[House Hearing, 106 Congress]
[From the U.S. Government Publishing Office]



                 DEPARTMENTS OF LABOR, HEALTH AND HUMAN

               SERVICES, EDUCATION, AND RELATED AGENCIES

                        APPROPRIATIONS FOR 2000

_______________________________________________________________________

                                HEARINGS

                                BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS
                              FIRST SESSION
                                ________
  SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
                    EDUCATION, AND RELATED AGENCIES
                 JOHN EDWARD PORTER, Illinois, Chairman
 C. W. BILL YOUNG, Florida           DAVID R. OBEY, Wisconsin
 HENRY BONILLA, Texas                STENY H. HOYER, Maryland
 ERNEST J. ISTOOK, Jr., Oklahoma     NANCY PELOSI, California
 DAN MILLER, Florida                 NITA M. LOWEY, New York
 JAY DICKEY, Arkansas                ROSA L. DeLAURO, Connecticut
 ROGER F. WICKER, Mississippi        JESSE L. JACKSON, Jr., Illinois
 ANNE M. NORTHUP, Kentucky
 RANDY ``DUKE'' CUNNINGHAM, 
California                          
                          
 NOTE: Under Committee Rules, Mr. Young, 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, Susan Ross Firth,
                and Francine Salvador, Subcommittee Staff
                                ________
                                 PART 3

                 DEPARTMENT OF HEALTH AND HUMAN SERVICES

                          PUBLIC HEALTH SERVICE

              (Excluding the National Institutes of Health)
                                                                   Page
 Centers for Disease Control......................................    1
 Substance Abuse and Mental Health Services Administration........  523
 Agency for Health Care Policy and Research....................... 1051
 Health Resources and Services Administration..................... 1323
                                ________
         Printed for the use of the Committee on Appropriations
                                ________
                     U.S. GOVERNMENT PRINTING OFFICE
 56-642                     WASHINGTON : 1999





                         COMMITTEE ON APPROPRIATIONS

                   C. W. BILL YOUNG, Florida, Chairman

 RALPH REGULA, Ohio                  DAVID R. OBEY, Wisconsin
 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             STENY H. HOYER, Maryland
 TOM DeLAY, Texas                    ALAN B. MOLLOHAN, West Virginia
 JIM KOLBE, Arizona                  MARCY KAPTUR, Ohio
 RON PACKARD, California             NANCY PELOSI, California
 SONNY CALLAHAN, Alabama             PETER J. VISCLOSKY, Indiana
 JAMES T. WALSH, New York            NITA M. LOWEY, New York
 CHARLES H. TAYLOR, North Carolina   JOSE E. SERRANO, New York
 DAVID L. HOBSON, Ohio               ROSA L. DeLAURO, Connecticut
 ERNEST J. ISTOOK, Jr., Oklahoma     JAMES P. MORAN, Virginia
 HENRY BONILLA, Texas                JOHN W. OLVER, Massachusetts
 JOE KNOLLENBERG, Michigan           ED PASTOR, Arizona
 DAN MILLER, Florida                 CARRIE P. MEEK, Florida
 JAY DICKEY, Arkansas                DAVID E. PRICE, North Carolina
 JACK KINGSTON, Georgia              CHET EDWARDS, Texas
 RODNEY P. FRELINGHUYSEN, New Jersey ROBERT E. ``BUD'' CRAMER, Jr., 
 ROGER F. WICKER, Mississippi        Alabama
 MICHAEL P. FORBES, New York         JAMES E. CLYBURN, South Carolina
 GEORGE R. NETHERCUTT, Jr.,          MAURICE D. HINCHEY, New York
Washington                           LUCILLE ROYBAL-ALLARD, California
 RANDY ``DUKE'' CUNNINGHAM,          SAM FARR, California
California                           JESSE L. JACKSON, Jr., Illinois
 TODD TIAHRT, Kansas                 CAROLYN C. KILPATRICK, Michigan
 ZACH WAMP, Tennessee                ALLEN BOYD, Florida              
 TOM LATHAM, Iowa
 ANNE M. NORTHUP, Kentucky
 ROBERT B. ADERHOLT, Alabama
 JO ANN EMERSON, Missouri
 JOHN E. SUNUNU, New Hampshire
 KAY GRANGER, Texas
 JOHN E. PETERSON, Pennsylvania     
                   
                 James W. Dyer, Clerk and Staff Director

                                  (ii)

 
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2000

                              ----------                              

                                       Thursday, February 11, 1999.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

                               WITNESSES

JEFFREY P. KOPLAN, M.D., M.P.H., DIRECTOR, CDC
WILLIAM H. GIMSON, DIRECTOR, FINANCIAL MANAGEMENT OFFICE, CENTERS FOR 
    DISEASE CONTROL AND PREVENTION
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, DHHS

                       Introduction of Witnesses

    Mr. Porter. The subcommittee will come to order. We 
continue our hearings on the budget for the Department of 
Health and Human Services this morning with the Centers for 
Disease Control and Prevention. We are very pleased to welcome 
the new Director, Dr. Jeffrey P. Koplan. Dr. Koplan was with 
CDC for many years and then became President of the Prudential 
Center for Health Care Research in Atlanta and now, after four 
years in the private sector, he is back at CDC as the new 
Director. We welcome you this morning and look forward to your 
testimony.
    Why don't you introduce the people who are with you and 
then proceed.
    Dr. Koplan. With me is Mr. Bill Gimson from CDC, Mr. Dennis 
Williams from the Department of Health and Human Services.

