definitional changes. But we 
will get you a detailed report for the record on that.
    [The information follows:]
    Offset Folios 273 to 275 Insert here



    Mr. Porter. I have a staff that thinks we're not getting 
accurate data in this regard. What I'd like to know, and you 
could provide this for the record, what are the actual figures 
for administrative costs for fiscal year 1997 and fiscal year 
1998? And did the agency limit the increase to 1 percent, as 
directed by the House Report?
    That's what I really want to find out.
    Dr. Broome. We'll address that.
    [The information follows:]

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

    Mr. Porter. Mrs. Lowey, do you have additional questions?
    Mrs. Lowey. Thank you, Mr. Chairman, and thank you again, 
Dr. Broome.

                           Colorectal Cancer

    I know the hour is late, and I'll be brief. But I just 
wanted to discuss two issues of the many that you are involved 
in, for the record, because I have been very concerned with our 
policy and our actions on colorectal cancer.
    As you know, an estimated 55,000 Americans will die from 
colorectal cancer this year. The good news is that when 
detected early, the cancer can be treated successfully. Yet 
despite the existence of screening tests, many people still do 
not get screened.
    Last year, we did appropriate $2.5 million for the CDC 
program to promote public awareness of the importance of 
colorectal cancer screening. If you could give us your 
assessment of how the program is progressing, what plans does 
the CDC have in this regard to expand your efforts. This is the 
number two cancer killer. We have the procedures but people are 
not taking advantage of them. Could you help us?
    Dr. Broome. We agree with you that fecal occult blood 
testing and other measures are effective in early detection of 
colorectal cancer, and have been proven to reduce death rates 
from this very common cancer.
    We will, the amount appropriated is being used to develop 
both the messages that we hope will be effective in reaching 
the whole range of populations at risk, and also developing 
what kind of programs will be effective, whether it's just a 
matter of messages, or whether we need to maybe work more 
actively with the Health Care Financing Administration to make 
sure that Medicare beneficiaries and Medicare providers are 
aware of the need to make those preventive services available.
    Mrs. Lowey. I thank you, and if you could keep this 
committee up to date, that would be very helpful to us, because 
as we put together our proposal for this year, this 
appropriations process, we'd like to get this information and 
understand whether the money appropriated was sufficient, what 
impact it is making, and what you really need to change these 
statistics around.
    Dr. Broome. We'll be happy to provide that information.

                                 Asthma

    Mrs. Lowey. Another area, I notice in your booklet on 
prevention, you mention asthma as one of the areas where you're 
doing research. I happen to have a bill which is directed 
towards frankly, 6 percent of New York City's population, which 
suffers from asthma, and to the other populations across this 
country.
    In fact, this really, rather than a question, is an 
invitation to work with me. Because so much remains to be done, 
education, educating parents, how do you know what's happening, 
what can we really do. You look at the number, the number of 
Americans suffering from asthma has grown 30 percent over the 
last 7 years, while the number of people hospitalized due to 
asthma has grown by 24 percent.
    And as I mentioned, this is particularly serious in the New 
York area. We can continue our discussion of asthma in follow-
up meetings, or if you care to share with us what you're doing, 
you're aware of the crisis that has received a great deal of 
publicity, certainly, in the New York area.
    Dr. Broome. Well, this is a national problem. We've seen a 
dramatic increase in the number of hospitalizations due to 
asthma. And at least 4.8 million of those are in children.
    Asthma is another of these areas where we know some of the 
approaches to education and medical management which will 
decrease the need for hospitalizations, decrease the deaths. 
But we need that information to be much more widely available.
    There's also an environmental component that's really under 
investigation as to what role household dust mites and 
allergens, animal hair, etc., may play in exacerbating asthma 
attacks, and can we intervene to prevent that exacerbation. We 
have an innovative program in the Atlanta Empowerment Zone, 
where we are actually training community health workers to work 
with families to improve both the environmental and the 
clinical management of asthma.
    We'd be very happy to work with you in this area.
    Mrs. Lowey. I thank you very much, and as I said, I'm 
planning to introduce a bill that will deal with the education 
component, the response of health departments and local 
schools, promote Federal guidelines on asthma prevention. I 
want to be sure that the CDC has the resources needed to 
address these and other critical problems associated with 
asthma.
    So as we're putting this process together, as this process 
is moving forward, if you could keep us posted and give us your 
best judgment on this, it would be very, very helpful.
    I thank you, Mr. Chairman. The hour is late.
    Mr. Porter. Mrs. Lowey, let me make an editorial comment at 
this point. I think we also ought to look into the role of 
stress, and what it does to create many of these kinds of 
diseases. Because I think, and I have, I know I'm not a 
scientist, but I think stress has a lot to do, or rather the 
reaction of the individual to stress, has a lot to do with a 
lot of the diseases that affect us. And asthma may well be one 
of those diseases.
    Mrs. Lowey. I want to thank you, because I know that we 
share those concerns. We feel that stress is certainly a factor 
in so many of the illnesses that we are currently working on. I 
thank you for bringing that up.
    Mr. Porter. Including chronic back pain. [Laughter.]
    Mrs. Lowey. I wasn't going to mention that one.
    Mr. Porter. Dr. Broome, you've done an excellent job today. 
Your opening statement was outstanding, you've answered all of 
our questions candidly. We appreciate your coming here to 
testify, and the fine job that you did. We got the message, 
with your help, we can do it.
    This subcommittee has placed CDC at a very high priority. 
As you remember, back in 1995, when we were required to make 
very severe budget cuts in order to be within our allocation, 
CDC was one of only 10 line items that got an increase or was 
level funded. We pulled CDC and NIH out of the budget wars and 
passed them separately because we valued the work that you do 
so highly.
    We will continue to make a maximum effort to give you the 
resources you need to do the job. Because I believe, as you've 
said, that with the help of resources, you can do it. And 
you're doing a wonderful job, and we thank you for coming to 
testify.
    Dr. Broome. Thank you very much, Chairman Porter. And we 
would be very happy to extend an invitation for you to visit 
CDC at any time with any members of the subcommittee.
    Mr. Porter. Now that my back is better.
    I really missed having gone on that trip, because Ireally 
wanted to come down. So I'll take you up on that.
    Thank you so much.
    Dr. Broome. Wonderful. Thank you.
    Mr. Porter. The subcommittee stands in recess until 2:00 
p.m.
    [The following questions were submitted to be answered for 
the record:]
    Offset Folios 284 to 677 Insert here



                                          Wednesday, March 4, 1998.

              HEALTH RESOURCES AND SERVICES ADMINISTRATION

                               WITNESSES

DR. CLAUDE E. FOX, ACTING ADMINISTRATOR
THOMAS G. MORFORD, ACTING DEPUTY ADMINISTRATOR
DR. MARILYN H. GASTON, ASSOCIATE ADMINISTRATOR, BUREAU OF PRIMARY 
    HEALTH CARE
DR. AUDREY H. NORA, ASSOCIATE ADMINISTRATOR, MATERNAL AND CHILD HEALTH 
    BUREAU
DR. JOSEPH F. O'NEILL, ASSOCIATE ADMINISTRATOR FOR AIDS AND DIRECTOR, 
    OFFICE OF SPECIAL PROGRAMS
DENA PUSKIN, ACTING DIRECTOR, OFFICE OF RURAL HEALTH POLICY
ANTHONY HOLLINS, JR., ACTING DEPUTY ASSOCIATE ADMINISTRATOR, BUREAU OF 
    HEALTH PROFESSIONS
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY FOR BUDGET, DEPARTMENT 
    OF HEALTH AND HUMAN SERVICES

                       Introduction of Witnesses

    Mr. Bonilla. Good morning. For those of you whom I have not 
had the pleasure of meeting before, my name is Henry Bonilla. I 
represent a congressional district in South and West Texas. 
Chairman Porter, chairman of this subcommittee, is delayed down 
the hallway testifying before another subcommittee, and I have 
been asked to go ahead and start this morning's hearings.
    I want to welcome Dr. Claude Fox to begin this morning, 
Acting Administrator for the Health Resources and Services 
Administration. Welcome, Dr. Fox.
    Dr. Fox. Thank you, sir. Glad to be here. I am accompanied 
by a number of staff. On my right is Dr. Joe O'Neill, who is 
the current Associate Administrator for HIV/AIDS and Director 
of the Office of Special Programs; Dr. Audrey Nora, who is 
Associate Administrator for Maternal and Child Health; Dr. Dena 
Puskin, who is the Acting Director for the Office of Rural 
Health; Mr. Dennis Williams, Deputy Assistant Secretary for 
Budget in the Department of HHS. And on my left is Mr. Tom 
Morford, who is the Acting Deputy Administrator for HRSA; Dr. 
Marilyn Gaston, Associate Administrator for the Bureau of 
Primary Care; and Mr. Tony Hollins, Jr., who is Acting Deputy 
Associate Administrator for the Bureau of Health Professions.

                           Opening Statement

    I would like to just make a brief opening statement and 
then we will be available for questions.
    Let me start by saying that I have been at HRSA some 11 
months, and trying to think of any common theme that really 
cross-cuts what this agency is all about, and if you had to 
pick out one area, it would be access--access to care. 
Virtually all of our programs have implications for access for 
people, in many instances low-income and special populations, 
but not all. We are about access to care for people who need 
organ transplants. We are about access to care for people who 
live in rural areas, access to children with special health 
care needs, access to individuals with AIDS, access for 
communities that don't have health care providers, access for 
primary care. So it really does cut across the whole agency.
    One of the things that I think continues to argue for 
continued support for these programs is the fact that over the 
last number of years, despite all the changes in managed care, 
the number of uninsured in this country really has not gone 
down. In fact, it has gone up.
    We know that for the most part, even the States that have 
had 1115 Medicaid waivers, the initial States like Tennessee, 
did attempt to expand populations, but the later waivers did 
not. And, overall, we have seen a continued need for access to 
our programs.
    There have been also a number of other factors that we 
think mitigate for that, and we are currently asking in 
ourpresent budget request for approximately $3.8 billion.
    We also think that we are having an effect and can show 
through a variety of performance measures that we have in the 
agency that HRSA programs are working. I would like to start 
out and share with you some comments about the area that 
invokes the primary care coverage, the Community Health 
Centers. We are currently asking for a $15 million increase in 
that area, primarily to deal with racial disparities. As you 
probably know, in this country we have a number of areas where 
we are not doing well, infant mortality being one, but we have 
a number of areas where the disparities among various racial 
groups--blacks, Hispanics, Asians, others--is far above the 
general population, and these dollars are to help target that.
    We currently serve about 10,000,000 people through the 
Community Health Centers and the National Health Service Corps, 
and, again, we have seen over the last several years an actual 
increase in the number of people coming to us that don't have 
insurance. One of the things that has happened has been that 
with the changes in managed care and the ratcheting down of 
costs, which have obviously benefited the general population in 
some ways, what it has done is it has prevented cost-shifting. 
And many people that were able to go to facilities where costs 
could be shared by other payment mechanisms are coming to us 
now. In fact, our first chart over on the left compares the 
percent of uninsured in the general population to the percent 
of uninsured we are seeing in the Community Health Centers.
    You can see that we are having a disproportionate number of 
people come to us now that don't have insurance or have limited 
coverage, which we think will continue, at least for the near 
future.
    The second thing--and I can give you more details about 
that if you would like. The second thing is for those people 
that we do see, we think we are doing a better than average 
job. We have recently instituted--and Dr. Gaston can talk more 
about this--a data collection mechanism with the Community 
Health Centers that gives us information on the care we are 
providing. Just one example, which is the second chart, is in 
the area of mammograms. We do through the Community Health 
Centers a better job of providing mammography to women that 
come through our centers than the general population. This is 
compared to the National Health Interview Survey that is done 
by the CDC.
    We think we are doing a better job in a whole variety of 
areas. This is one. Pap smears is another, immunizations, you 
can go on down the list. But the bottom line is that we think 
we are having an effect within the community.
    The second area where we are asking for an increase is the 
area of HIV/AIDS. There are two things that have happened in 
this area, one, bureaucratic, and that is that we have 
reorganized; and since I arrived at the agency, we placed all 
the Ryan White programs under one area, Dr. O'Neill's area. We 
think that will provide for better coordination and help us in 
thinking through the kind of things that we do for one title, 
we can do for the other. The second there has been a dramatic 
change in the care recommendations, as you are probably aware, 
and just in the last year or so, now there are treatment 
options available that have significant implications for 
survival. And so we are requesting an additional $165 million 
in the Ryan White budget; $25 million of that to Title I, which 
is grants to cities; about $127 million to Title II, most of 
that for the HIV/AIDS drugs. And I might mention here we have 
taken several steps to reduce the cost of drugs that I can, 
again, share later with the committee. But the bottom line is 
there continues to be a need there and the $100 million will 
help address that; $27 million for Title II increase will 
actually go to States for other care; $10 million to Title III 
for primary care; and $3 million to Title IV for pediatric 
care.
    The bottom line is that there is a need for drugs, but 
because effective treatments are available now, there is a need 
for medical care as well. And we have to have a system to 
provide that, and, again, many of the people that are being 
seen are uninsured.
    The third area is health professions, and although we are 
not requesting an increase there, I want to make some comments 
about this because I think there has been some misconception 
about what we do in health professions. We really are targeting 
health professions' budget in HRSA to distribution and 
diversity. We know there are many communities and there is 
overall a physician glut, but the physicians are not in the 
right place. We know that the providers that are out there 
don't reflect the community they may be trying to serve. And so 
we are targeting our dollars to address those two issues.
    We have increased our funding to minority institutions, to 
Hispanic-service institutions, to historically black colleges. 
And if you look at the charts here, the first one is on 
diversity, and the line that you see through the graphs is the 
average percent of diversity within the professional population 
and the graduates that are in general across all programs. The 
actual yellow lines are our numbers for the programs that we 
fund, and the bottom line is we are graduating more minorities 
to go out into various communities to provide health care.
    The second chart is on distribution. If you look at those 
numbers, with the line being the average of all programs, you 
can see for HRSA-funded programs, we are having a 
disproportionately positive effect on people going into rural 
and underserved areas.
    Also in the area of public health and preventive medicine, 
we are addressing issues that are not being addressed by the 
market.
    The fourth area is maternal and child health, and, again, 
although we are not requesting an increase in funds there, we 
are doing things that in my opinion are complementary to the 
CHIP, the Child Health Insurance Program. We are looking at 
systems of care, services that are not necessarily going to be 
provided through Child Health Insurance, including genetic 
issues, perinatal systems issues and, population-based issues. 
For example, the Back to Sleep Campaign that MCH has supported 
through its clearing house has had a major effect on the death 
rate in infants over one month of age, would not be something 
funded through the Child Health Insurance Program, but is 
having a major effect on infant mortality in this country.
    Organ transplantation, we are requesting an additional $1.3 
million in that area for organ donation. You know all the 
number of controversial issues around organ donation in this 
country and organ transplantation. But the sad fact of the 
matter is that for the last 2 years we had an increase of organ 
donations of two--not 2 percent, but two. And so the bottom 
line is that we are having a huge demand, increase in demand 
for transplantation, and the organ donations are notkeeping up 
with that. And the $1.3 million we are requesting will help us do that.
    The area of rural health, again, telemedicine and State 
offices networking, we want to continue to support. I come from 
a rural area, and I tell you that, again, managed care is not 
going to take care of the problems in the rural areas.
    Then the final area where we are requesting an increase is 
the area of family planning, and there is a request for an 
additional $15 million to address the issues of family 
planning, to look at providing additional services to teens, to 
involve males in the contraceptive issues in many ways that 
they have not been involved.
    Finally, let me say that we have been working hard on our 
performance plan. We know Congress has mandated under GPRA that 
we look at performance measures. All the people you see sitting 
at this table have been personally involved in developing the 
HRSA performance plan. We have not delegated it to mid-level 
staff. We all have been involved together to try to think 
through what are the things in HRSA we need to be looking at 
and what data systems do we need in place to be able to tell 
you and us when we are succeeding.
    So the bottom line is we are very proud of the activities 
we provide. We think the need is increasing, not decreasing, 
for HRSA programs, and we look forward to any questions that 
the committee might have.
    [The prepared statement follows:]
    Offset Folios 689 to 696 Insert here



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

                               uninsured

    Mrs. Northup. Thank you, Mr. Bonilla.
    I have a couple of questions that I would like to ask you. 
I had the pleasure of visiting the Family Health Centers of 
Louisville, Kentucky, earlier this year and met with the 
director, Oscar Canus. The Family Health Centers play a 
critical role in the community, providing access to health care 
to individuals who would otherwise go without basic health 
care.
    Part of the success of these centers is that they are 
governed by a local board which includes both patients and 
community leaders. Nevertheless, the Family Health Centers, 
like other health centers, is having difficulty meeting the 
needs of the uninsured because its grants have remained the 
same for over a decade.
    What suggestions would you have for these health centers to 
meet the growing number of uninsured?
    Dr. Fox. Well, we are doing several things, and, again, Dr. 
Gaston can comment further. But we have provided a tremendous 
amount of technical assistance to the centers, both in 
strategies to help them be more effective with the dollars they 
have, how to make sure that they are being as efficient within 
the health centers as possible. We provided even on-site 
technical assistance to help them negotiate with managed care 
plans and others within their community. We provided a lot of 
technical assistance for them to understand where managed care 
is, where it is going, again, what the implications are for 
them.
    There are actually dollars that have been made available to 
help them become part of networks within their communities so 
they can survive. And we basically feel that the strategies we 
have invoked have hopefully helped them, one, be a part of the 
evolving system within their community in a way that they can 
survive and be competitive and provide what assistance we can 
from the Federal level to give them the information and even 
the on-site technical assistance down to helping them negotiate 
to do that.
    Mrs. Northup. Well, I can assure you that, in visiting, 
they were very popular. People had nothing but good things to 
say about them. I think that they have actually internally 
increased their relationship with the community and built a lot 
of confidence. That is why I am concerned about whether they 
are going to be able to continue providing the services.
    Dr. Fox. We are as well, and, again, we want to do 
everything we can to assist them. Marilyn, I don't know if you 
want to comment any further. But I can't tell you how much time 
and effort we have spent in trying to think through the kinds 
of things that we can do to help them. Obviously there are some 
3,000 sites in this country, and it is difficult to generalize 
because each State, depending on what is happening with managed 
care, is at a different place. But what we are trying to do is 
give them the tools for wherever they are and whatever is 
happening in their community to be able to negotiate, to know 
how to spend what money they have well, and anticipate kind of 
where the market might be going.
    Dr. Gaston. As Dr. Fox said, yes, we share your concern. 
There is no question about it. As their uncompensated care has 
increased, we have also seen a decrease in their Medicaid 
dollars. There has been a 30 to 50 percent decrease in their 
Medicaid cash flow, and so they are really getting squeezed 
from both of these things that are happening.
    It is having a major impact on the centers. As a matter of 
fact, about 5 percent of the centers are either in bankruptcy 
or will be soon, and we are watching that very closely. There 
is another 5 to 10 percent that are at risk. There is another 
strategy that we have put into place over the past couple of 
years with the increase in the appropriation that you have 
given to us. We have tried to really target those health 
centers that have had a major increase in uninsured. And we 
have given themextra dollars to try to bolster what they have 
to do.
    Over the past 2 years, we have been able to give extra 
money for uninsured to about 259 centers across the country. 
That has really helped them.
    Needless to say, we are looking forward to and are very 
excited about the Child Health Insurance Program because 44 
percent of the 10,000,000 people we are currently serving are 
kids, and we have upwards of 2,000,000 children that are 
uninsured. So to get them insured--those are kids that are in 
care right now--that would be a major help to the centers, not 
to mention the outreach they can do to get more kids in.