                           Opening Statement

    Thank you, Mr. Chairman and good morning to you and Mr. 
Bonilla, Mr. Cunningham, the people here. I am Jeff Koplan. I 
am pleased to be here today to speak to you for the first time 
as Director for the Centers for Disease Control and Prevention. 
As Mr. Porter indicated, I was at CDC for 22 years, retired in 
'94 convinced that I would not return to government or the CDC. 
I am humbled to realize that I have returned. I couldn't miss 
the opportunity to lead this premier public health agency. It 
was an opportunity I could not refuse.
    For the past 5 years in the private sector, I have gained 
experience and knowledge that I think confirms my belief that 
the private and public sector, working together, have a mutual 
interest in preventing disease and injury.
    As we approach the end of the 20th century, I cannot help 
but reflect on the extraordinary progress we have made towards 
improving the health of the American people. And I would like 
to mention five public health achievements that have had a 
tremendous impact on our Nation's health and were achieved 
through disease prevention efforts. While there have been many 
such accomplishments, I have chosen just five that I feel 
address CDC's past and its future. These issues are reflected 
in our FY 2000 budget request.
    The first accomplishment is in vaccine preventable 
diseases. In our lifetime we have witnessed the virtual 
elimination of diseases that once killed thousands of children 
each year. Measles, polio and smallpox, to name a few, are 
horrors that parents today do not face. Nor does society have 
to deal with the emotional or economic consequences of these 
diseases. We must continue the efforts begun in the U.S. over 
the past decade to raise immunization coverage for all children 
and adults in the country. Our vigilance is now more important 
than ever. Therefore, I am requesting $17 million, to support 
our global effort to eradicate polio. Eliminating that plague 
will be a legacy for our next generation.
    The second major achievement of the 20th century is the 
development of a strong public health system at the Federal, 
state, and local levels for our country. The U.S. public health 
system--with its ability to monitor trends in disease; identify 
interventions to prevent illness; and implement effective, 
scientifically based programs--is the envy of the world. CDC, 
in its 50 years of service, has contributed to the 
strengthening of this system. A recent example of the value of 
this system is our identification of a widespread listeriosis 
outbreak and rapid implementation of control measures.
    Our successes and ongoing challenges push us to set equally 
important goals for the new century. I am requesting $138 
million to ensure that state and local public health agencies 
will be able to respond rapidly to threats now posed by 
bioterrorism. An additional $25 million for infectious disease 
control will strengthen food safety programs and other emerging 
infectious disease problems, such as hepatitis C and pandemic 
influenza. We must be ready for both the malicious and 
purposeful, as well as the unpredictable and microbe-driven 
threats of the 21st century.
    A third accomplishment is the revolution in smoking 
patterns. Thirty years ago this room would have been filled 
with smoke and I would be fidgeting with my pipe in anxietyover 
this hearing. ``Smoke free'' was not in our vocabulary or in our homes 
or workplaces. From the first Surgeon General's Report in 1964 to the 
latest in 1998, there has been a powerful change in public perceptions 
and behavior regarding smoking. Adult smoking rates have continued to 
decline in the U.S. from 43 percent in 1966 to 25 percent today. 
Millions of Americans now recognize the danger of smoking and do not 
want their children to smoke. This change is in large part due to 
public health efforts. We cannot stop this fight now.
    CDC requests an additional $27 million to prevent and 
reduce tobacco use among youth and adults. This request will 
assist communities in their efforts to prevent youth smoking. 
It will also empower CDC to increase our scientific knowledge 
of the best practices to prevent kids from starting to smoke 
and to help those who have started to quit. Of course we hope 
when we have a similar review of public health accomplishments 
a hundred years from now, we won't be present at it, that this 
menace will be only a distant memory.
    The fourth accomplishment is preventing injuries. In recent 
years, we have come to the recognition that injuries are 
preventable, not accidental, and that has saved lives. Few of 
us think twice any more about using seat belts or child safety 
restraints. To build on these efforts to reduce injury, we are 
requesting $2 million to expand our injury surveillance efforts 
and build our partnerships with private industry through a 
program we call Safe U.S.A. In addition to dealing with an 
important aspect of intentional injuries, we are requesting an 
increase of $11 million to develop new partnerships and adapt 
science-based approaches to prevent violence against women.
    A fifth accomplishment is a safer workplace. Industrial and 
other worksites in 1900 were extremely dangerous. Asbestos, 
once common in the worksite, has been virtually eliminated from 
new use. Brown lung, a major cause of chronic lung disease, is 
essentially a disease of the past, and deaths from silicosis 
and black lung disease continue to fall. Fatal occupational 
injury rates have declined 41 percent from 1980 to 1994. All 
these successes have been accomplished through new scientific 
understanding and evidence that guide prevention efforts.
    We are requesting an increase of $12 million in fiscal year 
2000 to address gaps in knowledge and scientific information 
and occupational health. These resources will begin to address 
high priority areas in occupational health for the next 
century, including asthma, health risks to special populations 
and the impact of emerging technologies in the workplace.
    But we do have challenges for the future. Although we feel 
a sense of accomplishment from the achievements I have 
mentioned, we are not complacent about the future. Much remains 
to be done to achieve our goals of preventing unnecessary 
illness, disability, and death.
    At CDC, we take seriously our responsibility for monitoring 
the health of the Nation. It is our job to not only collect 
data but recognize trends in disease and injury and the factors 
that impinge on good health.
    To illustrate the complex health problems that we expect to 
face in the 21st century, I would like to show you some 
alarming trends we have detected in obesity. If I could turn 
your attention to the chart on your right. When you look at the 
data from 1985, you can see that relatively few states reported 
a high proportion of their citizens were obese. In these 
charts, the darker the red color, the higher the overweight 
proportion of each state's population. But when you look at the 
charts over the past 12 years, this is from 1985 to the 
present, you can see that 15 percent of the population is now 
obese in over two-thirds of the states. If this was a pattern 
for infectious disease, you would say there is an epidemic 
occurring in this country.
    Or put another way, obesity has increased by over 50 
percent among adults and over 100 percent among children and 
adolescents. Why should we be worried about this? Obesity is a 
risk factor for heart disease, hypertension, diabetes, and 
cancer, among other things, the major chronic diseases of our 
time. With our data systems, we are beginning to recognize the 
extent of the problem. The challenge before us is to work with 
our academic colleagues and sister public health agencies to 
identify the biological, behavioral and societal factors 
associated with obesity and develop effective prevention 
approaches.
    Information like the data I have just shown you on obesity 
is vital to help researchers. Our Nation's health statistics 
system is one of the basic tools used by all of us. I don't 
mean just those of us in public health and medical research. I 
mean drug companies, health care organizations, school 
teachers, the media, and members of Congress. To assure that we 
have the easily accessible health information we all need, we 
are requesting an additional $15 million in FY 2000 to 
reinvigorate our national health statistics systems.
    In summary, to prepare CDC to address the health challenges 
of the new century, we are requesting $3.1 billion, an increase 
of $178 million over our FY 1999 appropriation. My written 
statement and our full budget request detail both our current 
program and the specific increases we have requested so I will 
not go over those in detail. However, in good conscience, I 
cannot leave here today without sharing with you one of my 
deepest concerns: the deterioration of CDC's physical 
facilities. Since I returned to CDC, I have been distressed by 
the deplorableworking conditions our staff must tolerate. When 
the only environmental lab in the world with the capability of 
detecting many toxins was closed last month because there was a risk of 
rainwater damaging a multimillion dollar bank of mass spectrometers, 
our capacity to meet our responsibilities was seriously compromised. 
Unfortunately, this is not an uncommon event in our workspaces. On my 
e-mail this morning, it revealed a building closed yesterday due to 
broken pipes and flooding. The $22 million increase in our FY 2000 
budget request to support the completion of the Edward R. Roybal 
Infectious Disease Laboratory is a welcome step towards the renovation 
and rebuilding that needs to be done.
    The date for the new fiscal year 2000 has provoked a lot of 
rhetorical excitement and futuristic speculation. For us in 
public health, it offers the challenge to achieve a set of 
accomplishments for the next 100 years with a similar impact on 
the health of our children and grandchildren that we have 
enjoyed in the last century.
    I appreciate the opportunity to appear before you today. I 
would be happy to answer any questions you have.
    [The prepared statement follows:]

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Mr. Porter. Dr. Koplan, thank you very much for your 
testimony. The last thing you said I want to emphasize 
particularly. We had a subcommittee trip down to Atlanta a 
couple of years ago. I am not sure how many Members went, but I 
went later. When you go to the CDC facilities there, you have 
two things in mind, pride in all the wonderful things that are 
going on to address the health needs of more than the American 
people, really the world, and the overcrowding labs that aren't 
connected with one another. If you go out to the environmental 
health laboratories, those are quonset huts that really need to 
be replaced. I think that we should develop, and I hope that we 
get the resources so that we can develop, a plan to provide the 
kind of world class facilities for CDC that you ought to have 
and get rid of the buildings that have been there for so many 
years that really need replacement.
    So I take your message very strongly to heart and I would 
urge those Members who haven't been down to Atlanta to see what 
the needs are to take advantage of that and go down there and 
see it.

                                OBESITY

    I know you said you had to study the reasons why the 
American people have become so obese, but let me ask a 
question. Is the standard the same from 1985 through 1997?
    Dr. Koplan. What we see on these charts is not a reflected 
change in the standard. It is an absolute increase in what is 
called body mass index.
    Mr. Porter. It is sort of amazing because we have spent all 
these years emphasizing diet Coke and fat free foods which 
aren't lower in calories necessarily, but the fat calories 
themselves are more likely to add weight than others. We 
emphasize exercise and yet we are all getting heavier. You have 
to ask yourself why is this.
    Dr. Koplan. Our scientists are actually working trying to 
answer those questions. Some of the suggestions are that there 
have been changes that might well contribute to this increase 
in overweight. Among them are a considerable drop in physical 
activity in schools. Whether it is physical education classes 
or time spent with kids being physically active, there has been 
a precipitous drop over the last decade in activity in schools. 
So that is an issue for our children.
    The increased time spent watching TV in a sedentary posture 
is an issue. Some of our scientists and staff have developed 
programs looking at ways to change this and some of them have 
been very effective. We have a very effective program in Texas 
working with the university there that shows that children can 
be given alternatives that are desirable to them, and the 
investigator that led the programs received a letter from a 
parent saying she never expected her child to leave that couch 
and stop eating those snacks and he is a different child on the 
basis of this program. So there are educational and behavioral 
approaches that can make a difference in this.
    Mr. Porter. It seems that a lot of what we have to do is 
target lifestyle habits that get formed at a young age and then 
follow people the rest of their lives. It has been suggested 
more than once that what we have to do is forget our own 
generation and just focus on the young to get them off on the 
right foot because we are probably all hopeless. At least we 
can change health habits and get them ingrained at a young age 
to change all this. Apparently we are ingraining the wrong 
health habits early and they are sticking with us as we get 
older. That is something you are going to have to come back and 
tell us what you found because obviously there is a lot of 
different factors involved.