                              stroke bill

    Mrs. Northup. Last year, I brought to the attention of this 
committee and worked with the committee to make sure that there 
was language included about the stroke bill. There is an area 
of the country where the incidence of stroke is very high, and 
certainly Kentucky falls into that, especially in rural health.
    What the committee language suggested is that there be 
established a program that links a medical school, 
cardiologists, and a communications system with general 
practitioners that are actually out in the rural community. We 
know that there are far less specialists in those areas, but we 
know that they need the expertise really in preventive medicine 
to try to avert this high incidence of strokes that exists.
    I think that our community is a little concerned about 
whether or not that project has gone forth. I really want to 
ask you to work with that office, think that you can provide 
expertise and direction, and see that go forward.
    I think that, you know, it would be a good model for trying 
to provide more advanced care into areas where there aren't 
advanced practices that actually exist in those communities.
    Dr. Fox. I will ask Dr. Puskin to comment since she is in 
charge of the Rural Health Office, but obviously within the 
primary care area, we take care of a number of people who, by 
controlling the hypertension, hopefully we can avert stroke 
through the things in the Office of Rural Health as well as in 
health professions where they have the telemedicine issue. We 
are trying to link rural communities up with providers so that 
if people need a consult to find out why somebody who is on 
three medications is not responding with their blood pressure 
coming down, and making that kind of connection available, 
where needed.
    Dena, do you want to comment specifically on this area?
    Ms. Puskin. Yes. As you may know, there was some difficulty 
in the fact that that project didn't get into the conference 
report. But what we have been doing is we have been--Jake Culp 
of my staff has been in contact, I believe, with the folks. 
This is in Louisville where you are thinking about the project, 
I believe. Is that correct?
    Mrs. Northup. Yes.
    Ms. Puskin. And he has been in contact to provide some 
technical assistance in terms of the outreach grant program.
    I would also suggest that Kentucky Telecare, which is a 
telemedicine project that is currently being funded by the 
office, has tremendous outreach in a number of specialty areas, 
including cardiac and stroke. And I would hope that as we 
provide some technical assistance we might link up that project 
so that we get some synergy, because I think they are aiming 
through telemedicine to get at some of the same issues.
    Mrs. Northup. Good. Thank you. And so you will be 
continuing your work with them?
    Ms. Puskin. Right. And I think that we would welcome any 
help from your office.
    Mrs. Northup. Thank you, Mr. Chairman.
    Mr. Bonilla. Thank you, Mrs. Northup.

                           organ transplants

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

                           health professions

    The area I would like to start out with is health 
professions. As you know, Dr. Fox, in the past I have been 
frustrated with the administration's lack of support 
historically that it has shown for HRSA, and this subcommittee 
has had to take care of HRSA in spite of what the 
administration has proposed in recent years. And I am 
encouraged that the administration is now proposing a $155 
million increase in the budget, but I am concerned that this is 
not enough to truly make a difference in providing primary 
health care services to folks out there in severely 
disadvantaged areas.
    Each year one of my primary concerns in the HRSA budget is 
the health professions program, and last year the President 
proposed cutting health professions by over $82 million. I am 
pleased that the President's budget has recognized the 
importance of health professions training by providing nearly 
level funding. This is a good start, but we still have a long 
way to go toward ensuring that underserved Americans receive 
the quality health care that they deserve, as you outlined in 
your opening remarks.
    On page 8 of your testimony, Dr. Fox, you state that the 
return on the investment in the health professions program is 
considerable. Then you go on to state that the administration's 
budget request for health professions for fiscal year 1999 is 
$291 million, the same as the fiscal year 1998 appropriation.
    In fiscal year 1998, this subcommittee approved funding of 
the health professions program at $306 million. The final 
fiscal year 1998 appropriations for health professions was $293 
million, not 291. If I read these numbers right, the 
administration is actually proposing a cut, not level funding, 
of health professions. Could you explain the difference in the 
figures?
    Dr. Fox. We will double-check the figures while we are 
talking. I am not aware there has actually been a cut proposed. 
Obviously, the committee's support for health professions we 
appreciate, and we do in some areas affect supply, of course. 
We are a drop in the bucket compared to the GME funding, but we 
are one of the singular sources of directed funding of health 
professions. GME, as you know, is blanket funding, I guess is 
the way you could look at it, that goes out in a way that is 
totally different than thekind of funding we have within the 
Department within HRSA.
    The dollars that we have within the Bureau certainly will 
allow us to continue to do the things that we have done and 
maintain our institutional capacity. There are a number of 
areas where we could do things a little differently than we do 
right now, but the bottom line is that with the funds in the 
current budget, our ability to maintain our expertise within 
the agency and within the Department to look at graduate 
medical education issues through groups like COGME and others 
is certainly maintained.
    Tom, do you want to comment on--I wasn't aware that we had 
an actual decrease, but the recommendation coming forward from 
the Department was for level funding.
    Mr. Bonilla. Before you answer, Mr. Morford, I would like 
to point out that I mentioned the figure was $293 million. It 
is actually closer to $294 million. So there is a discrepancy 
here as we have gone over the numbers, and I just wanted you to 
clarify whether or not this is a proposed cut or not.
    Dr. Fox. Oh, there are two areas in there that are very 
high that are the two areas that would be reduced, and that is 
community scholarships and nurse training. Those are two areas, 
fairly small areas, within the budget that we had proposed 
picking up, and hopefully doing a better job with that through 
the Community Health Centers and through the National Health 
Service Corps. Both of those programs required a fairly high 
match. One of them required a 60 percent State or local match 
and had a fairly high administrative cost with it. So we were 
proposing that we would not fund those and actually pick those 
up through some of the other things that are going on in Dr. 
Gaston's Bureau.
    Mr. Morford. That is right. As a technical matter, they 
were moved from the budget lines that reflected health 
professions over into the primary care line. So that is why our 
budget tables technically showed a level funding amount, and as 
I said, it is really sort of a technical issue where the two 
items were moved over under the primary care line. And you are 
correct; those two areas have a decrease.
    Mr. Bonilla. I am glad we clarified that because we wanted 
to make sure that the members of the subcommittee understood 
exactly where the administration is coming from in this budget 
request.

                       allied health professions

    In my rural southwest Texas district, Dr. Fox, the need for 
all health professionals is tremendous. In some communities, 
non-physician allied health professionals are the only source 
of health care for many of the constituents in my area, and in 
many areas of this country.
    Which of the health professions programs focus on training 
allied health professionals?
    Dr. Fox. Well, we have several within the Bureau of Health 
Professions. Tony Hollins here, with the Bureau, I will ask him 
to comment. But we have approximately 42 line item budgets of 
which there is more than one that actually is involved in this. 
Tony, do you want to comment?
    Mr. Hollins. Good morning. Yes, we do, a number of our 
programs focus specifically on other than doctors, dentists, 
and nurses. We are looking at all of the health professions; 
nurse practitioners, PAs, dentists, as well as other 
practitioners.
    What we are focusing on is trying to get individuals from 
underrepresented areas to go into these programs, such as our 
HCOP program and our COE program. We are finding that if we can 
get people from the communities to go into training that the 
likelihood of them staying there is very high. The programs 
that we fund have shown a significant increase, and that is 
where we are focusing all of our efforts. We are even making 
preference in the priorities in these areas.
    Mr. Bonilla. As a follow-up to that, with the need for 
allied health professionals so great, is the $3.8 million--and 
maybe Mr. Hollins would like to answer this as well--provided 
for allied health special projects really enough to meet this 
need?
    Dr. Fox. Well, one of the things I wanted to share with 
you, we have about 32 percent of mid-levels that we also help 
fund through the National Health Service Corps. And, again, I 
think the issue in many of these areas is not so much the 
numbers; it is where they are, and the distribution within this 
country. We know even within the physicians we have not the 
right kind. So you could obviously spend more money in 
virtually any area, but I think it is more of an issue of 
trying to direct those funds to try to get them into 
communities, the rural communities, inner-city communities, 
where there is not enough mid-level or primary care providers.
    So, again, we can do whatever this committee would like, 
but the bottom line is I think that the issue of distribution 
for all the health professions, particularly within rural and 
underserved areas, is a real problem.

                             health centers

    Mr. Bonilla. I am going to move now to some questions I 
have about health centers, and I appreciate the opening 
comments that you made about the significance of what they are 
doing and how they are serving more people now.
    As you know, I have been a strong advocate of community 
health care centers across this country. It is a program that 
serves a vital need for 10,000,000 low-income children and 
adults in every State. The Community Health Centers play an 
important role in my home State of Texas. I am proud of the 
work that Rachel Gonzales is doing with this group, and I am 
going to elaborate on what she is doing a little more in just a 
second.
    I would like to commend HRSA for recognizing the 
overwhelming medical needs in the severely underserved regions 
of Texas. As you know, my region is one of the very few that 
received an increase in grant funds for Community Health 
Centers. I look forward to working with you in the future to 
ensure that these centers remain viable to care for the growing 
number of uninsured and underinsured in the South and West 
Texas area.
    I have visited the community health care centers numerous 
times in my congressional district, and I have got to tell you 
that is where the rubber meets the road. That is where a lot of 
folks that would have no place else to turn show up on the 
doorstep of these Community Health Centers, and they are doing 
good work for people who truly need this health care.
    Last year this subcommittee provided a $24 million increase 
for health centers, Dr. Fox. How has this increase been 
allocated?
    Dr. Fox. Marilyn, I am going to ask you to comment on the 
specifics of the program.
    I will tell you that we have funded new centers and 
continue to try to provide support. We actually within your 
area, Congressman, are working on the border with some specific 
initiatives down there, trying to pull together the health 
centers and the other funding within HRSA to look atparticular 
needs along the entire border area for areas where we currently have 
some health centers, but in an attempt also to bring together other 
resources in the agency such as the AHEC projects and health 
professions rural health projects that Dr. Puskin is dealing with, and, 
of course, MCH and AIDS as well.
    So we have had--in fact, we had a meeting in our upper-
level staff this past week on the Texas border area trying to 
look at things that we can do during the next year that will 
bring together the HRSA grantees at the local level to provide 
better service.
    I will let Marilyn comment on the specifics of the funding.
    Dr. Gaston. On the $24 million, in keeping with your 
congressional intent, we have tried to balance the dollars that 
go to the existing centers to help them with the uninsured, but 
also try to get more access points to serve people that just 
absolutely don't have any care. So, of the $24 million, about 
$12 million to $13 million went to existing programs that had a 
disproportionate share of the uninsured. About $9 million went 
to brand-new sites throughout the country where there is no 
health care at all.
    The small amount of remaining----
    Mr. Bonilla. What is an example of one of those?
    Dr. Gaston. Some sites in the Delta, Mississippi Delta. As 
you know, there are still places along the border where there 
is absolutely no care. Some places in the frontier areas also 
have no providers and no system of care.
    The small amount of remaining dollars went, as you heard 
Dr. Fox talk about, our technical assistance we give to them, 
also helping them become more and more competitive as they are 
moving into network arrangements with other programs. So that 
is about the extent of the $24 million.
    Mr. Bonilla. Thank you.

                          uvalde county clinic

    As you heard me mention earlier, we are proud to have 
Rachel Gonzales, who runs the Uvalde County Clinic in my 
congressional district. She testified before this subcommittee 
a few weeks ago. She has done a great job running the health 
center in that community, and it is one of the most 
economically depressed areas that she serves. She undertook an 
impressive fundraising campaign and will build a state-of-the-
art center that will enable more patients to be served. I had 
the honor of participating in the ribbon-cutting ceremony for 
that new center, and I look forward to its opening sometime 
this year.
    I invite and urge you to tour Rachel's center if you ever 
have an opportunity when it is complete and visit the other 
centers in my area, and we would be glad to host you anytime 
down there, because they are doing an outstanding job and we 
are proud to show it off.

              professional budget judgment--health centers

    Rachel's testimony of the state of health centers in this 
country is alarming. On page 2 of your testimony, you reference 
the ``growing numbers of uninsured persons around the Nation,'' 
Dr. Fox. As I understood it, over 1,000,000 new uninsured 
patients have been added to their rolls in the past 3 years 
alone. Clearly, the small 1.8 percent increase the 
administration has provided in its budget for health centers 
will not address this problem.
    Dr. Fox, what was your professional budget judgment for 
Community Health Centers as submitted to the Secretary and then 
to OMB?
    Dr. Fox. Well, Mr. Chairman, let me first say that if you 
look at the dollars for Community Health Centers, we are 
spending about $100 per new patient served, so we are really 
leveraging a lot of dollars out in the community. We are 
leveraging Medicaid. We are leveraging other dollars. And in 
some instances, we make up a large part of the budget of the 
health centers sum. But across the country, if you figure we 
are serving about 10,000,000 people with $800 million, it is a 
little less than $100 per patient.
    Obviously with 41,000,000 people in this country who don't 
have health care, there is a lot of room for additional care 
through a whole variety of sources. It depends on whether or 
not you want to fund it from what source. We did submit an 
additional $200 million request as a part of Community Health 
Centers for this year, again, knowing that there are limited 
dollars. But there is certainly 41,000,000 people out there 
that rely in many instances, as you have already alluded, on us 
for care.

                consolidated health center program fte's

    Mr. Bonilla. On page 68 of your budget justification, Dr. 
Fox, you state that there are only 10 full-time employees for 
the Consolidated Health Center Program. If that is the case, 
there is only one FTE per 1,000,000 patients served by the 
program. That is a very impressive number and testament that 
these Federal dollars directly benefit the patients.
    Are these statistics accurate?
    Dr. Fox. We have within Dr. Gaston's bureau the total 
funding, and, again, remember, we have the Community Health 
Centers, the Health Care for the Homeless, the National Health 
Service Corps, the Migrant Health Centers, and some other 
projects--I know I am forgetting, Marilyn--and we have 
approximately 300 people total in the bureau for all of the 
programs. How they are allocated, I will defer to Dr. Gaston to 
comment.
    Dr. Gaston. Those are the FTE's associated with the loan 
guarantee program.
    Dr. Fox. The loan guarantee.
    Dr. Gaston. We do have more FTE's that are administering 
the Health Centers Program--both in headquarters and in field 
offices.
    Mr. Bonilla. I am glad you cleared that up.
    Dr. Fox. I knew there were more. I didn't know--again, the 
total number is beyond that, but that was for the loan 
guarantee program, which is one fairly circumscribed program 
within the bureau.
    Mr. Bonilla. Thank you very much.
    At this time I am going to ask Mrs. Northup if she has 
further questions, and if she does, we can continue. If not, we 
are going to recess until Chairman Porter arrives.
    Mrs. Northup, do you have further questions at this time?
    Mrs. Northup. Just a few brief ones.
    Mr. Bonilla. Okay. I will then allow you to take the chair. 
I have got to go to another hearing at this time. Thank you.

                  health care integrity and protection

    Mrs. Northup [presiding]. Thank you.
    I would like to ask you a question about the Health Care 
Integrity and Protection data bank that was part of the 
memorandum of agreement that you signed with the Office of the 
Inspector General last year. I am interested in knowing how the 
development of that data bank is going and then to ask you to 
tell me how that works with the fraud and abuse efforts.
    Dr. Fox. The Federal Register notice to move forward on 
that we have been working with the inspector general on. Ithas 
been looked at and worked on with a great deal of time and effort 
within our Department and within HRSA.
    We are, as I understand, moving forward with that. Tony, I 
don't know if you want to comment on it, but we do plan to move 
forward with it. We have been--I think the last set of 
discussions we had, we were going to jointly issue that notice. 
But we are moving forward, and it will be a part of the overall 
effort that is combined with the data bank, with the National 
Practitioner Data Bank.
    Mrs. Northup. And is the goal to establish sort of 
parameters of practice and to then be used collaboratively with 
the fraud and abuse efforts?
    Dr. Fox. Well, again, we are working with them so that they 
have some input into where we are headed with this. We do plan 
to make it a part of the overall effort, and, again, even 
though the National Practitioner Data Bank is a separate 
effort, it will be a part of that whole unit. And we will be 
working closely with the IG so that we are doing the type of 
things that were a part of the congressional language.
    I think we are moving forward on that. We have had some 
discussions in negotiating with the IG exactly how to go 
forward, but I don't know there is any disagreement on whether 
or not to go forward, and, in fact, we actually have a set of 
regs that we are working on together and will probably jointly 
put out.
    Mrs. Northup. Well, is there a time line? I am sort of 
trying to get a better feeling for it.
    Dr. Fox. There is a time line. Again, I can't tell you 
specifically when it will be done, but, you know, we are moving 
to get it done expeditiously. We are hoping sooner rather than 
later. I am not going to try to predict the time line within 
the Government because, lest I do that, since not everything 
that is involved with this is under my control, I couldn't give 
you a specific date. But we are planning on moving forward with 
this, and hopefully within the next month or so we will have 
something on the street. But it is not----
    Mrs. Northup. Would you be able to provide my office with 
the time line and what the parameters are?
    Dr. Fox. Sure. We would be glad to.
    Mrs. Northup. You know, what are sort of the limits of what 
you intend to do?
    Dr. Fox. Sure. I would be glad to.

                              heal program

    Mrs. Northup. I wanted to also ask you about the HEAL 
Program. I know with all of our Government programs we are 
concerned about default rates, and I wondered about the 
estimates of defaults and what the total amount of the defaults 
has been and what actions you might be taking.
    Dr. Fox. Well, as you know, the HEAL Program goes back a 
number of years. We have had overall--for the entire program a 
4.2 percent default rate. There has been a big spread between 
disciplines, however, and the default rate has varied as much 
as 14 percent for chiropractors and 1.8 percent for allopathic 
physicians.
    We are doing everything we can to collect that money, and 
in fact, I would point out that 96 percent of the people that 
get HEAL loans repay them as they have agreed.
    We have recently issued a Medicare/Medicaid exclusion list 
of HEAL defaulters. We are working with DOJ to follow up on 
that, and, this is the third time we have excluded defaulters. 
The first two times netted $31.5 million for the Federal 
Government in money that was recouped. We have posted these 
names on the Internet, and we will be continuing to update and 
modify that list.
    I think, quite frankly, short of taking the firstborn 
child, we have done about everything we can, and we don't 
necessarily want that firstborn child because then we would 
have to support it.
    The requirements for filing a default claim are that there 
be a State judgment, then it is turned over to a collection 
agency. We then go after them, and DOJ can seize their assets. 
But the bottom line is we have about 1,400 individuals that are 
in default and excluded from Medicare/Medicaid.
    We have a total loan guarantee of $4 billion-plus, and only 
about $430 million that we are in contention with right now. We 
are making every concerted effort to collect that. As you know, 
we are not in the process of making new HEAL loans.
    Mrs. Northup. That is great.

                               ryan white

    Another question about the Ryan White funds. I think last 
year there was some concern that the Ryan White funds are 
supposed to be the payer of last resort, and, of course, if 
they aren't the payer of last resort, they can offset some 
other money, and so the total amount of money that goes to 
serve the AIDS community is reduced overall.
    Can you give me an update on what sort of information you 
are providing States and how carefully you are monitoring that?
    Dr. Fox. Well, I guess, again, it depends on which title 
you are talking about. I would just say in general, 
particularly for Title I, remember that Title I is provided to 
cities, and those dollars are really expended under the 
direction of a community board. And so there is a lot of 
community input as to what happens there.
    On the ADAP for the drug funding, if that is an area of 
concern, then I will ask Joe to comment. On the ADAP, we again 
provide the funds to States. The States then basically buy 
those drugs through a variety of mechanisms. We have been 
working with them, quite frankly, through a number of 
mechanisms, including going to a national rebate program to 
provide the States additional options to lower their cost, and, 
in fact, are in the process of publishing a Federal Register 
notice that really requires them either to do a rebate or 
direct purchase unless they can show that they can get a lower 
price.
    So there are a number of strategies that we would be glad 
to give you additional information on that we have done to try 
to lower the costs for particularly the medications.

                 inspector general's report--ryan white

    Mrs. Northup. I was actually referring to the IG's report 
last year on the Ryan White funds, and I am not sure what area 
that was.
    Dr. O'Neill. Let me say that this is an area that I 
personally and HRSA are very concerned about as well. We are so 
appreciative of the resources that we have to do this, and it 
is absolutely clear in my mind that any time we are allowing 
any other resources to be supplanted by these, particularly 
private insurance or entitlement programs, it is taking 
medications, life-saving medications and treatment away from 
people who desperately need them. So we really have, I think, a 
strong sense of passion about really trying to tighten up as 
much as we can on this.
    Now, the mechanisms that we have in the Ryan White program 
to varying degrees allow us to do this. We have been very 
aggressive about monitoring across all of the programs. We have 
worked with the inspector general, and it has beenactually a 
very good relationship, and we have appreciated their help.
    There was a particular study they did in one State that 
looked at some of the issues that you mentioned, and they did 
point out areas to us where we were--they weren't huge areas, 
but they were areas where we did need to tighten up, and we 
have. And I would be glad to give you some additional 
information in writing later about, you know, the various steps 
that were taken. But I do really want us to go on record as 
saying that we see this as a very important issue and not one 
that we will ever be comfortable with.