                              BIOTERRORISM

    Let me focus for a moment on bioterrorism. Last year when 
the Administration submitted a budget amendment to request 
funding for bioterrorism, that amendment arrived with very 
little supportive documentation that laid out a plan on how to 
deal with the threat both in the short term and in the long 
term.
    We know that the threat exists and that we probably aren't 
as prepared as we must be for it. That is why the 
Administration amended the budget request last year and why 
Congress agreed to provide for the funding. But there is still 
some concern about the coordination among the agencies and the 
Departments involved in this effort. I wonder if you could 
describe who's taking the lead, who'sparticipating, and how the 
coordination works or doesn't work.
    Dr. Koplan. In HHS, the coordination is through Dr. Peggy 
Hamburg, who is Deputy Assistant Secretary for Planning and 
Evaluation, and she helps coordinate it across the agencies 
within HHS and across other departments. From the health side, 
CDC has been a beehive of activity on this. Large amounts of 
staff are now designated to work on this and a new coordinator 
in our National Center for Infectious Diseases links with other 
parts of CDC to provide weekly updates by this group--a 
creation of clusters of people working on different pieces such 
as the stockpile, surveillance, epidemic investigations, and 
new threats. A day doesn't go by when we are not in 
conversations with the Department of Defense on issues related 
to this and on other investigative activities. Our role, of 
course, is not the side of investigating perpetrators or the 
legalistic side. Ours is detecting early when a problem occurs 
and seeing that it ends as quickly as possible. We are actively 
at work trying to get that done.
    Mr. Porter. In the FY99 appropriation, all funding for 
bioterrorism activities was included in the public health and 
social services emergency fund. The budget request for 2000 
continues to request bioterrorism funding through the emergency 
fund except for a $20 million request that is included in your 
infectious disease program. Why is the $20 million broken out 
from the rest of HHS's bioterrorism request?
    Dr. Koplan. The $20 million focuses on surveillance, which 
is an area that we have to beef up considerably in state and 
local health departments so that when those first cases occur 
at a local level, they are recognized and then they get 
reported quickly to people who can do something about it. So 
that piece is a separate piece from the overall bioterrorism 
plan.
    Mr. Porter. I am not sure why it should be. Dennis, do you 
have any insight on that one?
    Mr. Williams. I think it is related to--the Centers for 
Disease Control has a broader surveillance strategy. 
Bioterrorism is one aspect of part of this surveillance 
strategy. So I think it was thought better to keep them all in 
one place rather than to separate it out, separate the 
bioterrorism out.

                        CHRONIC FATIGUE SYNDROME

    Mr. Porter. Dr. Koplan, I want to raise a question you and 
I have discussed directly and it deals with CFIDs. I just want 
to get an answer on the record as to the Inspector General's 
progress and when you expect a report.
    Dr. Koplan. We have been working with the Inspector General 
for a couple months now in a very cooperative manner. They are 
near the end of their investigation, and we expect sometime 
over the next several weeks to have a final report from them 
and are committed to take rapid and aggressive action on 
whatever their findings are. In the meantime, we have developed 
a proactive spending plan for this year which is transparent 
and clear and we plan to share it with the chronic fatigue 
syndrome advisory committee so there is a common sense of what 
we are about.
    Mr. Porter. For the information of the Members who may not 
be aware of this, this is a matter where a whistle blower 
within CDC has brought to the attention of Congress the fact 
that there is an indication that the amounts spent on research 
into chronic fatigue syndrome were not accurately given to 
Congress and there is some evidence or some allegations that 
there may be other information that is not accurate for us and 
the IG is looking into it.
    We are operating under the 8-minute rule. Mr. Hoyer.
    Mr. Hoyer. Thank you very much, Mr. Chairman, Dr. Koplan. 
Welcome.
    Dr. Koplan. Mr. Hoyer.

                           HEALTH STATISTICS

    Mr. Hoyer. At last year's hearing Dr. Broome and I led a 
campaign for increased funding to help support the efforts of 
the National Center for Health Statistics to help provide an 
accurate picture of America's health, obviously for the 
government, but for the private sector as well. Tell me, Dr. 
Koplan, how is the increased funding for fiscal year '99 at 
NCHS programs being used?
    Dr. Koplan. Thank you. National Center for Health 
Statistics is a national treasure for all of us. It has been 
basically flat funded for a decade now, such that much of its 
capabilities have eroded. As you well know, it conducts major 
national surveys, one of which is the National Health and 
Nutrition Exam Survey, collecting invaluable information for 
all of us. One of the ways these funds will be used is to beef 
that up, to permit it to do some testing it wouldn't be able to 
do before, to get it on the road, to bring it back up to its 
desired level of performance, and similarly with other aspects 
of our data systems, birth and death data, measuring 
information on aspects of our health care delivery system. All 
of these will be increased in capability by virtue of this 
funding.
    Mr. Hoyer. Were the obesity statistics that you referred to 
in these charts garnered from those statistics?
    Dr. Koplan. These particular ones come from our Behavioral 
Risk Factor Surveillance System. Those get done on a state-by-
state level. It is crucial to have these either confirmed or 
see what other information there is through something like the 
National Health and Nutrition Examination Survey (NHANES) that 
creates an alternative approach with different conclusions that 
can be drawn so they are very complementary.

                               PFIESTERIA

    Mr. Hoyer. Thank you. Another subject, because our time is 
short. I am going to go relatively quickly on these questions. 
Pfiesteria, as you know, doctor, all of us on theAtlantic 
Coast, Maryland and North Carolina, in particular, but generally the 
Atlantic coast are very concerned about this. I had $7 million on the 
CDC budget fiscal year '98 two years ago for this and charged the CDC 
with leading a surveillance and research effort to evaluate whether 
pfiesteria poses a public health risk. Can you bring me up to date?
    Dr. Koplan. Thank you. Pfiesteria is a terrific example of 
an emerging infection, a new one we wouldn't have had a few 
years ago and is a major issue both for health and economics. 
We created a six-state surveillance system for pfiesteria 
involving states that are affected or likely to be affected 
from it. We funded cooperative agreements in several states 
including Delaware, Florida, Maryland, North Carolina, and 
Virginia. They were given funds to implement specific studies, 
cohorts of large populations to investigate the potential 
association between pfiesteria and various human health 
effects. There is a lot of activity going on. We thank you for 
that.
    Mr. Hoyer. When do you expect to have some findings?
    Dr. Koplan. The surveillance system should be developing 
information throughout the year. These studies will probably 
take, a year or so before we start to get some information 
back.
    Mr. Hoyer. There is some information--a major article, I 
think it was--it may have been the Sun, with reference to the 
lack of nutrients in the food chain for certain fish which some 
folks postulated was weakening the fish. In other words, there 
was no new phenomena causing pfiesteria. What was happening is 
the nutritional level of fish in the Bay was going down and 
therefore they were less able to confront the disease, not 
necessarily that there was greater risk. I don't know whether 
the study will speak to that or not but I presume it will have 
some observations like that.
    Dr. Koplan. I think we will be seeking input from a variety 
of specialists, including marine biologists, as well in dealing 
with this issue.

                                 ASTHMA

    Mr. Hoyer. Thank you, Doctor. Over 307,000 Maryland 
residents have self-reported they had asthma, and this seems to 
point to a growing trend. We have discussed this before both 
with the National Institutes of Health (NIH) and with you. 
Would you please describe the asthma epidemic, if in fact it is 
an epidemic, and indicate the reasons for the increase in the 
incidence of asthma?
    Dr. Koplan. There has certainly been a regular increase in 
asthma and particularly in disadvantaged populations around the 
country. And we don't have a clear answer as to why this is 
occurring. Studies are certainly needed to elucidate what the 
relationship is. Whether it is allergens or environmental 
factors may well contribute to some of this. We are working 
closely with the American Lung Association, with NIH and with 
the Environmental Protection Agency (EPA) to implement 
education activities around asthma and are trying to work with 
states to improve their capabilities, particularly on the 
environmental side and the community basis to improve care and 
prevent asthma attacks from occurring.

                         VIOLENCE AGAINST WOMEN

    Mr. Hoyer. Doctor, last subject I will deal with. You have 
in your statement $11 million. Obviously there is also an item 
dealing with rape and other sexual offenses of a much larger 
figure, but $11 million, I am not sure whether that is an 
increase. You go from 124 or $118 million, am I correct, on the 
rape study itself? I was just looking at that. Does that ring a 
bell with you? Excuse me. That was in the bioterrorism. The 
rape prevention, included in the crime bill, $45 million is a 
constant figure. Can you tell me both in terms of the $11 
million increase for violence and women and that $45 million, 
what those studies are focused on and what if any findings or 
results we seek to get?
    Dr. Koplan. I believe the $45 million figure you are 
referring to, Mr. Hoyer, is a form of block grant that provides 
rape counseling in states around the country. Of the $11 
million----
    Mr. Hoyer. That is from the block grant.
    Dr. Koplan. That is from the block grant, yes. The $11 
million increase is for a particularly new initiativethat is 
part of a departmental initiative the Secretary has spearheaded which 
focuses on violence against women. And about $7.5 million of that are 
specific service oriented programs at the state level and the local 
level to demonstrate innovative ways to deliver services, to look at 
culturally appropriate services for different groups, to support 
scientific evaluation and research as to what the best interventions 
that can take place. And then 3.5 million that has been designated for 
its building national partnerships for children and adolescents and, in 
essence, is a link to the business community in doing some joint 
projects together.
    Mr. Hoyer. I would be interested in the specifics on that.
    Dr. Koplan. We can provide you with more specifics.
    [The information follows:]