                         organ transplantation

    Mrs. Northup. Okay. The budget increase for $1.3 million 
for the Organ Procurement and Transplantation Program is 
targeted towards increased organ donation and education. I 
asked, I believe, last year about this. I am concerned about 
whether or not this is going--how these are targeted and what 
audience it is targeted to.
    Dr. Fox. Well, let me first say we are not trying to remake 
the wheel here, and just to tell you some of the things we have 
done in the last several months, we have had intense 
discussions with the Coalition on Donation, as you know, a 
national group that has done a lot of work in this area, and 
actually have an agreement with them to work with them on 
further dissemination of the message, have them actually help 
man a 1-800 line to take calls and referrals.
    We are looking at working with other groups, again, just to 
give you some examples, the AMA, with the various medical 
groups, to try to get physicians to obviously take this message 
to families and patients; with the Bar Association, to try to 
have people think about this in advance directives; and with 
other groups, churches.
    The bottom line is that it is not so much--I mean, we need 
an increase in the number of people who are willing to donate, 
but the big problem is that people don't tell their families; 
and for those people that do agree, even if the family is not 
informed, many times the medical providers is hesitant to do 
that at the time of death.
    So we have a variety of areas we, again, are trying to use 
the mechanisms that are out there, not create a new system, and 
I am confident that we will be able to see change.
    As you know, the other thing that the administration is 
doing is looking at the conditions of participation, the 
hospital conditions of participation, and really looking to 
require that hospitals refer to the organ procurement 
organizations those individuals where they think that might be 
a potential so that somebody who is trained can talk to the 
family and do it in a way that is sensitive to their needs at 
the time.
    So we have a lot of this going on, and obviously we are 
very concerned about this, because despite all the controversy 
in the organ transplantation area, if we had increased donation 
it would really lessen a lot of the other pressures.
    Mrs. Northup. I think I was worried last year about you 
were targeting children that were in grade school and high 
school, and I guess my feeling is, first of all, they are 
probably the least likely group of people you are going to get 
donations from in the immediate future, but also I think their 
parents have to co-sign, and that seemed like--if we have not 
enough resources, that might not be the target audience. So I 
think it is important that we do target the money well.

                         pilot project with irs

    I also was aware that you all--I thought you had a pilot 
project with the IRS where people had a check-off system, and I 
just wondered how that went and what sort of response you got.
    Dr. Fox. Let me ask Joe if he wants to comment. Let me tell 
you before he does that we also have had a general effort 
across all Federal employees, and we have had information that 
has been sent out in pay stubs to all Federal employees, 
information in employee bulletins. And so we are really 
targeting all of the Federal workforce in addition to other 
specific groups that we might do something special with.
    Dr. O'Neill. I would just add there was a model which 
included information with the IRS tax refund checks. I am not 
sure how we can really--we could have really evaluated the 
impact of that. In terms of the Federal program, we are 
actually--when people call in, there is a way when the calls 
come in that we can determine whether those calls are coming 
from the Federal workforce presumably as a result of the 
campaign versus coming from the general public. So we will have 
some better information about the effectiveness of that kind of 
activity.
    Mrs. Northup. Okay. Well, thank you very much. I know that 
you serve a lot of people that need your services. You 
certainly have made a difference in my community, and I 
sometimes think we have some examples of health services that 
have been very effective, very efficiently delivered, and very 
appreciated and high quality. Certainly in my district, I have 
seen an example of that. I sometimes think we don't value and 
increase those efforts as much as we should.
    Thank you very much.
    Dr. Fox. Thank you so much for those comments.
    Mrs. Northup. We will now recess until Mr. Porter gets 
here.
    Mr. Porter [presiding]. The subcommittee will come to 
order.
    Dr. Fox, let me apologize to you. I was at one of my other 
subcommittee hearings. The Secretary of State is here to 
testify this morning, and I wanted to have the opportunity to 
ask some questions there. I understand Mrs. Northup has been in 
the chair, and we appreciate her taking the chair and covering 
a lot of the material that we wanted to cover with you.
    Mr. Stokes, I would be happy to recognize you right away. I 
realize you have other obligations as well. Why don't you 
proceed?

                            minority health

    Mr. Stokes. Thank you very much, Mr. Chairman.
    Dr. Fox, I am pleased to see you here this morning, and I 
apologize for not being here earlier. However, I am on another 
subcommittee that meets at this same time, As the Chairman was 
saying, he had to go to another subcommittee, too. We are 
balancing our activities this morning.
    Dr. Fox, I am advised that since your arrival at HRSA you 
have worked very diligently to ensure that this committee's 
recommendations with respect to minority health and minority 
health schools have been carefully adhered to. I want to thank 
you for your leadership and your responsiveness to that.

                           health disparities

    How do you see HRSA playing a continuing role in reversing 
health status disparities between the races?
    Dr. Fox. Mr. Stokes, I appreciate those comments. We feel 
strongly about our support to the various institutionsand 
groups out there that we have and will continue to work with.
    HRSA really has a major role in the health disparities 
issue. If you think about virtually all of the funding that we 
do through primary health care, a large percent of the 
populations we serve, we feel like we have some impact, and I 
had shared earlier that actually some of our numbers show that 
we have a disproportionate positive impact on various groups 
who are disadvantaged.
    The MCH area as well, Ryan White obviously, and I think 
even within what we do around working with providers--as I 
understand it, 50 percent of our providers in the Ryan White 
Program are minority, which I think is a pretty good record. 
The health professions area, we do a better job in almost every 
situation than the community as a whole in training and placing 
out African American, Hispanic, and other providers. Again, 
rural health, we know that--so I guess overall, of our almost 
$3 billion budget, a lot of our services do go to deal with 
health disparities, and we think we are having a 
disproportionately positive impact on that, and we certainly 
appreciate your support for HRSA and for the programs that we 
deal with, and the other programs that we work with, like 
public housing and various training efforts that really help us 
get the job done.
    So we have a lot to do, obviously still a significant 
problem with disparities. I will tell you that the Healthy 
People 2000 effort is looking at trying to not necessarily 
narrow disparities in the next 10 or 15 years, but we want to 
eliminate them.

                             allied health

    Mr. Stokes. Dr. Fox, during this year's public witness 
hearings, we heard testimony about a medical technologist 
training program being supported at the University of Maryland 
in Baltimore that has a 52 percent minority student enrollment 
at a majority institution and an average 95 percent student 
retention rate. This impressive effort, as I understand it, is 
supported by the Allied Health Project Grant Program.
    Is the Allied Health Project Grant Program geared at 
helping to support efforts to solve national problems like the 
shortage of minority health professionals?
    Dr. Fox. Let me make a comment, and then I also want to ask 
Mr. Hollins with the bureau to comment as well.
    We really are trying to look at every funding source within 
the Bureau of Health Professions and ways we can leverage that 
to increase the representation of minority providers. We are 
doing that now. We have had some discussions since I arrived at 
HRSA at how we can place additional preference within the grant 
awards, what we can do with our requests for proposals to try 
to do this in all areas, and I think there are some ways we can 
further leverage that we are working on.
    So it is on our radar screen, and we are trying to think of 
all the levers that we can pull within--all of them, as you 
know, have a variety--we have some 42 authorities with the 
health professions that cut across a number of areas to try to 
do that. We are not about supply. We are about diversity and 
distribution. Again, we feel like within programs like that and 
others we can continue to do that and probably have some ways 
we can actually put a little more pressure on. There are 
training programs that exist in this country to do a better 
job.
    Tony, do you want to comment as well?
    Mr. Hollins. Thank you very much. Yes, we are making a 
concerted effort to focus funds so that we can try and close 
the gap on diversity, especially in the allied health programs. 
These are areas where we can make a difference.
    As Dr. Fox said, we are making special considerations for 
funding preferences and priorities. We are going out to make 
sure that we provide the necessary technical assistance to 
these institutions so they will qualify for our funds. And the 
focus here is to get people into school and get them trained.
    Mr. Stokes. Dr. Fox in your professional judgment, if 
additional funding were put in this area, would that help?
    Dr. Fox. We certainly could do more in this area. Again, 
the workforce overall, as you know, does not reflect the 
populations that are out there that are being served and that 
need to be served, and certainly additional effort could be 
made in that area.

                   minority health care professionals

    Mr. Stokes. That leads me to my next question. Health 
professions training studies have revealed that minority 
physicians are much more likely to serve minority poor and 
Medicaid populations, and care for significantly more patients 
of their race and ethnic group than other physicians. How 
critical is the expansion of the number of minority health care 
professionals to addressing the health care needs of those 
living in these underserved inner cities, and rural communities 
across the Nation.
    Dr. Fox. We think it is very critical. There are obviously 
a lot of reasons why we don't have health professions in the 
communities in need in this country. Part of it is the kind of 
support systems that are out there. Part of it is funding to 
make that available. Part of it for them having a system to 
work in. And part of it is having somebody who understands the 
community and can work with the community in ways that are 
culturally sensitive. And we think HRSA programs do that and 
are committed to continue that effort. It is very important.
    Mr. Stokes. During last year's discussions with your 
predecessor, Dr. Sumaya, he indicated that the Administration 
is very concerned about the low representation of minorities in 
the health professions and is committed to improving the 
situation. How is this commitment reflected in the Fiscal Year 
1999 budget request?
    Dr. Fox. Well, of course, Mr. Stokes, we have been able to 
maintain and we are very pleased that we were able to maintain 
funding for health professions overall. I will tell you that 
having reviewed the HRSA budget prior to coming to this 
hearing, we have increased in virtually every area within 
health professions our funding for minority training.
    If you look at the COEs, HCOPs, for African American, for 
Hispanic, all those numbers have gone up--and we can provide 
those to you--within the health professions. So we are actually 
going beyond what the law requires as far as the set-aside, and 
we are going beyond what we have been asked by this committee 
to do.
    Obviously, again, there is always additional need that you 
could fund, but we are doing everything we can with the monies 
we have available to really sincerely target this area.
    Mr. Stokes. Please feel free, Dr. Fox, to expand upon that 
in the record, if you would like, to provide any additional 
data.
    Dr. Fox. Yes, sir.

                             welfare reform

    Mr. Stokes. Enacted by the Congress, what impact has 
recently enacted welfare reform legislation had on the services 
provided by your agency?
    Dr. Fox. It has increased the demand on our service 
overall, Mr. Stokes, and obviously each area is a little 
different as to how those nuances play out. But we are seeing 
overall an increase in the number of people who are depending 
on HRSA systems because they do not have Medicaid. We know that 
for mothers who might be illegal aliens and have a child who is 
born a U.S. citizen, those individuals we feel like probably 
are not coming into care. So there is an issue of that plus the 
fact that a lot of people were on Medicaid in the past who 
might not be now and the need to find those people, and part of 
the HRSA effort is to not only provide the care but get out and 
find them.
    One of the major things we do in the Maternal and Child 
Health Bureau is involved in outreach where we go out and find 
the people who are eligible for services. It is one problem to 
not have health insurance or Medicaid available, and another 
for people who might be eligible to have it and who aren't 
enrolled. And so we try to find those people who could qualify, 
and many of the people who might still qualify for Medicaid who 
perhaps are not on it now because of changes in welfare reform. 
We are really trying to use our systems to find those people 
and provide care, and even those not covered that were 
previously, are depending on our system.
    So it is really increasing the demand for almost all of our 
systems within HRSA.
    Mr. Stokes. Do I still have some time, Mr. Chairman?
    Mr. Porter. Go ahead.
    Mr. Stokes. Dr. Fox, to what extent will your Fiscal Year 
1999 budget request allow you to be able to respond to this 
demand that you have just spoken to?
    Dr. Fox. Well, of course, we understand there are limited 
funds and are trying to stay within a balanced budget, have the 
funding areas within, again, some additional money to reduce 
racial disparities as far as the Health Centers, and the 
largest amount of funds for the Ryan White area. But, again, 
there is obviously a need across a number of the programs and 
within the budget constraints we try to do the best we can with 
placing dollars within the agency to address those needs, 
knowing that there are still unmet needs. And, you know, we 
will work with this committee in any way we can to try to 
address those.

                               uninsured

    Mr. Stokes. Dr. Fox, I understand that over the past year, 
in Ohio, which is my State, of course, the amount of Medicaid 
dollars available has decreased by 11 percent, while the number 
of uninsured has increased by 18 percent. This situation, of 
course, is alarming. As you know, Health Centers are the 
primary preventative health care providers serving the 
uninsured.
    It would seem that to help alleviate the growing problem of 
the uninsured the investment in Health Centers should be 
significantly strengthened. In your professional judgment, is 
the amount requested sufficient to do the job? And, how does 
that compare with the funding level for Fiscal Year 1998?
    Dr. Fox. Well, again, obviously, there is need out there, 
as I alluded earlier. We are spending approximately $100 per 
patient per year, but what that means is not the cost is $100 
per patient per year, but the fact that we are leveraging a lot 
of dollars within the community.
    With 41,000,000 people who exist in this country now who 
are uninsured, it really is, I guess, a professional judgment 
call on the part of both the administration and Congress of how 
much of that we want to try to address with the Community 
Health Centers. We are working to try to, again, encourage 
States to expand Medicaid programs and other things. We, again, 
know that there is a tremendous unmet need for additional 
dollars, but it kind of depends on which way you want to try to 
fund that, whether you want to go through expanded Medicaid or 
through other programs. The Community Health Centers, again, 
are--we are serving about 10,000,000 with the programs right 
now today with an estimate 41,000,000 people who don't have 
health coverage in this country.
    You can see the unmet need, that whatever mechanism this 
Congress or the country decides to take to cover that, there is 
certainly need there.

                         african american/aids

    Mr. Stokes. Someone may have covered this issue since I was 
not here earlier this morning when you were being asked 
questions. I am quite concerned about the current situation in 
the African American community relative to the disproportionate 
number of AIDS cases. And, as you know, this is a major 
national problem.
    I am concerned about the degree to which Ryan White 
initiatives under your agency are being responsive to this 
national emergency.
    Dr. Fox. Well, again, in Title I, 50 percent of our 
providers--and these are round figures, not exactly, but 
approximately 50 percent of our providers in Title I are 
minority, about 25 percent of our providers in Title II are 
minority, and that is certainly greater than the general 
population. And Dr. O'Neill is in the process of--and I had 
mentioned before you came in that we have recently pulled all 
the Ryan White programs together in a single bureau. And we 
have a goal of having--and, Joe, you may want to elaborate on 
this, but we have a goal, as we bring leadership into the 
agency, to have a majority of that leadership within the Ryan 
White area to be represented by minorities.
    But in our own leadership structure, we are trying to be 
attentive to that. Within the community, we feel like that 
there is certainly a good representation of providers. But also 
the things we are doing, we hope that will set the stage for us 
and the community to work to ensure that the groups that are 
adversely affected out there, that the emphasis is 
appropriately placed to try to get at those groups, to provide 
the services that they need. There may be another strategy you 
might want to detail, Joe, but I think it is an issue of very 
much concern of ours, and I think we do have some strategies 
that we are attempting to do to address that.
    Mr. Stokes. Dr. O'neill, would you like to respond?
    Dr. O'Neill. Mr. Stokes, yes, thank you for that question. 
As you may or may not know, I volunteer one half-day a week and 
have for about the last 10 years working as a physician 
providing AIDS care in the inner city of Baltimore, and I have 
watched this epidemic in the African American community 
explode. And I absolutely share your concern on this issue.
    Approximately, in the last year's report to the CDC, about 
64 percent of new cases of AIDS were among African American and 
Hispanic Americans; 43 percent, actually, among African 
Americans and 19 percent amongst Hispanic Latinos. Idon't need 
to tell you that that is a huge--given the percentage of populations in 
the overall area, that we are looking at a tremendous disproportionate 
impact.
    For calendar year 1996, in the Title I program, 62 percent 
of clients served in the Title I program are African American 
or Hispanic. In the Title II program, 56 percent are African 
American or Hispanic. In a survey of our largest providers, 
meaning institutions which serve over 6,000 clients, 77 percent 
of people served in that group were African American or 
Hispanic.
    Now, we are not complacent about that. I think we are 
doing--I mean, I am proud that we have good representation, but 
when you step back and look at the social fabric upon which we 
are trying to provide these services, the changes in health 
care financing, the changes in welfare, the general lack of 
other services to these communities, I think we need to--I 
still challenge ourselves to do a better job in a number of 
areas. One is in terms of providing high-quality clinical 
services to this population of people such that the tremendous 
benefits of these new treatments are equally distributed. In 
other words, it is one thing for us to count numbers of people 
served, which I think we look good, but I do want to put on the 
table that I think we have to do a lot of work in the area of 
making sure that the quality of care that is provided in these 
communities is every bit as good as the person with the best 
private insurance in the country.

                               aids trend

    Mr. Stokes. I appreciate that, and I guess one of my 
concerns is whether or not your budget request is going to 
enable you to be able to follow the trend of the disease, which 
I think is equally important here.
    Dr. O'Neill. I have been saying for a number of years that 
what we really need to be doing is designing a program that is 
going to be in place for where the disease is going to be in 5 
and 10 years, given the tremendous medical and social 
complexity of this illness. This is no longer a simple--I guess 
it never was simple, but the clinical aspects of this disease 
are such that we are challenged to have to develop fairly 
sophisticated health care systems that are also culturally 
competent and placed in communities where they can be accessed.
    Those things take years to put together. I think we have--I 
guess I would sort of echo what Earl was saying earlier. With 
more we can do more. But with what we have, as an administrator 
I am very challenged to just make sure that we can do the 
absolute best and achieve the best social justice and equity we 
can.
    Mr. Stokes. You mentioned the social fabric, and in that 
respect, I am concerned about the small service organizations, 
particularly those who operate in the inner city, and those who 
are geared toward minorities.
    What are we doing in order to try and ensure equity in the 
delivery of HIV/AIDS health care services?
    Dr. O'Neill. Just to give you the statistics that we have 
from the Title I and Title II programs on this, using a 
definition of minority provider that reads defined as which the 
majority of the board or the staff are members of a minority 
population with reference to the U.S. population, using that 
definition, as Earl mentioned, 50 percent of the Title I EMAs 
reported--let me rephrase this. Fifty percent of providers by 
that definition in Title I would be classified as minority and 
28 percent in Title II. I would not go through what I have said 
before. I am not complacent about that. I think we have to--
now, you asked the question of what are we doing to help 
bolster that.
    This really turns on a number of issues. Number one, I 
think, is the adequacy and quality of the technical assistance 
that we can provide and target to these types of organizations. 
We are particularly concerned about the issue of managed care 
and the impact of managed care.
    We can supply additional details on this, but we have a 
fairly aggressive managed care strategy, technical assistance 
strategy where we actually go out into these centers and work 
with them to help them prepare for managed care activities. We 
are ready, willing, and able, and have done it, to provide a 
range of other technical assistance services when requested.