      Building National Partnerships for Children and Adolescents

    The $3.5 million requested for changing social norms among 
children, adolescents, the business community and the general 
public is part of a $28 million departmental initiative that 
Secretary Shalala is spearheading which focuses on Violence 
Against Women (VAW). That initiative requests $11 million for 
CDC activities which will enhance services ($7.5M) and change 
social norms ($3.5M) CDC requests $3.5 million to begin 
targeting specific groups, including the business community, 
regarding the unacceptability of attitudes and behavior that 
leads to violence against women. A national effort is needed to 
change social norms about women to emphasize the elements of 
healthy relationships. Changing social norms will enhance 
support for survivors and ultimately, prevent VAW from 
occurring in the first place.
    CDC proposes, in collaboration with the Office of Women's 
Health and other HHS agencies, to lead an HHS effort to work 
with multiple sectors of society, including corporate and 
education partners together with VAW advocates, researchers, 
and other experts to: (1) shape more positive attitudes and 
provide practical skills training through workshops for 
teachers and others who interact with youth; and (2) work with 
business groups, corporations and worker organizations through 
the National Institute for Occupational Safety and Health to 
build on existing efforts to develop policies and educational 
materials regarding VAW prevention and services. In addition to 
sexual harassment policies, CDC would help these organizations 
guide companies developing policies that help identify and 
assist women who are survivors of violence and conduct or 
advertise VAW prevention activities.
    CDC will also conduct longitudinal research on the 
developmental pathways of VAW to help better understand how 
social norms and associated behaviors affect violence against 
women. Such research will assist in identifying ways early 
childhood exposures to violence affect subsequent risk, and 
help to modify existing programs or develop new prevention and 
intervention strategies to address VAW.

    Mr. Hoyer. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Hoyer. Mr. Bonilla.
    Mr. Bonilla. Thank you, Mr. Chairman. Once again, Dr. 
Koplan, we are proud of what you do and we want to continue to 
strongly support you on this committee as much as we can.
    Dr. Koplan. Thank you.

                                DIABETES

    Mr. Bonilla. My first question today is about diabetes. I 
have been a very strong advocate of research dollars for 
anything that can help with that problem and we appreciate in 
Texas the awarding of the comprehensive diabetes grant and 
really help us with education efforts in Texas as we have such 
a disproportionately high number of people affected in Texas. 
This, of course, is a very important initiative that should 
continue. My question is the CDC budget calls for level funding 
of diabetes programs, if I am reading page 145 of the budget 
justification correctly. Tell me why there was not more money 
provided by the present CDC budget and did you ask for more 
money for diabetes?
    Dr. Koplan. I think in the midst, as you would imagine, in 
the midst of competing priorities and needs, it was felt that 
diabetes was adequately funded.
    Mr. Bonilla. Well, I disagree with you on that. I think 
that there has been a realization nationally by many 
researchers that diabetes is something that probably at this 
point needs more attention, not level attention. We have 15 
states in addition to Texas that have a CDC comprehensive 
diabetes program and only 34 states have core diabetes 
programs. How much funding would be required to expand these 
comprehensive diabetes programs and how much funding would be 
required to expand the core diabetes program?
    Dr. Koplan. Well, the average grants through our 
comprehensive programs, which deliver more services and have 
considerable impact on places where they exist, is about $800 
thousand to a million dollars each. In the core support, not 
comprehensive, it is about $250 thousand average. That is in 34 
states. So to bring all states up to a more comprehensive and 
effective program, we are probably talking about $10 million. 
[Clerk's Note:--Later corrected to ``in the range of $25 to $30 
million'']

                              FOOD SAFETY

    Mr. Bonilla. I want to move now to food safety. I also deal 
with this very extensively on the agricultural subcommittee. I 
just want to make sure there is not a duplication of roles in 
this area. For example, the CDC's specific role, my 
understanding is, is as a reporting entity, not so much in 
terms of being out there making announcements when there is an 
emergency somewhere. Is it correct that CDC has strictly the 
reporting role related to what happens in other agencies, for 
example the United States Department of Agriculture (USDA)?
    Dr. Koplan. There is good coordination between the 
agencies, the scenario I have worked in for nearly 30 years and it 
works well. CDC's role is both to detect when there is an increase in a 
problem, and we have increasingly powerful biological and molecular 
biological tools to do that, and then to investigate it when it does. 
So it is not just getting numbers in. It takes an active investigation 
by highly trained people to go out and figure out what is going on and 
then make linkages. When it is time for regulatory type action to take 
place, that is where the Food and Drug Administration (FDA) and USDA 
come in and again there is hourly communication between our 
investigators in this area, epidemiologists and surveillance people, 
and the folks in FDA and USDA, many of whom actually are alumni of 
CDC's programs.
    Mr. Bonilla. So you are not concerned at this point with 
duplication?
    Dr. Koplan. In what we are doing now? No, I am not.
    Mr. Bonilla. Do you believe that each agency then 
understands a clear identity of each role then, CDC and USDA 
for example?
    Dr. Koplan. I do.
    Mr. Bonilla. In recent press reports it has been quoted by 
some in the food industry that CDC often may publicly release 
information about foodborne pathogen investigations without 
informing first companies involved and the appropriate 
regulatory agencies. You can imagine this would cause a lot of 
concern among some groups out there because they at least would 
like to know what they are dealing with before it is out there 
and sometimes possibly scaring people without a proven 
substance. Does CDC have an established policy for sharing 
information obtained in an investigation of foodborne pathogens 
of affected companies or other food safety agencies such as FDA 
and USDA, before it is made available to the public?
    Dr. Koplan. There is a large amount of discussion and 
sharing of information before this information gets released to 
the public. Certainly there is concurrence of opinion between 
FDA, CDC, and USDA on these issues and certainly the affected 
industry involved knows well what is going to be released 
before it gets released.
    Mr. Bonilla. Would it be possible then that CDC would 
release information before the entities are advised, companies 
or the communities?
    Dr. Koplan. It may have happened at some time but it is 
certainly not our policy. It is not good public health practice 
either.