                               aids etcs

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

             community health services and medicaid access

    Mr. Porter. Thank you, Mr. Stokes.
    Mr. Stokes referred to this and you have referred to it 
several times, but we have a very changing health care delivery 
system in America. I wonder if you have looked at all the 
programs under your jurisdiction and made an assessment as to 
how they fit within this changing system and what you should be 
doing to restructure them to the extent that they do not. We 
talked about community health services and Medicaid access. Can 
you address that, Dr. Fox?
    Dr. Fox. Yes, sir. The short answer is yes, we have. I will 
give you a little detail.
    Since I came to HRSA, we have backed up and really tried to 
rethink our strategic plan. And I have said I never met a 
strategic plan that I liked. I think most of them are put on 
the shelf and are never used. But we have really tried to come 
back and we have involved the leadership at this table and 
other upper-level leadership in the agency, and myself, and we 
have actually gone off--for instance, let me take as an example 
Dr. O'Neill's area. We went off for a day, took Joe, his upper-
level staff, and every one of the other bureau directors that 
you see here, and their leadership, theirupper-level staff as 
well, to talk about what was going on in the Ryan White program and how 
does it impact every one of the other programs. And then we did that 
same thing with each one of these other areas, so that when we took 
Marilyn Gaston's area of Primary Care, the Rural Health, Maternal and 
Child Health, Health Professions. So we tried to, one, sit back up and 
say where do we think we need to be based on the demography, on the 
change in the system, managed care, 5 years from now, 10 years from 
now, what do we need to be doing. And so we are trying to basically 
construct that scenario.
    The issues of change in the Child Health Program and 
Maternal and Child Health are significant, and the fact that we 
may end up 5 years or 10 years from now with all children 
insured, raises questions about what we should be doing in 
Maternal and Child Health? Well, there are a number of things 
we're looking at. These include: having the information that 
allows us to know we have gotten there; the need for Medicaid 
and State Maternal and Child Health to pool databases to give 
States the information to know what is happening; the issue of 
doing outreach and the fact that these children are not going 
to come in to the system; the issue of systems of care around 
genetic services and kids that are screened for sickle cell, 
for glycemia and for PKU, and who makes sure that they get into 
treatment once they are identified. We also worry bout 
underinsured children. So those are all things that MCH could 
do.
    We looked at every one of the areas in the agency and tried 
to think not only where should be we be in 5 years in light of 
what is happening within the system, but how do they interface. 
And what we are trying to do is think strategically to get 
outside of our stovepipe, categorical mindset and think across 
agencies in the areas that if we--for instance, telemedicine. 
We have telemedicine activities in health professions, in rural 
health. We also support them in other ways through other 
funding sources. But how can we make sure that in the 
community, our AHECs and our rural health telemedicine 
activities are coming together?
    So we really have tried a lot of strategic thinking. We are 
not there yet, Mr. Chairman. I think that we are working on it. 
We have a strategic plan that we think begins to reflect that. 
What we are doing now is trying to actually make sure that our 
operations, our business plan for the agency reflects 
strategically where we want to go and that the performance 
measures that we then provide to you and to the rest of this 
Congress then will tell us when we get there and that they 
track. And I don't think it has ever tracked before, but our 
plan is for it to track from the strategic goals to the 
business plan, to the performance measures, and then to the 
budget request and the budget expenditures.
    So that is a long answer to say that we really are trying 
to think through this. We have spent a lot of time. It has not 
been delegated to lower-level staff. And I hope that as we move 
forward--and I think we have something better now than we had a 
year ago, and a year from now I think we will have something 
even better. And in the process, we are trying to think what 
type of information do we not have that can better tell us.
    Health professions, we are trying to do some things. We 
know there is some need for additional information there. So I 
think we are moving in this area, and I am very pleased with 
where we have gone in the last year, and I think a year from 
now we will have even more information for you.

                     research, delivery, evaluation

    Mr. Porter. Dr. Fox, I like the way that you think.
    When we talked to the Secretary yesterday, we talked about 
the 21st Century Fund for Research and about how to integrate 
research, delivery, and evaluation. The Secretary used the 
example of NIH, CDC, and ACHPR. You also have an interest in 
moving research into the delivery system. Have you looked more 
broadly as to how you can integrate your work in that same way?
    Dr. Fox. Well, a couple comments. One, as you know, we have 
some discretionary money, and two programs come to mind, 
although we have a little bit everywhere. But in Maternal and 
Child Health, with the SPRANS, we have a set-aside of dollars 
that fund training and various demonstration projects. And we 
have in HIV/AIDS, SPNS, which does some analogous activities.
    One of the things we are trying to do is think through in 
an applied research way how can we spend that money to help us 
better direct services for mothers and children. How can we 
spend part of that 15 percent set-aside to tell us what we 
ought to be doing with the 85 percent state funds.
    The SPNS money, which is $25 million of a billion-plus 
dollars in HIV/AIDS. What can we be doing with the SPNS money 
that helps Joe O'Neill and the people that are under him figure 
out where we should better be targeting and spending the $1 
billion. And so that is one thing we can do.
    The second thing we can do is work with other groups, like 
ACHPR. We have had some conversations since I arrived about 
joint efforts to try to, again, think through, for instance, in 
the child health area, when this Congress--when the money that 
you have provided is spent in child health insurance, how do we 
know what we have done? And what are our tools to do that? And 
I think that we are trying to think through that with ACHPR.
    Then the final thing in the area of what the--the example 
of the treatment guidelines, for instance, that are coming out 
of NIH, work very closely there. Dr. O'Neill is working right 
now on what kind of things we can do within the primary health 
care system and within our other providers, rural health, to 
make sure that we get out to the community as quickly as 
possible the--as things come out of the research community and 
they tell us we ought to be doing X, Y, Z, whether it is an 
AIDS treatment or hypertension or whatever, that we get that 
out to the practice community and to the providers so that they 
can actually translate it into what they are doing in providing 
care.
    We have some specific things we are working on in that 
area. We had a teleconference last week, in fact, where we 
actually did that. We have had a live hookup for people to call 
in and to ask questions. We are looking at some online 
computer-based mechanisms where we can actually have infectious 
disease fellows who can actually be on a computer and provide 
real-time counseling to people out in the community, if you 
have an AIDS patient who wants to know what to do.
    So there is a lot going on, and we want to continue to push 
that way, and I think it is a very appropriate part of what we 
do.

                      organ transplant regulations

    Mr. Porter. Thank you very much.
    Either Friday or Monday--I can't remember which--Secretary 
Shalala issued a regulation that will revamp the system for 
allocating livers to people awaiting transplants. And if I 
understand the regulation, what it attempts to do is to give 
livers to those who are most in need of them and tocircumvent 
the regional allocation that we have had in the past, so that someone 
who is going to die if they don't get a liver and doesn't live in a 
region where there is one available can receive one.
    Is there likely to be a lawsuit over this by the 
organization that has done the organ distributions and had 
apparently complete responsibility for it? Secondly, if this 
makes sense in reference to livers, would it also make sense in 
reference to other organs? Was this limited to livers simply 
because it is politically difficult to do all organs at the 
same time?
    Dr. Fox. Mr. Chairman, out of respect to this body, the 
Secretary has delayed the release or the implementation of the 
regs, so they have actually not gone out. At the request of 
many of the Members, we were asked not to do that, and we have 
withheld those.
    Mr. Porter. That may be a mistake, but all right.
    Dr. Fox. Well, I think the plan is for them to go out. But 
to have the opportunity to have dialogue, I think there was a 
concern that we would release them while many of the Members 
were on recess previously, and we want to give the Congress a 
chance to basically have a dialogue with the Department around 
that. I think that they will be released.
    Let me just say that the regs do not specify a specific 
allocation policy. In fact, what they do is--the language 
actually provides specifically that the allocation policy in 
this country around all organs, not just livers, will be the 
responsibility of the Board of Directors of the OPTN, the organ 
agency, basically UNOS right now. And so that that policy still 
will rest with the transplant community to formulate.
    Now, the Secretary will maintain oversight over that, and I 
think that what we want to do is continue to rely on the 
transplant community to come up with a more equitable 
transplant policy. It may be national allocation. It may be 
regional allocation. I think the bottom line of what we want to 
see is equity in people's ability to get a transplant in this 
country. And the fact that if you live in one place in the 
United States, you may have a 5- to 10-fold waiting time in the 
time it takes you to get an organ if you are in need of 
transplant. We want to see that equal.
    And so the intent of the regulation is going to be to try 
to equalize that and to introduce what we think will be some 
fairness. We don't want to put transplant centers out of 
business. That is not our goal. Our goal is to try to have 
equity in the system. And, again, we are not specifying a 
specific allocation policy either for livers, kidneys, or 
anything else. What we are doing is laying out a framework and 
a set of performance goals for the system to say that how 
somebody gets on a list, where they sit on the list, ought to 
be based on objective medical criteria, and that should be the 
same across this country. It is not right now. That the 
allocation policy should take into account a variety of things, 
waiting times and other things.
    And so what we have tried to do is lay out some parameters, 
because I think that with the change in technology and the 
change in the way transplantation is going in this country, it 
would be inadvisable for us to put specific allocation policies 
in regs. So what we have done is lay a framework to charge 
UNOS, the OPTN board, to do that but within some general 
performance parameters.
    Mr. Porter. Well, it seems to me that there is something 
inherently immoral about allowing someone to die in Las Vegas, 
Nevada, while there is an abundant supply of organs in Chicago 
but people do not need them as badly.
    I think the Secretary should proceed. The Congress is 
obviously trying to protect its own base, which means its 
nearest center. We are always going to say, well, we are going 
to look out for our own supplies but, it seems to me that this 
is at least a national matter where lives can be saved and to 
allow someone to die is just not acceptable, and I think the 
Secretary is aiming in the right direction.
    Should not you do this with all organs?
    Dr. Fox. We are proposing with all organs.
    Mr. Porter. It is all organs?
    Dr. Fox. Yes, sir.
    Mr. Porter. So, I first heard it was all organs and then I 
read the press and it only referred to livers.
    Dr. Fox. There is actual little difference in the timing 
but it is basically all organs.
    Mr. Porter. All organs.
    Dr. Fox. Yes, sir.

              comprehensive performance monitoring system

    Mr. Porter. Good. The Bureau of Health Professions, within 
your agency, has been working for years on the development of a 
comprehensive performance monitoring system to be used to 
measure the outcomes of the health professions and nursing 
education programs. What is the status of this initiative and 
when will you have a system in place to do it?
    Dr. Fox. Well, we are working on that. As I understand it, 
it is within the clearance process within the Department. I 
believe it is actually being reviewed by OMB, right now. We 
think if you give us more information, I think actually we have 
more information than we had a year ago, and some of the things 
that we portrayed up here we want to build on.
    What we have got to do is make sure we can actually track 
the people that graduate from these programs and have some idea 
of what communities they are going into. And we think this will 
help us do this.
    So, we are working on it. It is within OMB now being 
reviewed and we are trying to make sure that we can get what 
information is going to be out there in order to report back to 
this committee. It is on track and, as soon as it is cleared 
through OMB, we will proceed with it.

                     performance measures standards

    Mr. Porter. On performance measures under the Results Act, 
many of the measurements are dependent on data gathered from 
grantees at the State and local level. In order for goals and 
outcomes to be meaningful it seems all entities involved must 
be using the same set of terms, standards, and benchmarks. What 
are you doing to address this problem and will additional 
funding be required to implement these standards? If so, is 
there an estimate for it?
    Dr. Fox. Well, you have to--obviously we are trying to 
start at the actual ground level and I will give you an 
example. One of the things that Dr. O'Neill is addressing with 
the Ryan White Program right now is to make sure that we are 
using the same definitions and the same reporting methods that 
go across all the Ryan White titles, four titles.
    And, so, we are starting there and we are trying to also 
look across the agency. We have an internal--Mr. Morford 
chairs, something we started back a month or two ago, an 
internal data subcommittee, it sounds like a boring subject.
    But the bottom line is that we are trying to look 
acrossagencies at what data we are collecting, how we are collecting 
it, and are we collecting it in ways that it is duplicative, or we 
collecting it in ways that we can pool the data and have a better idea 
of what is going on out there?
    We have several other projects that I think interface on 
this, one being in the maternal, child health area. Dr. Nora 
and her staff have initiated, and piloted with the States, an 
electronic disc, with a reporting form for block grant monies 
that provides some consistency across all of the States, and it 
does it in a way that is very user-friendly.
    We have asked the States what works and what does not work. 
In the past, we would have had up to a three year lag time to 
get our reports and information in, and now it is going to be 
six months.
    And we actually are in the process--this again has been 
cleared by OMB--we are in the process of getting it off the 
ground. So, a lot more needs to be done, Mr. Chairman, as you 
might suspect, but I think we are working within HRSA to try 
to--we are doing this on several fronts. It is a data issue 
that we are specifically looking at now by having a weekly 
meeting of data of our folks within the agency trying to look 
across data. We are doing the same thing in distance-based 
learning and in some other areas as well trying to, again, 
bring everything together that we are working on.
    So, there is a lot going on in this area.

                     secretary's initiative on race

    Mr. Porter. The mission of the health centers is to 
increase access to comprehensive primary and preventive health 
care and to improve the health status of underserved and 
vulnerable populations.
    Is not the Secretary's new initiative on race and health 
disparities duplicative of this?
    Dr. Fox. We actually think it is complementary. I, for one 
think, and I suspect most people here sitting with me would 
agree, that most of what we do at HRSA is really targeted at 
racial disparities.
    And most of the groups that we serve through any program 
that is represented at this table is having, I hope, and I 
think we can show in many ways a disproportionate positive 
effect on health disparities. But the problem is that in many 
instances our health disparities continue.
    Infant mortality being a prime example, where the low birth 
rate and the infant mortality rate among our African-American 
infants is, in most places, twice that of whites and, in some 
places, three times that of whites.
    And in many communities we are not narrowing the gap, it is 
widening. The stroke incidence among African-Americans is much 
higher, the deaths from cardiovascular disease is much higher. 
And, so, we, I think, particularly for HRSA, because of the 
role and charge we have, it is very complementary to what we do 
and fits in very well.
    And, again, we see this as part of what we do anyway and I 
think it will help us in our mission.
    Mr. Porter. I was not questioning the need for it. I was 
simply saying is it not already being done?
    Dr. Fox. Well, again, I think that you will see a whole 
variety of agencies, and HRSA is not alone in this, that 
address issues that you would say are giving attention to 
racial disparities. But there is not enough effort there.
    And again if you think about the disparities in virtually--
in fact, NCHS has their Healthy People 2000 data unit, actually 
publishes an annual report that lays some of this out in fairly 
graphic terms--and we think that there is certainly a need for 
additional effort in virtually any health condition that you 
could take in this country because the disparities are so 
great.

                    health centers guaranteed loans

    Mr. Porter. A total of $160 million was provided in fiscal 
years 1997 and 1998 for guaranteed loans for community health 
centers. Loans could be used either for construction or for 
developing managed care networks. How many requests for these 
funds have you received and how many loans have you actually 
made?
    Dr. Fox. This is a very, very difficult situation and one 
of the problems we have with the community health centers is 
they do not have generally a lot of assets. And Dr. Gaston and 
I, in fact, will talk about talking about this earlier and I am 
going to ask her to comment on it. But it is an area we are 
very concerned about.
    We are working hard through a variety of strategies to make 
sure that loans are available to community health centers but 
this has been a very problematic area for us. And maybe I will 
ask her to detail that.
    Dr. Gaston. As Dr. Fox is saying, it is very difficult for 
our programs that have no assets and no cash reserves to 
convince banks that they are a good credit risk.
    And, so, that is one major barrier. It takes about two to 
three years to really move a project that is a new capital 
investment, a new facility. There are a lot of issues around it 
that relate to just the architectural and, again, getting back 
to needing to get a loan. We have received 12 requests for the 
loan guarantee. At this point in time, we have definitely 
approved two and three more are very close to being approved.
    But that is why there is not a request this year because we 
can make it through 1999 with funds appropriated in fiscal 
years 1997 and 1988.
    But it is a very complex area and it has required review 
and compliance with complicated laws and regulations. There is 
only one other program in HRSA that does loan guarantees. So, 
this was a challenging project for all of us in the department.
    Dr. Fox. And, in fact, Mr. Chairman, if I could--we can 
provide you--there is a fairly detailed set of things that we 
have done to try to move this issue that we would be glad to 
provide you.
    Mr. Porter. It is both new to the Department and new to the 
community health centers. You mentioned credit risk, but this 
is a guarantee program and the Federal government guarantees 
the loans, so I do not think it is a credit problem. It seems 
to be a problem of not having done this before and something 
new to both the provider and those applying for the loan.
    Dr. Gaston. You are absolutely right. If I may, the 
facility loan is not a 100 percent guaranteed. There is a 20 
percent risk that the bank would take and for the networks and 
the plans there is a 15 percent risk. So, there is some concern 
in that arena.
    Mr. Porter. We think banks ought to take a little risk from 
time to time.
    Dr. Gaston. We agree with you. [Laughter.]

                        hansen's disease center

    Mr. Porter. Can you tell me the status of transferring the 
Hansen's Disease Center in Carville, Louisiana to the State?
    Dr. Fox. Yes, sir. We are moving along with that. Asyou 
know, there was some money provided in the 1998 budget to prepare the 
facility for the transfer. The individuals who will be retiring, there 
has been a provision made for that and then the patients that are 
actually at the facility that really fall into two groups. The ones 
that want to stay in some type of residential care and those 
arrangements are being made. And then for those patients that do not 
want to stay there they will get a stipend to basically support them. 
That is being done.
    We will have and are in the process of working up a plan, 
Mr. Chairman, that will provide for this body what we will need 
from this point on. Right now, the slight decrease in the 
Hansen's money that is requested for 1999, again, reflects the 
one-time money last year for the facilities.
    There may be some other funding that is needed. Right now, 
we are not in a position to delineate that. We will have the 
report. At this point, we anticipate having it by June and we 
could provide it to this body. And I think it will give you 
fairly explicit comments as far as what is needed from this 
point on. But it is on track.

                         centers of excellence

    Mr. Porter. The House report included language regarding 
its concerns with the Centers of Excellence program. The 
committee recommended this program refocus on providing support 
to the historically Minority Health Professions institutions 
and report back to the committee on the progress of this effort 
by February 1, 1998. It is now March 4th and the committee has 
not received the report. When will we get it and can you 
summarize its findings for us?
    Dr. Fox. I prefer to tell you when the report will be 
available. But let me just tell you that I have spent a fair 
amount of time, as hopefully Mr. Stokes and all of us know 
since my arrival at HRSA, to look at this issue.
    And, again, we have, I think, ensured and done everything 
we can to ensure that we are making the expenditures that this 
body provided and, in fact, we have increased the funding for 
both--and in the COE and HCOP--for both the historical black 
colleges and the Hispanic-serving institutions in the HRSA 
budget. I think we have gone beyond what we had to do. And, 
again, if there is any concern, at this point, I certainly 
would love to have the details on it.
    But we feel like we have complied with both the letter and 
the spirit of the law in this area and will continue to do so. 
And as far as the actual written report, I will defer to Tony 
for when we will have that. But, again, we have the numbers and 
I can give you the breakdown for the numbers in the various 
programs and what we have done and I do know that we have that 
that we could provide this committee right away.
    Mr. Porter. The date of the report?
    Dr. Hollins. I will have to get back to you. I do not have 
a specific date but, as Dr. Fox said, we have numbers that will 
detail what monies have gone where. And we can make that 
available to you.
    Dr. Fox. We can actually get that to you within 24 hours 
and I will get the date for the report, as well.

                                coe/hcop

    Mr. Porter. How are the Centers of Excellence and the 
Health Careers Opportunity programs different?
    Dr. Fox. The COE really targets faculty and a lot of the, 
what I guess you might consider infrastructure support. The 
HCOP is more an issue of what we do with the students now 
trying to make sure that there is a pipeline of minority 
students into the programs. Obviously, both of these programs 
deal with, in many instances, the same institution and in some 
instances, not. But, that I guess if I had to draw the main 
distinction between the two, that would be it.
    Mr. Porter. Funding was provided for the first time in 
fiscal year 1998 for the Abstinence Education programs. Since 
States are required to match every four Federal dollars with 
three State dollars, how many States have applied to receive 
this funding?
    Dr. Fox. Mr. Chairman, all the States have applied. We have 
had a few territories that have not. And all States were 
funded.
    We did have grant conditions on all the States and we are 
working with them. Again, we feel that we have worked hard to 
comply, not only with the letter of the law but with the spirit 
of the law, and follow the guidance that the law provided for 
what these grants should do.
    So, every State applied and every State was funded.
    Mr. Porter. Let me recognize Mr. Stokes right now. He has a 
few more questions.

                            infant mortality

    Mr. Stokes. I have just a couple of more questions. I see 
we have a vote on, Mr. Chairman. I will submit the others for 
the record.
    But I was particularly interested in your mention of infant 
mortality, Dr. Fox. I have, I guess for more than two decades, 
sat on this committee talking to health officials about infant 
mortality which I think is a major problem for the United 
States.
    How do we now compare with our global counterparts in terms 
of the rate of infant mortality?
    Dr. Fox. Overall, we are still high as far as an 
industrialized country. If you break it down, however Mr. 
Stokes, as I am sure you know, the infant mortality rate for 
groups like our African-American babies is still quite high.
    Part of the problem is the low birth weight rate. And the 
major contributor to infant mortality in this country--I mean 
there are obviously a lot--but the major contributor is the 
problem of low birth weight. And quite frankly, it is an area 
that we really do not have the key to turn that lock yet. We 
know there are things like smoking and nutrition and access to 
prenatal care that will impact, however, the low birth weight 
rates in this country for the most part for the last 10 or 20 
years have remained static.
    We have made improvements in increasing the survival of low 
birth weight infants and of infants in the post-neonatal 
period. We have made improvements there with SIDS, major 
improvements in SIDS.
    We have made improvements by making sure, again through 
maternal and child health and others, that mothers and infants 
will get into care and that they get the care in the right 
place based on the risk.
    So, we have made progress but the infant mortality, the low 
birth weight rate in this country is still an enigma, and it is 
an issue, in my opinion, that we do not know the answer to and 
there is more research that is going to be required in that 
area. And because it is the major chunk of infant mortality, 
until we deal with that, we are, I mean we continue to make 
progress, but it is a major problem.

                             healthy start

    Mr. Stokes. I notice that your budget proposal flat-funds 
Healthy Start program. Wouldn't more funding help in this 
particular area?
    Dr. Fox. Again, we are in the process of funding some new 
grants. What we have done is actually transitioned the initial 
Healthy Start grants that were demonstrations and are now, 20 
of the 22, are going to be mentoring sites and take those 
lessons that they have developed and learned and will provide 
them then to 41 new grantees that we are funding. We are also 
assisting 14 other communities with planning grants.
    And what we are trying to do right now, we are working with 
Mathematica and others who are helping us massage the data to 
really tease out those things within Healthy Start that we have 
the most impact on. We know that we have improved access to 
prenatal care. We know we have changed, improved the issue of 
substance abuse among many of the communities we serve. We know 
that we have increased visibility around infant mortality in 
the community and there are things that are very positive that 
I think we have done.
    So, what we are trying to do right now is to make sure that 
those lessons get disseminated and working with various 
communities in planning grants. And I think it is not 
inconceivable that we may want to look at other options down 
the road. But the bottom line is I think we have taken and 
actually broadened a number of communities. What has happened 
is we have gone to a smaller number of grants for more 
communities.