                            TOBACCO CONTROL

    Mr. Bonilla. I want to move now. The time is limited and 
move right to another area, and that is the area of tobacco. 
With the combining--the new initiative of national tobacco 
control program which combines the ASSIST and IMPACT programs, 
how much money has been spent on the ASSIST and IMPACT programs 
to date and if you would please provide funding levels for each 
of these programs for each fiscal year since their inception. I 
know you may not have that at your finger tips. If you could 
provide that for me.
    Dr. Koplan. I can provide that for you for the record.
    [The information follows:]

                 Funding for ASSIST and IMPACT Programs

    Starting in FY 1999, CDC is funding all 50 states, the 
District of Columbia, and the territories, for core tobacco 
control programs, thereby establishing the National Tobacco 
Control Program. This program combines the CDC IMPACT program's 
32 states and the District of Columbia, with the 17 ASSIST 
states previously funded by the National Cancer Institute. In 
FY 1998, CDC provided funding to the 32 states and the District 
of Columbia under the IMPACT program totaled approximately $12 
million. In FY 1999, funding for all 50 states, the District of 
Columbia, and the territories under the National Tobacco 
Control Program will total $51 million. The average award for 
IMPACT states is $850,000 and the average awards for ASSISTS 
states is $1.2 million.

CDC State Tobacco Control Program Funding

FY93 (22 states)..............................................$2,966,273
FY94 (32 states).............................................. 2,084,739
FY95.......................................................... 5,040,947
FY96.......................................................... 5,043,316
FY97.......................................................... 5,020,040
FY98..........................................................12,000,000
FY99 (50 states)..............................................51,000,000
FY2000 Request................................................66,000,000

    Mr. Bonilla. Would it make sense--I know you are asking for 
a total budget now of $101 million for these two combined 
programs making one. Wouldn't it make sense that combining 
programs that may be duplicative would save money? I am curious 
as to why you need 36 percent more funding if these programs 
are being combined.
    Dr. Koplan. They are in different states. The IMPACT 
program which previously was just a CDC program has lower 
funding levels. ASSIST, which was previously the National 
Cancer Institute's, was transferred to us by Congress last 
year, has higher funding levels. We want to bring them up to 
the same level so they are capable of delivering the same 
services in each place.
    Mr. Bonilla. Are they then going to continue to exist then 
simultaneously or----
    Dr. Koplan. There will be one state program in tobacco 
control in each state. Whatever the name ends up being--they 
won't be seen as separate entities. This is a transition year 
from two parallel programs in different places to now a--it is 
one of the reasons why you all transferred this to us--a 
coordinated approach. So in many ways the efficiency has 
occurred through this transfer.
    Mr. Bonilla. And that is, I guess, what I am driving at. 
For example, in the private sector if you combine two entities, 
you generally get a saving, not a higher cost. You see where I 
am coming from?
    Dr. Koplan. It may be that the folks that no longer have to 
work on this from where it was transferred are able to do other 
things. But CDC has gained a new program so we have had to 
implement that program. If there were 20 states before in one 
program and 30 states before in the other, we now have 50 
states that deliver basically the same program.
    Mr. Bonilla. But you understand----
    Dr. Koplan. I understand what you are saying.
    Mr. Bonilla. The department is proposing to increase grants 
to states by 29 percent from $51 million in fiscal year '99 to 
$66 million '00. How many additional states will receive grants 
in FY '00?
    Dr. Koplan. There won't be additional states. They will 
have an increased amount in their budgets so all states have 
roughly the same level of effort.
    Mr. Bonilla. How will you ensure that funding through the 
state grants will not be used to lobby state legislatures, 
counties and local officials regarding tobacco control and----
    Dr. Koplan. I believe we have a regulation that prohibits 
lobbying and that is part of the grant language.

                            RACE INITIATIVE

    Mr. Bonilla. I have a final question about the race 
initiative. CDC has done an outstanding job of dealing with 
diseases regardless of what culture they occur in, and I am 
impressed with that. And I am wondering why the President would 
ask for another $145 million total across several agencies, $35 
million in CDC for this initiative on race which is a new 
program which I have discussed in this hearing last year. Why 
do we need to fund a new program when the CDC has clearly been 
addressing this problem for years? Wouldn't it be more 
efficient to increase funding for existing programs which are 
already doing the job instead of creating another layer of 
bureaucracy and, instead use the money to help you with your 
facilities as well. Wouldn't this, for example, be a better 
area to put money into?
    Dr. Koplan. This initiative, I believe represents a 
recognition and an emphasis on the fact that for many of the 
important diseases we deal with, there remains a large and 
difficult to tolerate difference amongst many ethnic and racial 
groups for important diseases in terms of the burden, death 
rates, incidence, et cetera. The initiative has targeted 
certain key health areas that are quite consistent with our 
existing programs, heart disease, diabetes, some of the 
cancers. And because of that, the grants we are using and the 
way we are using this funding to target those same diseases. So 
in many ways, they are linked and related and support and 
supplement the existing programs that we are concerned about, 
diabetes, heart disease, breast and cervical cancer, et cetera.
    Mr. Bonilla. Again, I know my time is up but I just want to 
commend you for already addressing that. I continue to wonder 
why that money might not be better spent elsewhere.
    Dr. Koplan, thank you. Bill, Dennis, thank you for being 
here today.
    Dr. Koplan. Thank you.
    Mr. Porter. Thank you, Mr. Bonilla.
    Mr. Cunningham.