                            low birth weight

    Dr. Gaston. If I can brag about the community health 
centers in terms of what we are doing with low birth weight. As 
you know and as Dr. Fox said, that nationally the rate for 
African-American babies is twice that of the majority 
population.
    In the health centers population we have brought the rate 
to the level of the majority population. It is not twice for 
African-Americans that of white babies. And, so, it goes to 
show that with aggressive programs that are community based, 
doing outreach, keeping mothers in care make a difference.
    Mr. Stokes. Thank you very much.
    Mr. Chairman, I appreciate the time. I will submit the 
balance of my questions for the record. But I do want to say to 
Dr. Fox and his colleagues how much I appreciate the 
responsiveness and the attention that you are paying to these 
type of programs that I am particularly concerned about and 
where, I think, the whole nation should be concerned about.
    Dr. Fox. We agree.
    Mr. Stokes. Thank you.

                     health administration program

    Mr. Porter. Thank you, Mr. Stokes.
    A final question, Dr. Fox. This is in the context of pages 
133 and 134 of the budget justification, which is the 
supporting documentation of the budget request for the Health 
Administration program. The programs is used to help subsidize 
the tuition burden of financially needy health administrator 
students and the average per student cost per year is $392.
    We would ask how cost-effective can this program be because 
that has got to be way short of what the costs for a student 
are? In other words, how can $392 help a graduate student? And 
the broader question is, how often do you evaluate programs you 
administer? Do you look at them to determine how effective they 
are every year, every three years, or every 10 years? What do 
you do to marry the facts out there with the facts of the 
program?
    Dr. Fox. Let me just say that part of the problem is that 
many of the stipends that we provide are below what, I think if 
they were optimum money available, we would like to see done. 
We try to again spread the limited dollars we have as far as we 
can and hope that we can provide enough to make the 
opportunities available.
    The Health Administration area, as the public health area, 
as preventive medicine area, are those areas that I think for 
the most part the market is not going to take care of. These 
are areas that really provide an infrastructure for this 
country around what we do in prevention and in public health. 
And for that reason, I think it is important that we can 
support that.
    We do look at these programs. I know we have reports that 
are required annually. I will have to get the details on this 
particular area. I cannot tell you right off the top of my 
head.
    Mr. Porter. Dr. Fox, my point though is that it is almost 
useless to give $400 a year to a number of students. It does 
not do anything for them or almost nothing considering the 
costs that they have to bear and maybe the program ought to be 
completely changed so that we target it better, give it to the 
most needy, give them substantial monies rather than spreading 
it around. It just does not make any sense at all to me. It is 
just money out the window basically.
    Dr. Fox. Well, we will be glad to look at that, Mr. 
Chairman, and I think that these areas, like I said, 
particularly in those particular categories are areas that, you 
know, the market is not going to take care of. So, I think 
there is, in my mind, there is no question about the need. 
There may be a question about how we target the dollars. And we 
will be glad to look at that and reevaluate that as part of 
what we normally do.
    Mr. Porter. Dr. Fox, let me thank you and your team for the 
fine job you are doing. Thank you.
    Dr. Fox. Thank you so much, Mr. Chairman, thank you.
    Mr. Porter. Thank you.
    The subcommittee will stand in recess until 2:00 p.m.
    [The following questions were submitted to be answered for 
the record:]
    Offset Folios 765 to 1205 Insert here



                                            Tuesday, March 3, 1998.

       SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

                               WITNESSES

NELBA CHAVEZ, PH.D., ADMINISTRATOR
BERNARD S. ARONS, M.D., DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES
KAROL KUMPFER, Ph.D. DIRECTOR, CENTER FOR SUBSTANCE ABUSE PREVENTION
CAMILLE BARRY, ACTING DIRECTOR, CENTER FOR SUBSTANCE ABUSE TREATMENT
DONALD GOLDSTONE, M.D., DIRECTOR, OFFICE OF APPLIED STUDIES
DARYL W. KADE, DIRECTOR, DIVISION OF FINANCIAL MANAGEMENT, SAMHSA
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, HHS
    Mr. Porter. The subcommittee will come to order. We began 
our hearings of the Department of Health and Human Services 
this morning with Secretary Shalala, and our hearings for the 
Department continue this afternoon with the Substance Abuse and 
Mental Health Services Administration. We are very pleased to 
welcome Dr. Nelba Chavez, the Administrator. Dr. Chavez, will 
you introduce the people who are with you and then to proceed 
with your statement.

                           Opening Statement

    Ms. Chavez. Thank you, Mr. Porter. To my far left is Dr. 
Goldstone, who is the Director for the Office of Applied 
Studies; Dr. Karol Kumpfer, the new Director for the Center for 
Substance Abuse Prevention. I might add this is her second 
week.
    Mr. Porter. We will be nice to her.
    Ms. Chavez. I feel very good that she is with us. She comes 
to us with a great deal of experience and very well known in 
the field of prevention. Also we have Dr. Bernie Arons, who is 
the Director for the Center for Mental Health Services. To my 
far right, we have Dennis Williams from the Department.
    We also have Dr. Camille Barry, who is the Acting Director 
for the Center for Substance Abuse Treatment and Daryl Kade, 
who is the Director of Budget.
    Mr. Chairman, we have submitted SAMSHA's full testimony for 
the record. Mr. Chairman and members of the subcommittee, I am 
pleased to present the President's 1999 budget for SAMSHA. We 
are proposing $2.3 billion, a $132 million increase over our 
1998 level. As on previous occasions, we will highlight for you 
some of the remarkable accomplishments, some exciting paths we 
are taking, and the challenges we must face in the 21st 
Century.
    In his State of the Union address, the President spoke of 
``an America where every citizen can live in a safe community, 
where families are strong, schools are good.'' As we look to 
the new century, two threats to the promise of a healthier, 
better future are clear. Mental and addictive disorders are 
among the most prevalent and most often ignored health problems 
in our Nation. In fact, by 2020, the World Health Organization 
projects that depression will become the second leading cause 
of disability in the world, exceeded only by heart disease, and 
nothing threatens the health and productivity of the United 
States more than our appetite for drugs and alcohol.
    Drug and alcohol abuse ravages the lives of millions and 
fuels crime, domestic violence, disease and death. In a recent 
survey of adults, 52 percent listed drugs as the top problem 
facing American children today and tomorrow. SAMSHA has 
repeatedly demonstrated the effectiveness of federally 
supported mental health services and drug and alcohol 
prevention and treatment programs. For example, children 
receiving services through our Comprehensive Community Mental 
Health Services for Children and Their Families programs have 
made substantial mental health gains and improvements in school 
performance and school attendance. Yet, two-thirds of the young 
people in this country. who suffer from a mental disorder, are 
not receiving the help they need.
    Likewise, our treatment programs have shown that a 50 
percent reduction can occur in drug use. As a result, people 
have better job prospects, better incomes and better physical 
and mental health. They are less likely to be homeless and less 
likely to be involved in criminal activity and risky sexual 
behaviors.
    The tragedy is that 63 percent of those who would benefit 
from treatment, which is approximately 3.3 million people, did 
not receive it in 1996 and the gap is growing.
    To help stem the tide, the President has proposed a $1.5 
billion investment, which is a 15 percent increase in SAMSHA's 
Substance Abuse Block Grant. This $200 million increase will 
support and maintain State efforts to fund treatment and 
prevention programs. However, block grants are not enough. A 
strategic approach also requires a Federal investment in 
service research and development and in cultivating a system 
that is responsive to current and emerging needs.
    First, wise investments in service research and 
development, through our KDA Program can speed findings from 
the laboratory to community health centers. We give it life. It 
can stimulate the discovery of new, more efficient and more 
cost-effective ways to deliver services paid for by block 
grants, Medicaid and Medicare. For example, getting homeless 
people who have multiple diagnoses, such as mental illness, 
substance abuse and chronic health conditions like HIV/AIDS 
appropriate care and off the streets is a serious challenge.
    Our Center for Mental Health Services Access program found 
new service approaches that reduced homelessness by 76 percent 
and increased independent housing by 43 percent. With these 
findings, we are embarking on a redesign of homeless services 
in five communities, in Alaska, California, Louisiana, Alabama 
and right here in Maryland.
    The progress we have made during the last few years in 
understanding the brain and psychological responses to drugs is 
extraordinary. I have no doubt that within the next decade, we 
will develop medicines to treat addiction just as we have 
medicines available to treat epilepsy and some forms of mental 
illness. However, medicines alone will not eliminate the 
problem.
    As we have learned from our experience with Naltrexone, 
even when we have effective medicines, there is no assurance 
people will use them. We must continue to study why people 
abuse drugs or develop mental illness, how to prevent their 
causes, what treatments work for people in their homes and 
communities, as compared to the experimental setting and why 
people fail to take advantage of treatment.
    Many times, people fail to take advantage of treatment 
because the treatment is inappropriate, the treatment is not 
available, or they don't have the access, access not only in 
relation to the accessibility but, more importantly, access in 
ensuring that it meets the cultural and racial differences.
    We are very concerned, about the critical questions that we 
have not yet been able to answer but are in the process of 
addressing through many of our KDA programs. What we are 
finding is that many of our KDA funds are increasingly being 
used to leverage State and local resources and Block Grant 
funds in order to address the most urgent and emerging issues.
    For example, with KDA dollars our State Incentive Grant 
Program, is working with Governors in Vermont, Connecticut, 
Illinois, Kansas and Oregon to develop statewide strategies and 
deliver science-based prevention services developed by SAMSHA 
and others. We are very excited about this because of what is 
happening in these five States that we were able to fund this 
year, and we will submit for the record someinformation that I 
think you will find very exciting about how governors are now 
coordinating all of these funding streams for prevention that are 
coming into the States and are developing prevention strategies that 
are based on science.
    In addition to adapting science-based prevention programs 
to local needs, one of the requirements of the State Incentive 
Grant is for governors to account for coordinate and 
strategically manage the many funding streams in their State, 
including the 20 percent Substance Abuse Block Grant prevention 
set-aside and the dollars that they get through the Department 
of Education, and their Safe and Drug Free School programs.
    This July, we expect to fund an additional 15 to 18 new 
States, and an additional two states in 1999. To cultivate a 
treatment system that is responsive to current and emerging 
needs, we are initiating our new Targeted Capacity Expansion 
program. It would be used to help fund States, cities, 
counties, or others that identify an emerging need in a 
geographic area and can rapidly put into place an effective 
treatment approach to stop or slow deadly drug epidemics. These 
are regional problems that we are dealing with, and we will 
talk later about what we mean by that.
    Some of the examples include the outbreak of 
methamphetamine use that has spread throughout the Southwest, 
or heroin use, which can be localized as it is in a small town 
in Texas. This new use of our KDA funds directly supports Goal 
3, Objective 1 of the President's National Drug Control 
Strategy.
    Finally, our 1999 budget incorporates our first annual 
performance plan. The goals and measures are both linked to our 
budget and the HHS GPRA Strategic Plan. We look forward to 
Congress' feedback on the usefulness of our plan, as well as to 
working with Congress on achieving the goals described.
    Mr. Chairman, we have a three-part strategy--for closing 
the treatment gap, which includes investing in services 
research and development through our knowledge, development and 
application grants;
    Second, cultivating a system that is responsive to the 
current and emerging needs through targeted capacity 
development; and
    Third, supporting and maintaining State systems through the 
Block Grants. We feel this strategy provides the balanced 
approach needed to seriously address the gap between people in 
need and services available.
    Our budget is a down payment on closing the gap that 
exists. It strengthens the bridge between laboratory research 
and everyday health care delivery, and it supports the 
President's vision for the 21st century.
    We will be pleased to answer any questions you may have. 
Thank you.
    [The prepared statement follows:]
    Offset Folios 1215 to 1232 Insert here



                                drug use

    Mr. Porter. Dr. Chavez, thank you for your fine opening 
statement. I am afraid I have to subject you to my very brief 
sermonette, which goes something like this:
    The President's budget was fine, but the revenues, the new 
revenues that the President suggests in his budget that support 
a good deal of the discretionary spending increases are very, 
very problematical. It is very unlikely that they are going to 
be adopted this year; and that means we probably are not going 
to have the resources that otherwise we might have to work 
with. This is going to make it difficult to meet the spending 
targets, obviously, that every agency and department coming 
before us is suggesting.
    We will do the best that we can, and your area of 
responsibility is obviously a very important one. Your agency 
spends about a billion and a half dollars a year on substance 
abuse, both prevention and treatment activities, and yet, after 
years of decline, we are now seeing drug use in our country on 
the rise, especially among young people. I would add that your 
agency is just one of many Federal agencies that spends money 
on the fight against illegal drug use. How do you explain the 
increase in drug use at this point in time?
    Ms. Chavez. Mr. Chairman, there have been some dramatic 
changes that we have seen in the past 10 years, and one is that 
drug use, has become very glamorous. We see that often through 
the media, through our movies, through our videos, through 
other media.
    We also have seen a change in the attitudes that young 
people have toward drugs, especially when it comes to the use 
of marijuana, in that many youth feel that it is not wrong to 
use marijuana.
    In addition to that, the glamorization, or how drug use is 
viewed, we have another issue that we have been dealing with 
that many parents grew up in the 1960's and the drug use at 
that time was somewhat different. Marijuana was not as strong 
as it is today, and many of these parents find it very 
difficult to talk to their children because of their own past 
use.
    I would like to have Dr. Kumpfer expand on this answer a 
little bit more in terms of these uses. SAMSHA is taking some 
very strong measures but it is not just SAMSHA. We are working 
with General McCaffrey and the Office of National Drug Control 
Policy.
    Dr. Kumpfer.
    Dr. Kumpfer. Dr. Chavez, that was a very good answer. I 
have done research on the factors related to drug use in youth 
across the country. The causes of drug use are complex and 
involve many different aspects of the youth's environment, 
including the family, the school, the community, the cultural 
community, the media, a number of the factors that Dr. Chavez 
has already mentioned.
    I think one of the other major factors that we need to take 
into consideration is the breakdown of families. I had 
predicted at least 10 years ago that we would have this upswing 
in drug use, because of changes in family statistics. If you 
look at the amount of time that parents are spending with their 
kids, over time, through Child Trends, you could see that it 
was predictable that parents were not spending as much time 
with their children; hence they were not going to have as much 
positive socialization influence on their children. They were 
not going to be talking with their children as much, and 
helping to ensure that those children would not use drugs.
    Youth who like their parents are less likely to use drugs. 
Research such as the Pride survey and the NIMH Resnick study 
suggest that the primary reason for youth not to use drugs in 
this country is the family. If the family is opposed to drug 
use and children are attached to their parents, they are not 
going to use drugs, even though the primary influence to use 
drugs is the peer group. So we have got to, through our 
prevention efforts, keep the family strong; and that is what I 
have dedicated my life to.

                            Future Drug use

    Mr. Porter. Well, Dr. Kumpfer, can we assume then that 
since we have had, in the near term, a much greater emphasis on 
family, that this is going to give us some optimism about 
future drug use?
    And the second question would be, if the effort for 
prevention is the one that is going to keep us--or help us get 
away from having increased drug use in the future, why aren't 
we spending more money there and less money on treatment, since 
preventing a case of illicit drug use probably will not save 
individuals, but it will save a great deal of resources in the 
long term if we don't have the incidence in the first place?
    Dr. Kumpfer. Thank you, Chairman Porter. I certainly agree 
with you. This has been a very exciting time for the prevention 
field. I have been in this field for over 20 years, and what we 
are seeing now is really a confluence. It is like the stars are 
coming together. We are finding that across many different 
Federal agencies and research agencies that we now know, after 
so many years, what works in prevention and what doesn't work 
in prevention. Family strategies really have become much more 
popular.
    Actually, I published an article about 10 years ago called 
the ``Cinderellas of Prevention, Want to Come to the Ball, 
Too.'' It was about a need for more family-based approaches and 
environmental approaches. And what we have found is that 
finally, over the years, we now know the strategies that work. 
The most effective approach is a comprehensive, coordinated 
strategy. It involves strengthening the family, strengthening 
our schools, strengthening our communities and also working 
with the larger environment, such as the media, and policies. 
To create a consistent no-use message and a caring place where 
kids are successful and happy.
    And what you are saying is right, that a number of Federal 
Research agencies like NIMH, NIDA and, now--NIAAA, have gotten 
much more involved and in testing family-based approaches. In 
fact, I have been working with OJJDP for the last 10 years to 
locate best practices through the research literature and to 
disseminate information on the top parenting and family 
strengthening programs, to the field.
    And that is the critical job that I envision for CSAP. We 
are the needed bridge between research and practice. We now 
know what works in research, and we can serve as the bridge to 
get that information out to the States and to the local 
communities through the State block grants, through the the 
State Incentive Grants (SIGs), et cetera, and support them to 
do the prevention programs that work.
    So in terms of your question, yes, there is a great deal of 
optimism. We can now do that very effectively. After 25 years, 
we have gotten out of our infancy in prevention, and we are now 
mature. And, yes, we are seeing a little bit of hope, because 
states and communities, with our help are starting to do more 
effective prevention programs.
    We are seeing that the eighth graders for the first time 
are not using drugs as much and--I hope we are going to start 
seeing a reverse trend if we continue with good prevention 
programs.
    Ms. Chavez. Chairman Porter, may I comment on that, please?
    One of the things that I don't think we have done very well 
as a country and in our society is really focus our prevention 
and interventions in children at a much younger age. In the 
past few years, more and more research findings have been 
coming out about how important it is to focus on children at a 
very young age. One of the programs that we introduced last 
year, Starting Early/Starting Smart, includes 12 projects, 
Chairman Porter, is to examine children zero to 7--not just 
from a prevention perspective, but also in terms of their 
mental health and substance abuse.
    Where do you find these populations? You may find them in 
primary care settings or you may find them in child development 
centers.
    We have been able to support 12 of these projects 
throughout the country; and the beauty of this strategy is that 
we are going to be examining integrated services, a very 
holistic approach. The question of which interventions are 
appropriate by the child's developmental age is number one.
    We are not undertaking this effort alone. The Department of 
Education is investing resources for the evaluation component, 
and other Federal agencies are doing the same.
    But I think the most critical aspect in terms of ultimate 
goal, is the fact that we have the Casey Family Program 
involved. Their role has been key from the outset. Not only 
they are putting money in; but after the Federal dollars are 
gone, they will continue to support some of these communities 
that have demonstrated that, yes, we can make a difference.
    One of the reasons that the Casey Program became involved 
in this endeavor is because they have been very much involved 
in foster care, and from that perspective they have begun to 
notice that many children needing services are coming in too 
late. So we believe very strongly that prevention is very 
important.
    For example, our idea of prevention 15 years ago was to go 
in a class and do a 1-hour presentation, and then we had done 
our job. We have learned a lot since then, as noted by Dr. 
Kumpfer.
    But it is not just SAMSHA. We are beginning to coordinate 
more and more with ONDCP. But SAMSHA has a very important and 
very unique role to play. I mean this not only with respect to 
prevention--we cannot treat prevention in isolation. We must 
also consider treatment, needs and not forget that we have many 
individuals that suffer from co-morbidity. Many young children 
have mental problems in this country as well, and many later 
develop substance abuse problems.

                       21st Century Research Fund

    Mr. Porter. I certainly agree with what you are saying, and 
I also would add that mass media often can address the glamour 
part of this equation.
    I think you have to go where kids are and where their 
attention is. I know that this doesn't necessarily apply to 
drugs, although it certainly is a relevant tangent, but when my 
kids were young, for example, they picked up from television 
that cigarettes were not good for you. That was about the time 
that I had quit smoking, but their mother had continued to 
smoke and those kids used to go into her purse, steal the 
cigarettes and flush them down the toilet because they knew 
that it was bad for her and they wanted her not to do it. 
Today, while she continues to smoke, none of our kids has ever 
even thought of smoking. So, if you reach them at the right age 
with the right message through the right medium, you can change 
their conduct and make a difference in their lives, I think 
even in a broader sense.
    Let me ask either you, Dr. Chavez or Dr. Kumpfer, when the 
Secretary testified this morning, she was talking about the 
21st Century Research Fund. Her example was the use of NIH 
working together with AHCPR and CDC, jointly, to address 
infectious diseases. Has the Secretary gotten you in the same 
mode of working with other relevant agencies that can combine 
research and outreach and evaluation efforts? In other words, 
are you part of this concept as well?
    Ms. Chavez. Chairman Porter, we are not exactly part of 
that one concept. However, SAMSHA and its three centers work 
very closely not only with all of the NIH, but with CDC, HRSA, 
ACF, all of the HHS programs.
    But we also go beyond that. We work with the Department of 
Education; we work with HUD; we have partnered with Justice on 
many things. One of the best programs that we support is our 
GAINS program. The Center for Mental Health Services through 
Dr. Arons' leadership, and the Center for Substance Abuse 
Treatment, through Dr. Barry's leadership, are working very 
closely with Justice in the area of the dually diagnosed. As 
you well know, many individuals that are incarcerated have not 
only a substance abuse problem, but also have serious mental 
problems. So we are doing a lot of partnering in that area as 
well.
    In terms of our evaluations, Dr. Goldstone's Office of 
Applied Studies and Dr. Arons have been working closely in the 
areas of data collection and evaluation.
    I think it is very important to highlight once again that 
SAMHSA serves a very important role in this country. SAMSHA is 
the only agency that can take a large segment of the research 
that has been done in these areas and give it life in the 
community.
    Earlier, I spoke about some medications. Other effected 
medications have been developed, and we have spent billions of 
dollars of taxpayers' money to do so, for example, methadone, 
LAAM, et cetera. Yet we still have in this country 600,000 
addicts, and these individuals are still addicted to heroin.
    There is treatment available and that is methadone, and 
also LAAM. And guess what? Only 115,000 of these people that 
are taking these medication, which are very effective. The 
question is, why? A variety of reasons.
    Examining such questions represents a very important niche 
for SAMSHA, because it doesn't do the taxpayer any good for the 
Federal Government to continue to spend money on treatment if 
we cannot apply that knowledge at the community level where 
people need it the most.
    Mr. Porter. Well that is why I asked about the 21st Century 
Research Fund because it seems to me that if the model of NIH, 
CDC, and AHCPR is a good one, then why isn't the model of NIDA, 
or NIMH, SAMSHA and AHCPR also a good one? In other words, why 
wouldn't you put all the agencies that work in the same areas 
together in coordination with one another doing the research, 
applying it and then analyzing the results to see whether you 
have gotten a good result and what works and what doesn't work?
    Dr. Arons. Yes, Mr. Chairman. I would like to take a moment 
to try to address some of those issues; and for me, I try to 
remember back to the direct recipients of care that we are 
really improving the systems for, whether it is an individual 
who is homeless and on the streets of our cities with a severe 
mental illness, or a child in school where the teacher is 
concerned because this child isn't functioning as well as they 
might because of a serious emotional disturbance; or 
individuals who, unfortunately, these days are sometimes put in 
jail, sometimes even without a charge, because of a mental 
illness and inadequate services.
    In all of these areas, I think the notion of partnerships 
is critical, but the process of building appropriate 
partnerships varies somewhat depending on the different 
concerns and populations involved. This is really very much a 
focus of what we at CMHS are all about. Let me give just a 
couple of examples.
    In the homeless area, wherever possible we try to build 
upon NIMH findings and with the help of HUD and with other 
agencies, serving, and that of individuals who need our help.
    In the criminal justice area, we work with a slightly 
different array of partners in developing our programs. We are 
working very closely with the Department of Justice as well as 
other agencies on our, Criminal Justice Diversion Program which 
is looking at models of identifying individuals with mental 
illness in the criminal Justice System and getting them into 
appropriate treatment settings.
    In each of these situations, we are looking to communities 
to identify what the needs are in those communities, and then 
respond to those needs with the appropriate partners.
    Mr. Porter. Thank you, Dr. Arons.
    Ms. Pelosi.
    Ms. Pelosi. Thank you very much, Mr. Chairman. Mr. 
Chairman, before I ask my questions, I want to say how proud I 
am of Dr. Chavez. As you know, she was in San Francisco before 
she was assigned here. She served as Director for Juvenile 
Probation Service for the City and County of San Francisco.
    Our colleague, Mr. Hoyer, mentioned this morning, Secretary 
Shalala had made history by being the longest serving HHS 
Secretary. And I want you to know that Dr. Chavez made history 
because when she was appointed by President Clinton and was 
confirmed by the U.S. Senate, Dr. Chavez was the first Hispanic 
women to head an agency of the U.S. Public Health Services 
since its inception in 1798--in 200 years. This, I think, is a 
tribute to the Clinton administration.
    This is my favorite time of the year, when we have such 
excellent representatives of the Clinton administration who 
come in and provide background on their programs.
    So I want to get back to what you asked, Mr. Chairman, 
about why kids still use drugs. I think that young people 
believe they are invincible, Dr. Kumpfer talked about the 
media, family, school, & other influences on drug use. But I 
think that one way we could curtail the young people from 
starting the use of drugs is to include them all in the health 
care system.
    We say to them that their health is important, and yet we 
don't give them guaranteed access to quality health care. And 
using drugs is harmful and perhaps even fatal to their health. 
I see many of the drug users in my community as being outside 
the loop of any access to quality health care. I think if we 
are saying that your physical well-being is important, so don't 
use drugs, we should also say, your physical well-being is 
important, we place a value on it, and so you will have access 
to quality health care. To me, they are connected in the same 
way as when we say to kids: education is important, so you 
should go to school.
    We should have some integrity about what we are saying to 
children regarding the importance of these issues.
    So I think if we had universal access to quality health 
care for all Americans, including all young people, the 
importance of their physical well-being would be driven home to 
them more clearly and they wouldn't hear two messages about 
their invincibility or lack thereof.
    Now, I will ask my first question, unless someone would 
like to comment on that.
    Ms. Chavez. Congresswoman, may I comment?
    Ms. Pelosi. Yes.
    Ms. Chavez. It is wonderful to see you again, and I bring 
you greetings from Dr. Lee, who is back there with you now.
    I think it is important to develop a comprehensive system 
of health care for children and adolescents as well. That 
system, in my opinion, would be a system that is focused on 
children and adolescents; that it is not an adult system that 
has been dropped on our children. And in saying that, any part 
of a health system must include mental health, as well as 
substance abuse treatment and prevention. Thank you.

                children mental health services program

    Ms. Pelosi. I would completely agree with you. That was by 
no means meant to minimize the importance of the other or 
influences on young people. And I will just follow up with a 
question on mental health.
    Is there an estimate of the number of children in the 
United States with serious mental and emotional disorders? In 
addition, is it your opinion that the children's mental health 
service program is responding to the needs of these youngsters, 
and if so, how? Particularly, I am interested in whether the 
program improves their educational progress and reduces their 
involvement with the juvenile justice system.
    Ms. Chavez. Congresswoman Pelosi, let me just start out, 
and because I know that Dr. Arons would not talk to me for the 
rest of the day if I did not allow him to talk about some of 
the great programs that they support at the Center for Mental 
Health Services.
    In the area of mental illness, I think the projection is 
close to 7 million children between the ages of 9 and 17 who 
are so impaired--with serious mental problems--that it affects 
their school performance, their attendance, et cetera.
    One of the most interesting things is that we have 
information on children. Age nine and over, however, we don't 
have the research or the numbers on children that are under 9 
years of age. What we are finding, as understood by other 
experts throughout the country, is that the number of children 
under age 9, who have serious mental problems and/or other 
emotional problems is much higher than the 9 and over what.
    Let me ask Dr. Arons to respond to the question in terms of 
the small investment that we are making, the payoff, and the 
real need to sustain this investment in the future.
    Dr. Arons. Congresswoman Pelosi, let me start first by 
saying a little bit about our estimates on the numbers of 
children and adolescents with serious emotional disturbances.
    It is actually quite difficult to make an accurate 
projection. We don't have the kind of national surveys, 
national statistics, that can do the job. What we have been 
working on for the past couple of years is taking smaller 
studies that have been done and analyzing them and come up with 
the best estimates. It is now estimated that between 9 and 13 
percent of young people have serious emotional disturbances 
with some impact on their functioning in school or their 
communities.
    Ms. Pelosi. This is 9 and over?
    Dr. Arons. Yes, and in about half of them we find the most 
serious emotional disturbances, where you clearly see a 
profound effect impact on school, community, their functioning 
and their families.
    We have a number of ways that we approach these issues, and 
they are clearly very important issues. Certainly a partof the 
block grant funds that go to States are serving children, adolescents. 
You have heard before about our Starting Early/Starting Smart program. 
We also have some specialized studies as part of our knowledge 
development and application, looking at the impact of managed care on 
children's services.
    Another very important approach to this is our 
comprehensive systems of care for children, the program that 
helps communities develop and put into place comprehensive 
systems of care in which the education system, the juvenile 
justice, child welfare--all the different systems that serve 
children--come together and serve those young people in a 
coordinated way. This program is just in its early years; it 
was first funded in 1992. We are finding, in looking at some of 
the preliminary evaluation data, that we are achieving some 
important successes.
    We are looking at a number of aspects of success, such as 
reducing the number of shifting family arrangements, and we are 
finding that after 6 months, more of the children are in one 
living arrangement, not shifting around to others. They are 
attending school more often, fewer contacts with the juvenile 
justice system; and we look forward to tracking this and other 
data and hopefully seeing further indications of the success of 
this program.
    Ms. Pelosi. It sounds like one of the most important things 
that can be done. Thank you for your answer and for your work.
    Last year, the subcommittee commended your work on the AIDS 
mental health demonstration program. The House report strongly 
encourages the Center for Mental Health Services to use the 
findings of the demonstration in formulating new knowledge 
development grants, or KDAs, for programs directed to people 
with HIV. What is the status of the follow-up on this?
    Ms. Chavez. Dr. Arons.
    Dr. Arons. Yes. As I mentioned before, we are very 
concerned about people who have problems with mental illness, 
and children with serious emotional disturbances in a variety 
of settings. One of those groups of concern is those 
individuals who become HIV positive or are living with AIDS, we 
are doing a number of things in that area.
    We are continuing our effort to educate the mental health 
providers so that they will become the leaders in the society 
who can educate others about the psychosocial and 
neuropsychiatric aspects of HIV/AIDS.
    We are just completing the studies that were done around 
models of intervention for delivering mental health services to 
people with HIV/AIDS. One of the important things we learned 
through that program was the need to study further the impact 
on outcomes, on health outcomes, the impact on the cost of 
services to individuals, and in particular individuals with an 
addictive disorder who become HIV positive and need of mental 
health services.
    And even as we speak, we are receiving applications for the 
next series of grants in that area, which will look at those 
individuals and try to develop information so we can better 
serve those individuals.
    Ms. Pelosi. Thank you, Dr. Arons.
    Thank you, Dr. Chavez.
    Mr. Chairman, thank you very much. I know my time is up, 
and I have to run to the floor. If I don't get back in time for 
more questions are we able to submit questions?
    Mr. Porter. Oh, absolutely. And we will continue on this 
hearing until about 2:30.
    Ms. Pelosi. 3:30.
    Mr. Porter. Sorry, 3:30 and then we will take up the IG.
    Ms. Pelosi. Thank you, Mr. Chairman. I will probably be 
back in time for that.
    Mr. Porter. Mrs. Northup.

                            synar amendment

    Mrs. Northup. Yes. Dr. Chavez, thank you so much for 
passing on to my office a copy of the Synar amendment and for 
the progress you all have made in enforcement. I would like to 
ask you a couple of questions about your involvement in 
creating a national strategy.
    In fact, as I reviewed the information that took place in 
your testimony, I think you specifically spoke about the 
importance of a national strategy and about what the components 
of the national strategy might be. I am concerned about our 
focus or lack of focus on a national strategy when it comes to 
drugs and smoking. I mean, I happen to be one of the believers 
that believe that smoking is a gateway drugs, that kids go from 
smoking to drinking to illegal drugs. And I appreciate the 
grants that are given through CDC and SAMSHA, and some of them, 
through CDC, the Impacts grants--there are two different ones--
for State-based tobacco reduction policy.
    Ms. Chavez. We have, Congresswoman, the block grants that 
go to the States which require compliance with the Synar 
amendment, and are part of our treatment and the prevention 
activities.
    In addition to that, we have knowledge development and 
public education and prevention programs, which all require 
that there be some component in terms of nonsmoking, and 
reduction of tobacco use by young people.
    Mrs. Northup. I think I was talking actually about a 
different set of grants.
    Ms. Kade. CDC and NCI.
    Mrs. Northup. Right. CDC and NCI. Every State has one or 
the other, as I remember.
    Ms. Chavez. Yes.

                           tobacco settlement

    Mrs. Northup. But the point is that they are basically 
State-based, grass-roots efforts. And that is an important 
component to tobacco control, and there is an important 
component that has to do with what State and Federal laws are--
in terms of whether kids can buy, whether we are going to have 
vending machines.
    But in addition to that, we have to appeal to their minds 
and hearts not to smoke, and there have been some very 
successful campaigns, television ads, States that have 
initiated these. It is very expensive, especially for a small 
state like Kentucky, to put on their own ad program. And not 
only that, but for Kentucky to design education programs, a 
curriculum, along with a mass media program, that would be 
effective takes a lot of effort, expertise and money. I don't 
think it is particularly good strategy to think that 50 States 
would be able design their own.
    And I have been surprised that SAMHSA, which has the 
experience of setting sort of national preventive policy, 
hasn't been proposed to get some of the money from the tobacco 
settlement to actually design and at least make available--
especially to small States, information on--the efforts that 
would coordinate all the research; all your pastpractices; all 
the efforts that have been effective; and ways that states should avoid 
that aren't effective.
    Any thoughts on that? Or am I putting you too much on the 
spot?
    Ms. Chavez. I will answer part of it, and then ask the 
Department to respond to the other component of your question.
    Mrs. Northup. Well, actually I did ask the Secretary this 
morning about it, and she said you had been at the table, but 
there isn't an extra penny in the settlement that goes to the 
effectiveness of anything you might develop.
    Ms. Chavez. Congresswoman, I will address a couple of 
issues that you brought up. For example, one involves the media 
campaign in your State, Kentucky. CDC has a media campaign 
resource center which provides support for local campaigns for 
every State. But there is another such campaign, the current 
ONDCP media campaign, where, as you know, the Congress 
allocated $195 million. That amount would be matched by the 
private sector to reduce drug use in this country. That 
campaign includes tobacco, marijuana and drugs, alcohol, et 
cetera. So we do have those campaigns, which I really believe 
are necessary in order for us to deal with the issue of smoking 
among young people. It is like the Chairman noted earlier, when 
his children were very young and they saw anti-smoking programs 
on TV, this was very helpful in teaching them not to smoke. But 
every generation changes, so our approaches have to change.
    One of the most important things that we have to consider 
in addressing this massive problem is that there are many 
people engaged in trying to deal with teenage smoking and the 
availability and appeal of tobacco for young people--and the 
President, the Secretary, and SAMHSA are all very committed to 
reducing youth tobacco use and we believe that it requires a 
very comprehensive plan.
    Part of that plan is addressing access, addressing the 
availability and addressing the appeal. The other aspect has to 
do with pricing, and studies have indicated over and over that 
the higher the price, the less likely that kids are going to 
buy tobacco.
    We are at the table and have been involved in the 
discussions. We work very closely with FDA; we are working very 
closely with CDC; we are working very closely with NIH and many 
other agencies in trying to address the issue of tobacco among 
young people.
    Dennis, do you want to comment?
    Mr. Williams. I think the only other thing I would say is 
that the Food and Drug Administration clearly does have the 
lead regulatory responsibility in this area, but in the 
Department, in terms of trying to organize and coordinate a 
program that is aimed at youth smoking prevention, everyone--
all of the agencies mentioned so far are at the table, and it 
is being coordinated at the very top levels of the Department, 
because of its importance and because of the range of issues 
involved.
    But on counteradvertising, community prevention programs, 
enforcement, all aspects are being--are assigned to the various 
agencies, and SAMHSA is involved in that, as well as the other 
agencies. But there is some regulatory leadership with FDA that 
I think one needs to remember.
    Mrs. Northup. Well, I guess that my concern is that we 
haven't seen the use by children go down yet. And if we don't 
give one penny of the proposed tobacco settlement to lead 
agencies that are making public policy--it is nice that they 
are all at the table, but it is sort of hard for me to 
understand how we are going to make a difference.
    We have spent the proposed settlement on all of these new 
ideas. We have not spent it on the prevention side of it, not 
in funding a specific message for kids at a certain age, nor to 
have all the strategies coordinate. I would challenge you to 
tell me what agencies besides FDA are to get any of it? Who 
does get it? You just said everybody gets it, it is a 
coordinated effort. Well, where is the money going?
    Mr. Williams. Well, if you--the 1999 budget request, there 
is a $100 million increase for tobacco in the Food and Drug 
Administration. That is on top of existing resources there. The 
Centers for Disease Control also has additional resources in 
the budget, about $50-some-odd-million in their budget for 
increased efforts in this area.
    Mrs. Northup. Targeted for tobacco?
    Mr. Williams. Yes, targeted at tobacco as part of the 
administration's overall youth prevention.
    Mrs. Northup. It won't go far. Like I said, last year we 
were talking about how important it is that we have a mass-
media-based program. It would be hard to think that level would 
fund it.
    You know, you can't advertise marijuana right now, but we 
know that kids know where to get it. What that tells us is that 
we have to go beyond having a policeman stand and watch what 
kids buy and go to approach them on why it is bad for them, why 
they should not want to smoke it, and sort of help rebuild the 
sense of why a child would say no from within, in addition to 
making it a threat that they might get arrested if you use it.
    Now, tobacco, we know we don't have public policies that 
slow down kids from purchasing it, but even if you do, I would 
daresay that you are not going to be any more successful than 
you are with marijuana, unless you help children, from within, 
decide that they are not going to smoke. And I don't see the 
resources going to that. That is what my point is.
    Mr. Williams. And we----
    Ms. Chavez. Congresswoman--go ahead.
    Mr. Williams. Let me just say, we certainly agree with you 
with respect to the need for media campaigns and affecting 
youth and the way they think about tobacco; and as part of the 
President's budget, we have indicated support for comprehensive 
tobacco legislation.
    Part of that legislation--that legislation would generate a 
lot more revenues than are currently in our budget request. 
There are bills in the Congress now on tobacco, comprehensive 
tobacco legislation, like the Conrad bill. Those would, if 
enacted, would produce revenues in the neighborhood of $60-$65 
billion over the next 5 years. Those bills and others talk 
about various aspects of trying to deal with this problem in 
making money available through that legislation for media 
campaigns, local community prevention programs and other 
aspects of trying to reduce tobacco use by youth in the 
country.
    Ms. Chavez. Congresswoman, may I respond, to onething?
    Mrs. Northup. Yes.
    Ms. Chavez. What I hear you saying is that one of the most 
important things to consider within a successful media campaign 
is that progress will be achieved through prevention and 
treatment, and where the money is going to come from to support 
of this continuum becomes very critical.
    Mrs. Northup. Well, that is what I am talking about.
    Ms. Chavez. That is what I hear you saying.
    Mrs. Northup. We know in California that money was used 
pretty effectively for reduced use of tobacco, and we have a 
possible new funding stream, but I don't want to get into a 
partisan fight here, but I haven't seen anybody suggest from 
the administration side that we would use it in some of these 
strategies for reducing tobacco use.
    We all have new teacher programs. We have new day care 
programs. We have a lot of other research, which I am very much 
for, but I do not see it being used to fund the things that are 
pretty strategic in reducing youth use.
    Thank you.
    Thank you, Mr. Chairman.
    Mr. Porter. The Chair would like to interject one thing 
here that may not sound mainstream Republican. It seems to me 
that our users of the airwaves, both television and radio, have 
a responsibility to the public to spend a little bit of their 
resources and allow public service announcements to be aired. 
Rather than having the government pay for every single penny of 
air time, I think we ought to change FCC rules and require them 
to do some of these things. Now I realize there is a limit to 
it, obviously, but it seems to me that the media do virtually 
next to nothing. The only public service announcements that 
really get aired have to be paid at high rates, and that 
doesn't seem to me to be the appropriate use of public 
facilities.
    Ms. DeLauro.

                    Kick Butts Connecticut Campaign

    Ms. DeLauro. Thank you, Mr. Chairman. And just to follow up 
on this effort, I will be happy to sit down with SAMHSA or with 
the FDA and try to do a campaign to prevent kids from using 
tobacco. We have started, in the Third Congressional District, 
something called the Kick Butts Connecticut campaign. We 
started this about a year ago with middle school children, 
because that is the age range at which kids are beginning to be 
pressured to smoke.
    We have created an army of about 80 or 90 kids who, with 
information from the appropriate agencies about skits and all 
kinds of role playing, this army of kids is going into the 
middle schools. They go into all the grades up to middle school 
and particularly the younger grades, and talk about not smoking 
to their peers.
    I want to just build on that, because we get to what the 
Chairman was talking about in terms of the broadcast industry.
    We have now done this, as I say, for a year and a half. The 
kids have been into almost every middle school in the district.
    We just did a poster contest with these kids because--I 
think my colleague from Kentucky is right. What we try to 
portray to the kids is that they have the power, that if they 
are not going to start smoking it has got to come from within. 
They have got to not want to smoke. They have got to understand 
the pitfalls of this. They can be helpful to themselves, to 
their families and to their friends, and we designed a poster 
contest so all the kids participated, It was on a voluntary 
basis. There were five winning posters selected, seven kids 
involved.
    We now have cable TV--I have spoken to them. They are going 
to bring the kids on to deal with the public service 
announcements.
    The billboard companies have said that they are going to 
take the five winning posters, and they are doing a billboard 
which will be put up free of charge. I mean, they are donating 
the space, the time, the painting, and the kids will come in 
and paint these things to put them up in the community. One of 
them is a particularly great one. It is a frog and it says, 
``If you smoke, you croak.'' I mean, the kids did this in an 
unbelievable way.
    We have also the the big movie houses who are going to put 
the posters up.
    We were working with the attorney general's office in our 
State to do something that gets done with local resources and 
community resources and private resources, in an effort to get 
maybe a book cover so that you have got all of our kids every 
single day with their book covers looking at this stuff that 
says what will happen to you if you smoke.
    The radio stations were going to--to get the kids on. This 
is not a partisan effort. This is to get our young people 
engaged in the anti-smoking effort.
    I want to talk to you about a model for that, because I 
think it is worthwhile. I have been talking to my colleagues 
about it, and it is a package and easily put together, which 
engages kids and their families in the process of taking on the 
issue of not smoking.
    When I talk to young kids, I talk to them about the fact 
that I believe that we can have a big turnaround, like we did 
with the environment. We have a clean environment now in this 
country, because of what young people did and the effect that 
they have had on their parents. So I think that we can get some 
of the major corporations, some of the major institutes and so 
forth, without the Federal Government having to be the trough 
all of the time to get the money to do these things.
    I might also add that the settlement, as I understand it, 
deals partially with restrictions of advertising and so forth 
and so on in a national way in some of these efforts.
    It is not what I wanted to ask you about, and I am going to 
get to my question here, Mr. Chairman. But I would love to at 
some point talk to you about this model.
    Ms. Chavez. We look forward to that and thank you so much, 
Congresswoman.

                        Synar Amendment Findings

    Ms. DeLauro. Yes. I was pleased to receive the information 
on the Synar amendment.
    I would like to ask you to summarize some of the findings 
for us. I have had lots of conversations about this, what you 
did about it. Are you satisfied with the States' efforts to 
enforce existing laws regarding tobacco use by minors?
    Ms. Chavez. Thank you, Congresswoman, and let me goahead 
and summarize very quickly and then ask Dr. Kumpfer to address this 
issue in more detail.
    Yes, we are satisfied with the progress and I want to thank 
Chairman Porter and the members of the subcommittee for your 
input in pushing us to get this done. We have worked very hard. 
I want to commend the SAMHSA staff, because they have done an 
outstanding job.
    We have worked very closely with the States in helping them 
understand that we mean business with the Synar amendment and 
have been able to establish very specific performance measures.
    All of the States now have laws prohibiting outlets to sell 
tobacco to youth. So we are now focusing on compliance 
monitoring. But the aspect that I think is really important is 
that there are dollars attached to compliance, and basically 
what that means is if you don't comply and meet the percent 
that we have set as a goal, then the state will lose part of 
its Block Grant money in the area of substance abuse.
    Karol, do you want to just briefly outline some of the 
major areas in this report?
    I am sure everybody has a copy, and it does give you, State 
by State, their current status.
    Dr. Kumpfer. I also want to commend my staff and especially 
Lee Wilson, who coordinated CSAP's efforts on synar. I want to 
commend them for the really good job that they did in putting 
together this report to Congress and working collaboratively 
with the States, FDA, and CDC in establishing the baseline 
rates for this report to Congress. This report was just 
released last Friday, on February 27th.
    The goal of this, of course, is to reduce access of tobacco 
products to youth, to a goal of 20 percent of outlets that are 
selling to minors. In our report we have established the 
baseline rates for all of the States at this point. Actually at 
this point, we also have 40 of the second-year reports from the 
States, and about 15 of them have now been checked, approved, 
and validated. All of the States are now in compliance and 
things are looking very good.
    In fact, the overall state median is 40 percent of the 
outlets selling to minors, compared to 60 to 90 percent last 
year according to the studies that were done previous to Synar.
    So we are quite excited about the preliminary results, and 
all the States are in compliance. In fact, four of them already 
have met their 20 percent goal at this point.
    Ms. DeLauro. Mr. Chairman, my time has run out, I am sure.
    Mr. Porter. No, it has not. You have two more minutes.

                           treatment barriers

    Ms. DeLauro. Thank you very much, Mr. Chairman.
    Dr. Chavez, in your testimony, you mentioned that in 1996 
about 63 of those who have problems with substance abuse did 
not receive treatment. If you wouldn't mind, just take us 
through a little bit about what type of barriers keep these 
people from treatment.
    Do we have difficulty letting them know treatment is 
available? Do we have funds to serve everyone? And what funding 
level do you think we would need if we were to try to serve 100 
percent of the need?
    Ms. Chavez. Congresswoman, let me start by focusing on two 
points, and then I am going to turn it over to Dr. Barry, 
because I know that she wants to participate in this treatment 
discussion.
    The treatment gap is very interesting, because there is 
some geographic variety there. If we are serious about closing 
the treatment gap in this country for individuals who suffer 
from an addiction to--alcohol, drugs, and other substances, it 
will cost approximately $8 billion.
    Now, we don't have those resources, and I am talking about 
just the treatment gap for individuals that have a substance 
abuse problem. Our investments must increase in the area of 
prevention and early intervention, because the gap appears to 
be growing.
    Between, 1993 and 1996, there has been approximately a 34 
percent increase in the treatment gap. It is not getting 
smaller. It is getting a little bit wider.
    You asked whether people get into treatment. Yes, some 
people get into treatment. Do some people not get into 
treatment? Yes, some people still cannot get into treatment.
    And it becomes more interesting when you start looking at 
it by region. In some regions, for example, you may not have 
the high utilization rates of services as in other areas. Let 
me just give you one example that ties in with some of the drug 
trends that we are seeing.
    An article that I just read this weekend, has to do with a 
small town in Iowa. It is called Marshalltown, Iowa, with a 
population of about 25,000 people. One of the things that they 
have experienced is a tremendous increase in the use of 
methamphetamine. If you look at the methamphetamine increase 
throughout the State, it becomes more shocking--in 1993 there 
were approximately 252 people that sought treatment for abusing 
methamphetamine; in 1995, it is over 3,000 people.
    Now, is that community prepared to deal with this? No. One 
of SAMHSA's proposed responses is what we call our ``Targeted 
Capacity Expansion Program'' which helps communities, cities, 
and States cluster together to deal with issues that are 
specific to those areas addressing problems as viewed on a 
continuum that is going to help solve some of these emerging 
issues and problems that we are beginning to see are more 
regional in scope.
    Dr. Barry, do you want to comment?
    Ms. Barry. Yes. It is a very complex question, and it 
doesn't have a very easy answer.
    What are the barriers? Surely funding is one. There is a 
treatment gap, and that translates to the local level or to the 
city level in that there is not enough treatment to provide 
treatment on demand. There is not enough access, there is not 
enough availability. And that goes back to funding; there is a 
shortfall in funding.
    But it also has--
    Ms. Barry. Pardon me?
    Ms. DeLauro. In other words, we don't have the resources to 
deal with people who make the decision to get treatment and who 
need help, and go in to do that?
    Ms. Barry. Right. We do have waiting lists. We have waiting 
lists out there. That has been verified; they have been 
validated. There are waiting lists out there. But the answer 
not only lies in the amount of funding and the treatment 
capacity; it has to do with the improvement of the services 
that are out there, too.
    If we are looking at heroin addicts, we know they stay out 
on the street probably 7 years before they enter into 
treatment. We know that it is very difficult to treat 
methamphetamine users. We don't know enough about the 
neurocognitive and neurophysiological effects of 
methamphetamine to keep these people in treatment. It is a 
retention problem. Methamphetamine addicts experience severe 
depression after we withdraw them from the methamphetamine. 
This is another phenomenon for which we don't have adequate 
treatment approaches and interventions.
    And so it is a balance between providing the treatment 
services, but also improving existing services and making sure 
we have adequate knowledge, development and application in the 
field.
    In our 1999 budget we identified several initiatives in the 
pharmacologic area where we have effective medications 
including methadone, as well as antagonist drugs such as 
Naltrexone or Naloxone or LAAM. We find that there are barriers 
in the treatment field to using the medications that have been 
developed.
    Ms. Barry. We have to dispel the myth that we cannot treat 
drug addiction with drugs. That is another barrier that must be 
overcome. So it is a very complex question and requires a very 
complex answer. It is a combination of things that need to be 
addressed.
    Ms. DeLauro. Thank you, Mr. Chairman.

                            reduction in kda

    Mr. Porter. Thank you, Ms. DeLauro.
    Dr. Chavez, earlier we had talked about KDAs and their 
application in a number of instances. Your budget proposes to 
cut the program by almost 20 percent, and in your budget 
justification it states that SAMHSA will be developing a plan 
for fiscal year 1999 to identify programs for termination and/
or reduced funding. On what basis are you proposing this 20 
percent reduction and how did you determine the figure of $74 
million?
    Ms. Kade. Overall, our budget is increasing. But, 
obviously, our funding for the KDAs and, in particular, 
substance abuse is decreased. The priority this year is focused 
on the block grant and in expanding capacity. Since we are part 
of the overall department budget, it really is a balancing of 
resources. We didn't choose to be cut by $74 million. We didn't 
develop that number. But we are very supportive of the approach 
of focusing on the block grant in conjunction with the KDA. 
What we are doing in 1998 is starting what Dr. Chavez was 
talking about in terms of targeted capacity expansion to prime 
the States for the increase in 1999 in the block grant.
    We feel that this will be cyclical, and at this point, the 
focus is on closing the gap with the knowledge that has been 
developed in the KDA program, but that knowledge cannot be 
stagnant.
    As we shift, as we go through the cycle, even as the 
knowledge is generated by NIH, there are funding increases for 
the Institutes for 1999 as well. It will not happen unless you 
funnel those research findings into the KDAs and then funnel, 
with the technical assistance and targeted capacity, expansion 
to the States and augment--leverage, the block grant resources. 
This is not an instance where one program is being sacrificed 
for another as much as one being prioritized for this year.
    What we have been talking about has been the linkage 
between the KDAs and the block grant. This committee has been 
extremely influential in defining the KDAs. It was your 
language in the 1996 budget that basically started the program. 
And what we have done is to develop the linkage between the 
KDAs and the block grant through the targeted capacity 
expansion not only in prevention, which is the State incentive 
grants, but also in treatment. We have been talking with the 
Department, as well as OMB, in terms of how this fits within 
the overall range of funding.
    Certainly, we are not pleased with the reduction in KDAs, 
but we see it as part of an overall strategy, not in terms of 
phasing out the program, but in terms of this linkage, this 
cyclical nature in our funding.
    So with a $74 million decrease we will have a net increase 
of $82 million. That is how the numbers worked out. The 
emphasis is in block grants this year. We still have new 
programs that we are funding in the KDAs for 1998, additional 
State incentive grants for CSAP, additional capacity expansion 
and pharmacological interventions for CSAP, and of course we 
have level funding for CMHS.
    Mr. Porter. Dr. Kumpfer, do you see any unwillingness on 
the part of the States to take evaluations that show which 
programs are most effective and ignore those, or are States 
very likely to zero in on what really works and has shown 
itself to be evaluated as working well?
    Dr. Kumpfer. Thank you, Chairman Porter. In my experience, 
the States and the local community agencies are very, very 
hungry to know what works in prevention. The more effectively 
we get that information out through our five regional Centers 
for the Application of Prevention Technologies, the more 
science based approaches to preventing will be implemented and 
provided to youth in this country.
    I can give you just an example that--with my 
ownStrengthening Families Program (SFP). It was tested originally 
through a NIDA grant and then States and local communities started 
calling me saying;, Can we field-test this now with diverse 
populations? We used CSAP funds to test it with African-Americans in 
Alabama and in Detroit; Hispanics in Denver, Asian Pacific Islanders in 
Hawaii and diverse ethnic population in Utah. It was CSAPS funds that 
supports the field trials and we found that it was robust and worked 
with diverse populations in different areas of the country.
    What is interesting now is that a State like Texas is now 
using SFP as one of their model projects to disseminate with 
their own State funds.
    Ms. Chavez. Chairman, may I respond to that, because I 
think it is really important in terms of what we did last year 
and what we are going to do this year. We mentioned earlier the 
State Incentive Grants, which are part of our Youth Initiative 
to reduce alcohol, to reduce tobacco use, and to reduce 
marijuana and other drugs.
    One of the things that we did last year is initiate five 
State Incentive Grants, that I mentioned earlier we were able 
to fund. Let me tell you briefly a little bit about the five 
States that have received funding, because I think what they 
are doing is very important.
    The States were Illinois, Kentucky, Vermont, Kansas and 
Oregon. One of the most interesting aspects of the program is 
requiring governors of each State to look at all the prevention 
funding streams and then develop a comprehensive plan to deal 
with prevention needs in their State. Let me just read from a 
publication that I just picked up, which I thought was very 
interesting.
    In Illinois, which received a $3.2 million grant to 
implement their Prevention 2000, The State's Council on 
Prevention ``will coordinate the State's prevention funding and 
use local collaboratives to implement research-based prevention 
programs.''
    The same thing is occuring in Vermont, implementing 
research-based prevention programs. This goes back to what we 
talked about earlier, and that is we have come a long way. But, 
we must continue to work with communities and with States in 
moving more towards programs that work. For example, Dr. Barry 
was talking about the many treatment barriers, earlier.
    One of the barriers I don't think we were really prepared 
for, and which are now addressing in SAMHSA, the impact of 
managed care on treatment systems, especially for vulnerable 
populations, i.e., people that have addictions and people that 
have mental illness. So we have a lot of concerns about this 
issue.
    The other issues that are of great concern have been the 
dramatic changes in America's demographics in terms of 
diversity, especially shifts in our population, individuals 
getting older on average and, some groups that are very young 
and are becoming more diverse.
    These issues are going to impact not only the research, but 
also interventions in communities that are diverse not only in 
prevention, but also in treatment needs. This is an element, of 
the big equation that we are trying to deal with; and that is 
one of the many aspects of our knowledge application efforts.
    Mr. Porter. Thank you, Dr. Chavez.
    Ms. Pelosi.

                              managed care

    Ms. Pelosi. Thank you, Mr. Chairman. Mr. Chairman, I have a 
question not only for myself but on behalf of a number of our 
colleagues, including representative Sam Farr. Dr. Chavez, we 
are all curious about managed behavioral health care in the 
local county authorities in the 20 or so States that have State 
mandates to provide managed pay for health care. How is managed 
pay for health care affecting local county authorities in those 
States where there is mandated behavioral health care?
    Ms. Chavez. Let me go ahead and ask Dr. Arons to answer 
that, and then I will respond.
    Dr. Arons. As you know, managed care is becoming much more 
important across the country. It seems like each week another 
study comes out that shows the increasing numbers of people 
covered by these programs.
    We are beginning to study and to look at States and 
communities where there is mandated coverage for behavioral 
health. We have taken a look at five States in which there is 
mandated parity for behavioral health, including mental health 
and addictive disorders; and we are just beginning to put 
together the results of those studies. I am not sure that we 
have solid research-based findings about those areas.
    However, we do know that there is a tremendous change going 
on in the system as a whole. The usual community behavioral 
health providers are finding that they either have to become 
part of a network of providers, changing the nature of their 
relationships in their communities to provide services, or they 
are in jeopardy of losing the opportunity to remain a provider. 
So we are trying to track that very carefully through some of 
our managed care studies, and in next couple of months we hope 
to come out with some of those findings.
    Ms. Pelosi. We would be interested in seeing that. As you 
know, these are hard fights, to be able to have behavioral 
health care mandated, and we hope it can serve as a model to 
all the country.
    I wanted to follow up on some of the questions--and I know 
the Chairman will let me know when my time is up--about 
substance abuse. As you know, drug use and substance abuse in 
general contribute to the HIV epidemic. Demand for substance 
treatment far outweighs the current available services, and I 
just wondered if you could tell me how many people on any given 
day are trying to get into drug treatment.
    And then, following up on that, some local governments, 
including in my own City of San Francisco, are looking at 
providing substance abuse treatment on demand. As you know, 
this approach could have significant implications for public 
health service, for public health care system and for the 
primary.
    What is SAMHSA doing to assist in developing, implementing, 
and evaluating programs to provide substance abuse treatments 
on demand?
    Ms. Barry. I will take the second part of that question and 
then turn to Dr. Goldstone to talk about howmany people are 
trying to enter into treatment or are in treatment on any given day.
    We are working with the San Francisco area, and I commend 
the leadership that you have taken in treatment on demand. 
First of all, when we look at treatment on demand, we don't 
have that concept well defined yet. Are we talking about no 
waiting time whatsoever? Are we talking about a 24-hour wait? 
So we have to define that.
    Second, we also have to define what ``demand'' is, what the 
demand in the San Francisco area is. I don't think that the 
concept of demand is well-defined at this point in time. It is 
something very different to talk about demand and need. Those 
people who perhaps would benefit from treatment versus those 
people who are actually seeking entrance into treatment are two 
very different things.
    You are talking about treatment on demand, and we have to 
get at what your ``demand'' is.
    We are also working in the San Francisco area at this point 
in time in terms of your management information systems. You 
have got two systems out there, one which we fund through our 
KDA program, which is through the target cities grants. It is a 
management information system and it is connected to your 
public health system.
    And right now the only thing that we can get out is the 
billing of the particular patients. And what we want to do is 
track patients through the system, and I think we can get a 
better idea of how people are moving through the system and 
what your demand actually is.
    We are going to be working with San Francisco to develop 
the access and get over the hurdle of getting the information 
out of your computer system. In April, we are going to be 
meeting with city officials, together with CDC, HRSA, and 
different Federal agencies to talk about implementation and 
evaluation. We will address issues such as implementing 
treatment on demand and answering some of the questions that I 
just described to you that are very difficult?
    And we are going to be able, hopefully, in our 1999 budget 
and I say that because of the cuts that we have sustained, $41 
million to the Center for Substance Abuse Treatment's budget--
hopefully be able to assist you with the implementation and 
evaluation of treatment on demand.
    The person who is spearheading this initiative, as you 
probably know, is Barbara Garcia. We are working closely with 
her right now. I think that she is in the emergency shelters, 
helping out in the San Francisco area. But as soon as she gets 
back to her regular duties and responsibilities, we are going 
to be meeting with her and mapping out a blueprint of where you 
are right now with treatment on demand and where you need to 
be.
    Ms. Pelosi. Thank you. I appreciate that.
    Mr. Goldstone. I wish I could give you a precise answer.
    I can tell you approximately how many people are admitted 
in the course of a year to a facility that receives any kind of 
public funding. Assuming patients are admitted on any day of 
the week, we know there are 3,300 admissions each day for the 
37 states providing complete admission data. This estimate 
leaves out the for-profit facilities that receive no public 
funding. We would estimate 41,000 admission for all 50 states 
and we may not have an entire universe of even those that are 
receiving public funding. However, we believe the estimate is 
reasonably valid.
    Ms. Pelosi. Thank you.

                          treatment on demand

    Mr. Chairman, I think it is important because we believe 
that treatment is one way to reduce drug abuse. So treatment on 
demand helps us reduce our drug problem. And I hope that our 
experience in San Francisco is successful and will serve as a 
model to the rest of the country.
    Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Ms. Pelosi.
    Mrs. Northup.
    Mrs. Northup. Mr. Chairman, I just have one question.
    Last year I raised questions at this hearing about the 
differences of alcoholism occurring, depending on the onset of 
drinking. And I appreciated that there was a follow-up and that 
NIH concluded their study and concluded specifically that 
children who begin drinking before the age of 15 were four 
times more likely to develop alcohol dependence and the risk of 
developing alcohol abuse more than doubled.
    I just wondered if your agencies have been able to put that 
information to use in terms of educating our young people about 
not only the dangers of drinking, but the increased likelihood 
that they will actually become alcohol dependent?
    Ms. Chavez. Thank you, Congresswoman. I have Camille 
looking at me with a smile, because she wants to respond, I 
have Carol also wanting to respond. So I think I will respond.
    That is very important information and very true. And, yes, 
we are working with NIH. I will ask Dr. Barry and Dr. Kumpfer 
to talk a little bit about what we are doing with NIAAA. What 
is very important in terms of that finding is what we have been 
talking about, the continuum of early prevention, intervention 
and treatment.
    We also have studies that clearly indicate many of these 
young people have mental problems that often go undetected, and 
we have a wonderful window of opportunity to be able to work 
with many of them. If we don't get them before age 15, many of 
them will end up being dually diagnosed with either an alcohol-
mental problem or an addiction of some other sort.
    Camille, why don't you describe what we are doing with 
NIAAA in relation to adolescents?
    Ms. Barry. We started working with NIAAA even before their 
findings came out, and I attended that press conference, and it 
provided important information and gave us some direction. And 
what Dr. Chavez said is that we--and I think that this crept up 
on us--we saw the age at which people start drinking or the age 
at which people start taking drugs going back to the earlier 
years, and the treatment system wasn't ready for that. A lot of 
work needs to be done with adolescents in identifying effective 
treatment approaches and effective treatment interventions. We 
started working with NIAAA even before they released their 
results from that particular study, and we have subsequently 
developed a grant program and are collaborating with them.
    They are going to be working on the instrumentation and the 
methodology. We are going to be putting that information, as it 
is developed, out in the field. And of course, that is the 
beauty of the KDA program, implementing those models in the 
field so they can be replicated, thereby providing effective 
treatment for adolescents when they are suffering or 
haveproblems with alcohol.
    Dr. Kumpfer. First of all, I would like to mention that age 
of early onset is also an indicator of genetic and 
environmental vulnerability usually having to do with being a 
child of an alcoholic or drug abuse.
    We know that alcoholism is a family disease that runs in 
families through generations. In order to help combat this 
problem, one of the things that CSAP is doing this year is 
developing a initiative for children of substance abuseing 
parents (COSAPs). This COSAPs an initiative will dedicate $8 
million to field test research-based models that work for 
children of alcohol and drug abusers. We believe that this will 
also be a significant way of getting information back out to 
the field on what works, to help with this very high risk group 
of youth.
    I might also mention, as Dr. Chavez has discussed, that we 
are starting this month a collaborative effort with the 
National Institute on Alcoholism and Alcohol Abuse (NIAAA) to 
do a research project looking at the effects of alcohol 
advertising on underage drinking. That effort will support a 
longitudinal study that will determine whether alcohol 
advertising affects initiation of drinking among youth and 
whether it affects consumption patterns. And we anticipate that 
we will have four or five projects that will be funded for a 3-
to-5-year period, so this should also help address that issue.

                            alcohol problems

    Mr. Northup. Well, I met with Dr. Gordis after the result 
was finished because, of course, I had asked the original 
questions and had a few additional questions that I think are 
fairly important. It sounds like you all almost have decided 
what the interests are, but I think it is important to have 
science-based evidence, on questions including whether or not a 
child who starts at 14 is already inclined to drink and at 
whatever age they started they would then become a person that 
abused alcohol. In other words, was there already that 
tendency--or whether there is in the immature cells, sort of 
pleasure-seeking cells, a sort of untracked, unlearned 
resistance, and whether there is a window of vulnerability that 
exists for very young children that maybe when you are 21, when 
you begin drinking, that you are beyond that window of 
vulnerability and that there would in fact be people who, if 
they waited, could be social drinkers, healthy drinkers.
    We all know that alcohol is not a problem to even most 
drinkers; it is a problem to some drinkers. And it is very 
important that we either establish that there is sort of 
already a group of people that tend to have that problem or 
whether it is the years of vulnerability that add to it.
    It is probably some of both.
    Dr. Kumpfer. Congresswoman Northup, it is both. That is a 
very, very good question, and I really hope that NIAAA is 
willing to dedicate more research to that effort because we 
need to know that.
    One of the things that we do know, though, is that there is 
a research program called the Caspar Program that was able to 
significantly decrease substance use in highly vulnerable 
children of alcoholics by doing prevention programs through the 
schools with the children of alcoholics. The results were so 
strong that it is clear that many of them just choose, through 
that risk education and information, not to drink at all. So it 
is possible either way. But basically, environment overall is 
the number one factor.
    Mr. Porter. Thank you, Mrs. Northup.
    Well, Dr. Chavez, we have all managed to filibuster away 
our Results Act questions, but I know that you are so well 
prepared in that area that you can answer those for the record 
for us, if you will. There are also a number of other questions 
that we have for the record that we would ask you to answer.
    What I am encouraged about is that you and your team--and 
you have assembled a very fine and excellent team--are all 
focused on results, looking at what works and putting the 
resources where they can do the most good. That is exactly what 
we have been focused on. We will not always agree, but we are 
going to find a way to give you the resources so that you can 
place them where they do the most good for people and get 
results. On behalf of the subcommittee, I'd like to thank you 
for the fine job you are doing and tell you that we will look 
forward to continuing to work closely with you on these very 
important problems.
    Ms. Chavez. Thank you, Mr. Chairman. I never thought I 
would be in a position to filibuster on a subject with a 
subcommittee, but I love it.
    Mr. Porter. That is what I am worried about.
    Ms. Chavez. I do want to thank you and the other members of 
the committee, and thank your staff and staff of all the 
committee members, for their support and help. I would also 
thank the SAMHSA staff, because they have done an incredible 
job and continue to work what are sometimes difficult 
conditions. So thank you so much.
    Mr. Porter. Thank you.
    The subcommittee will stand in recess for 5 minutes.
    [The following questions were submitted to be answered for 
the record:]
    Offset Folios 1289 to 1556/2100 Insert here




 
                           W I T N E S S E S

                              ----------                              
                                                                   Page
Arons, B.S.......................................................  1089
Barry, Camille...................................................  1089
Broome, Dr. C.V..................................................   159
Chavez, Nelba....................................................  1089
Eisenberg, J.M...................................................     1
Fox, Dr. C.E.....................................................   605
Gaston, Dr. M.H..................................................   605
Gimson, William..................................................   159
Goldstone, Donald................................................  1089
Hollins, Anthony, Jr.............................................   605
Kade, D.W........................................................  1089
Koch, Rita.......................................................     1
Kumpfer, Karol...................................................  1089
Morford, T.G.....................................................   605
Nora, Dr. A.H....................................................   605
O'Neill, Dr. J.F.................................................   605
Puskin, Dena.....................................................   605
Williams, D.P....................................................     1
Williams, D.P....................................................   159
Williams, D.P....................................................   605
Williams, D.P....................................................  1089

 
                               I N D E X

                              ----------                              

               Agency for Health Care Policy and Research

                                                                   Page
AHCPR's Mission..................................................     2
AHCPR, Research and Decisionmaking...............................     1
Budget Justification.............................................    60
Budget Request, FY 1999...........................................4, 12
Caries, Early Childhood..........................................    57
Centers for Education and Research Therapeutics (CERTS)..........14, 33
Children's Health................................................    13
Clinical Preventive Services.....................................    14
Colorectal Cancer, Evidence Report...............................     3
Congestive Heart Failure.........................................    27
Consumer:
    Assessment of Health Plans Survey (CAHPS).....................4, 42
    Protection Information.......................................    26
    Satisfaction.................................................25, 26
Coordination of Research.........................................    27
Customers, Challenges Facing AHCPR's.............................     7
Customer Satisfaction............................................    26
Delivery of Health Care, Ensuring Quality........................    53
Demonstration Study, Underserved Areas...........................    28
Dental Health Services Research..................................    57
Diabetes.........................................................    49
Duplication of Research..........................................    25
Elderly and Chronically Ill, Outcomes for the....................    13
Elderly:
    Dental Care Problems and the.................................    58
    Dental Care Services for the.................................    58
Evidence Base, Building the......................................     8
Evidence-based Practice Centers (EPCs)............................3, 46
Government Performance and Results Act (GPRA).....................4, 15
Guidelines, Availability of......................................    24
HCSUS and AIDS-Related Research..................................    37
Health Care:
    Cost, Quality and Outcomes, Research on......................    37
    Quality, Initiative To Improve...........................13, 20, 39
    Quality, Measuring and Improving.............................    11
Health Centers...................................................    50
Impact of AHCPR's Research on People.............................    22
Importance of AHCPR..............................................     1
Information Dissemination, Consumers.............................    45
Information Dissemination, Medical Products......................    34
Managed Care and Quality.........................................    44
Measurement of Research Findings.................................    22
Medical Expenditure Panel Survey (MEPS)......................15, 30, 38
Medical Technology Assessment....................................    31
MEPS Users.......................................................    31
National Guideline Clearinghouse..............................3, 23, 56
National Guideline Clearinghouse and the National Library of 
  Medicine.......................................................    24
One Percent Evaluation Funds.....................................35, 48
Opening Statement, Oral..........................................     1
Opening Statement, Written.......................................     6
Outcomes Research Conference (Report)............................    20
Outreach and Public Education....................................    52
Partnerships......................................................3, 22
Patient Satisfaction.............................................    25
Peer Review......................................................    28
President's Advisory Commission..................................    46
Protease Inhibitors..............................................    32
Put Prevention in Practice Initiative............................    41
Reauthorization of AHCPR.........................................    36
Referral Patterns................................................    36
Research Findings.............................................2, 21, 22
Research Findings, Cost Saving and Health Promotion..............    55
Rural Managed Care Demonstration Centers.........................    35
Stroke Belt, Research............................................    27
Technology Assessments, Private Sector Financing.................    32
Training and AHCPR's Mission.....................................    29
Training Researchers.............................................    29
Translation of Research..........................................     2
Twenty-First Century Research Fund...............................    49
Witnesses........................................................     1

               Centers for Disease Control and Prevention

Administrative Costs...........................................203, 286
Arthritis........................................................   378
Asthma..........................................208, 212, 268, 370, 379
Birth Defects.............................................192, 228, 270
Block Grants:
    Abstinence Training..........................................   323
    Grants Oversight.............................................   342
    Rape Prevention..............................................   249
Blood Safety...................................................176, 327
Breast and Cervical Cancer................................184, 319, 375
Cardiovascular Disease Prevention....................193, 210, 338, 374
CDC Budget.......................................................   253
Chronic Diseases...............................................267, 281
Chronic Fatigue Syndrome..................................257, 260, 271
Clinical Laboratory Improvement Act (CLIA).......................   322
Colorectal Cancer..............................................207, 255
Congressional Justification......................................   380
Data/reporting Reliability.......................................   338
Diabetes...................................166, 266, 313, 327, 332, 356
Eliminating Racial Disparities.......................314, 344, 351, 366
Epilepsy.........................................................   367
Folic Acid.......................................................   192
Government Performance and Results Act (GPRA).............200, 264, 282
Gulf War Syndrome................................................   238
Health Disparities...............................................   277
Health Education.................................................   189
Health Status..................................................170, 198
Hemophilia.....................................................176, 327
Hepatitis B......................................................   264
HIV/AIDS...................................182, 299, 255, 283, 353, 373
Immunization.....................................................   278
    Polio Vaccination............................................   229
    Vaccines for Children......................................235, 326
    Vaccine Purchase.............................................   284
    Vaccine Stockpile............................................   250
Infectious Diseases:
    Emerging and Re-emerging.........................215, 315, 348, 364
    Foodborne Illness............................................   320
    H. Pylori....................................................   245
Injury Control:
    Bicycle Safety...............................................   336
    Fire Injury Prevention.....................................194, 342
    Firearm-Related Research...................................239, 269
    Firearms.....................................................   240
    Safe America.................................................   337
    Traumatic Brain Injury.....................................243, 269
Lead Poisoning Prevention......................................318, 351
Limb Loss Initiative.............................................   324
Military Health Activities.......................................   313
Minority and Women's Health......................................   365
National Center for Health Statistics (NCHS)..............196, 265, 371
    Behavioral Risk Factor Surveillance System...................   335
    National Health and Nutrition Examination Survey (NHANES)......198, 
                                                                    289
    National Health Interview Survey (NHIS)......................   252
National Institute for Occupational Safety and Health (NIOSH):
    Diesel Exhaust Study.........................................   296
    National Occupational Research Agenda (NORA).................   348
Needle Exchange...........................................186, 215, 271
Obesity and Nutrition............................................   333
Opening Statement................................................   159
Pfisteria........................................................   195
Prevention.................................163, 167, 168, 185, 187, 330
    Targeting Children and Youth.................................   163
Prostate Cancer................................................320, 360
Pulmonary Hemorrhage.............................................   361
Race and Health Initiative......................165, 171, 175, 201, 281
Reproductive Technology..........................................   191
Sexually Transmitted Diseases..................................196, 228
Teen Pregnancy/Infant Health..............................190, 191, 246
Tobacco...................................................173, 188, 266
    Adolescent Smoking and Health................................   343
    Children and Addiction.......................................   341
Tuberculosis.........................................214, 231, 238, 315
Violence.......................................................241, 249
    Youth Violence...............................................   362

              Health Resources and Services Administration

Abstinence Education Program.....................................   706
ACSC Study.......................................................   688
Administrative Costs.............................................   673
Advisory Committees..............................................   653
AIDS:
    African American/AIDS........................................   632
    AIDS ETCs....................................................   635
    AIDS Trend...................................................   634
    Drug Assistance Program....................................648, 705
Allied Health....................................................   629
    Professions..................................................   621
Annual Performance Plan..........................................   616
Bill Language for ADAP...........................................   668
Black Lung Clinic Funding........................................   672
Border Areas.....................................................   683
    U.S./Mexico Border Initiatives...............................   687
Budget Request...................................................   675
Carville Renovations.............................................   651
Centers of Excellence............................................   642
Childhood Immunization...........................................   656
Chiropractic Demonstration Projects..............................   661
COE/HCOP.........................................................   643
Community Health Services and Medicaid Access....................   635
Community-Integrated Service Systems.............................   700
Community School Model...........................................   653
Comprehensive Performance:
    Management System............................................   697
    Monitoring System............................................   639
Congressional Justification......................................   718
Cost of Training Medical Students in Rural/Underserved Areas.....   692
Council on Graduate Medical Education............................   656
Drug Discount Program............................................   714
Emergency Medical Services for Children Program..................   665
Faculty Loan Repayment Program...................................   659
Family Planning...........................................615, 670, 712
Federal Credentialing Program....................................   663
Financial:
    Exceptional Financial Need Scholarship (EFN).................   659
    Assistance for Disadvantaged Health Professions Students 
      (FADHPS)...................................................   660
Genetic Testing..................................................   651
Hansen's Disease Center..........................................   642
HEAL Program.....................................................   625
Health:
    Health Administration Program................................   645
    Health Care Integrity and Protection.........................   624
    Health Disparities...........................................   629
    Health Education Assistance Loan Program.....................   671
    Health Professions Students................................619, 671
Health Centers.................................................612, 622
    Area Health Education Centers (AHEC) Program...............660, 691
    Arkansas Communty Health Centers.............................   689
    Guaranteed Loans.............................................   641
    Health Education and Training Centers (HETC).................   660
    Keeping Health Centers Open..................................   693
    Loan Guarantee Program for Community Health Centers..........   675
    Professional Budget Judgment.................................   623
    Program FTE's, Consolidated..................................   624
    Rural Health Research Centers................................   668
    Savings from Health Centers..................................   686
Healthy Schools, Health Communities..............................   702
Healthy Start..................................................644, 708
HIV/AIDS.........................................................   613
HMOs.............................................................   712
Infant Mortality.................................................   644
    Rates at Health Start Projects...............................   657
Joint Working Group on Telemedicine..............................   669
Loan Repayment and Faculty Fellowships...........................   659
Low Birth Weight.................................................   645
Maternal and Child Health........................................   614
Minority Health..................................................   628
    Care Professionals...........................................   630
    Faculties on Health Professions..............................   683
    Improvement Act..............................................   694
National Health Care Fraud and Abuse Data Collection Program.....   681
Ocular Screening.................................................   655
Office of Drug Pricing...........................................   655
Opening Statements.............................................605, 610
Organ:
    Procurement and Transplantation..............................   615
    Transplantation..............................................   627
    Transplant Regulations.......................................   637
    Transplants..................................................   619
Performance Measures Standards...................................   639
Pilot Project with IRS...........................................   628
Program Management...............................................   615
Race Initiative..................................................   698
Reimbursements...................................................   652
Research, Delivery, Evalutation..................................   636
Reporting CHC Data...............................................   682
Request for $200 Million Increase................................   684
Rural Outreach Grant Fundings....................................   670
Ryan White.......................................................   626
    Care Program.................................................   705
    Clients Serviced.............................................   672
    Inspector General's Report...................................   626
    Title I Grants...............................................   666
Savings from Federal Tort Claims.................................   671
Secretary's Initiative on Race...................................   640
SIDS.............................................................   672
SPRANS...........................................................   652
State Child Health Insurance Program.............................   680
State Offices of Rural Health Funding............................   658
Stipend..........................................................   659
Stroke Bill......................................................   618
Title V Funds to Address Unmet Needs.............................   664
Uninsured.................................................617, 632, 697
Unobligated Balances.............................................   680
Uvalde County Clinic.............................................   623
Welfare Reform...................................................   631
Witnesses........................................................   605
Zenotransplant Patient Registry..................................   673

       Substance Abuse and Mental Health Services Administration

Alcohol Problems.................................................  1132
Administrative Expenses for Object Class 25......................  1159
Block Grant Formula..............................................  1140
Budget Justification.............................................  1194
Center for Mental Health Services................................  1188
Centers for the Application of Prevention Technologies...........  1155
Children's Mental Health Service Program.........1116, 1184, 1186, 1190
Closing the Treatment Gap........................................  1144
Community Coalitions.............................................  1174
Community Mental Health Services.................................  1162
Data Collection Activities.......................................  1138
Drug Free Communities Act........................................  1148
Drug Use on the Rise.............................................  1111
Drug Testing Programs............................................  1168
FY 1999 Budget Requests to DHHS and OMB..........................  1159
Funding for Knowledge Development and Application (KDA) Programs.  1153
Future Drug Use..................................................  1112
Government Performance and Results Act (GPRA)..........1134, 1153, 1158
High Risk Youth Programs.........................................  1137
Impact of Welfare Reform.........................................  1178
Kick Butts Connecticut Campaign..................................  1122
KDA Program and Substance Abuse Block Grants.....................  1163
Managed Behavioral Health Care...................................  1128
Managed Care Organizations with Substance Abuse Services.........  1154
Mental Health:
    Services for Welfare Recipients..............................  1163
    Studies in Progress..........................................  1149
    Studies Proposed for FY 1999 (New)...........................  1150
Minority Fellowship Program......................................  1152
National Crime Prevention Council................................  1168
National Technical Assistance Center.............................  1152
Number of Children with Serious Mental and Emotional Disorders...  1190
Number of People Who Need Mental Health Services.................  1144
Object Class Breakout for Program Management.....................  1144
Office of Managed Care Activities................................  1160
Opening Statement................................................  1089
Opioid Treatment Programs........................................  1146
Program Management...............................................  1142
Raising Awareness about Mental Illness...........................  1148
Research Fund (21st Century).....................................  1114
Reduction in KDA Funding.........................................  1126
Safe Passage.....................................................  1183
Services for Homeless Families and Individuals...................  1191
Spending on Data Initiative......................................  1143
Starting Early/Starting Smart Initiative.........................  1154
State:
    Compliance and Sale of Tobacco Products......................  1166
    Incentive Grant Awards.......................................  1155
    Owned and Operated Psychiatric Hospitals.....................  1161
    Substance Abuse Prevention Activities Inventory..............  1158
Statement by Dr. Nelba Chavez....................................  1094
Study of Televised Advertising on Youth..........................  1143
Substance Abuse Prevention Activities............................  1182
Substance Abuse Prevention Media Campaigns.......................  1156
Substance Abuse Treatment vs. Prevention Funding.................  1173
Survivors of Torture Conference..................................  1167
Synar Amendment......................1118, 1123, 1158, 1170, 1175, 1176
Targeted Capacity Expansion......................................  1141
Technical Assistance on Mental Health Effects of Trauma..........  1168
Tobacco Control Activities.......................................  1174
Tobacco Settlement...............................................  1119
Training for Mental Health Professionals.........................  1142
Treatment Barriers for Substance Abusers.........................  1124
Treatment on Demand..............................................  1130
U.S. Mexico Border Substance Abuse Initiative....................  1156
Witnesses........................................................  1093
Youth Substance Abuse Prevention Initiative......................  1179