                              FOOD SAFETY

    Mr. Cunningham. Thank you, Mr. Chairman. Dr. Koplan, I had 
a little girl named Lauren Rudolph in my district that died of 
E. coli. Her mom Roni started the program STOP, Safe Tables Our 
Priority, and it is both in San Diego and New York now. I think 
you see that is why a lot of us voted to enhance the meat 
safety. But yet I still see out there in the newspapers, 
whether it is the L.A. Times or San Francisco, where E. coli is 
a problem. I don't want to shut down ranchers and meat packers 
and those kind of things, but are there some other things that 
we could do in that area? Because I still see every once in a 
while E. coli crop up. Roni, Lauren's mom, said that they 
prayed for their little girl to die. She was in so much agony 
and there was no hope. I have got twodaughters and if you can 
imagine that, it is pretty grim.
    Dr. Koplan. Thank you, Mr. Cunningham. E. coli is a 
ubiquitous organism, particularly a threat when it comes to 
livestock and creating foods that get packaged. I think a 
positive aspect that we have got to deal with now is our 
ability to diagnose outbreaks of this immensity quicker. When I 
left CDC 5 years ago, we did not have the molecular biological 
capability we have now to detect an outbreak quickly and 
particularly for something like E. coli. That means when you 
have a couple of cases in San Diego and there is a case in 
Tulsa and there are two cases in Massachusetts, we now have the 
capability of linking them in a way we didn't have before, both 
through our laboratory techniques and through our communication 
system. That means we can detect outbreaks and then control it. 
That is a big advance.
    But, we would be happy to have no cases. The USDA and FDA 
play a role when it comes to the packing plants, the way the 
food gets shipped. So it is this combination of their need for 
a better technology, their need for better controls of the type 
you mentioned, but also our ability to get there quickly and 
put a stop to these things before they spread. I think our 
efforts will help to improve our food supply.

                             BIOTECHNOLOGY

    Mr. Cunningham. There is another area. I have got a biotech 
group business in my district that is called Mycogen. And they 
use actual DNA instead of pesticide on farm products and on 
growing different products, like corn and wheat and so on. And 
what that does, is that it keeps any pesticide from going down 
into the aquifer or running off into the ocean, which is a 
carcinogen in many cases. Has your organization looked into 
more biotech answers to some of those problems? Because I know 
it works.
    My daughter, she had a science project and I got 2,000 lady 
bugs. If you have ever tried to capture 2,000 lady bugs under a 
net in your garage without them getting into your house, good 
luck. But we had tomato plants and we put pesticide on one 
group and then we had a group with no pesticides. And then we 
had Mycogen product on the other. And then we had these big 
ugly caterpillars with horns on them. The pesticide killed, and 
so did Mycogen and the ones that didn't have anything were 
eaten by the bugs. But the point is, I think, with our farmers, 
we can save both the water and a lot of carcinogens for better 
health if we look at biotech for some of these answers.
    Dr. Koplan. Mr. Cunningham, given that experiment, we may 
have a spot for you in Atlanta in one of our laboratories.
    Mr. Cunningham. My daughter did it. She just scored 1,500 
on her PSATs, and is a junior, so we are very proud of her.
    Dr. Koplan. Sign her up. One of the things that has struck 
me in the few years I have been away is the increasing 
collaboration we have with startup companies, biotech companies 
looking at doing collaborative things together so there is a 
lot more of that going on in CDC now. Just the nature of the 
company you mentioned.

                       HEPATITIS AND TUBERCULOSIS

    Mr. Cunningham. One other thing, too, is that Rolf 
Benirschke was a kicker for the San Diego Chargers and he is 
fighting hepatitis--is it hepatitis C. That is the real bad 
one?
    Dr. Koplan. B and C.
    Mr. Cunningham. He was sick and actually had to stop being 
a kicker but he is fighting that disease right now. I think his 
was contracted through a blood transfusion. On the borders, I 
mentioned to you before we started--being a border State, and I 
imagine the gentlemen from Texas and Arizona and all the border 
states--we have almost epidemic proportions of tuberculosis and 
hepatitis. The Tijuana River that comes down, there is so much 
fecal count that we are having a lot of problems in San Diego 
and the border states with hepatitis, tuberculosis and those 
kind of diseases. If you can do anything in that direction too, 
it has been a real problem in San Diego.
    Dr. Koplan. Hepatitis B and C and tuberculosis are areas of 
high concern and priority for us. Hepatitis B--the good story 
is we have an effective vaccine being used more widely. It has 
the opportunity to actually prevent some serious chronic 
diseases, including liver cancer that we didn't have 10, 20 
years ago. Hepatitis C, we do not have those capabilities yet, 
but what we do have is the ability to identify it and to 
improve the blood supply to prevent further cases from 
happening. Tuberculosis, there is the opportunity within our 
lifetime to see a virtual elimination of tuberculosis within 
this country. Our efforts have been directly correspondent to 
the ability of resources we are able to put in tuberculosis 
control in this country and we have made considerable advances 
over the last few years with increasing funding that you all 
generously provided to us.

                                 ASTHMA

    Mr. Cunningham. I read an article in a medical journal last 
year. It was interesting about asthma that was brought up. It 
said many people with asthma moved to the deserts and the drier 
climates. Their offspring then get married and they have a 
higher susceptibility or probability of having asthma. They 
find these entire communities have problems like that. Just 
because of the ailment they move to the desert and then they 
have these attributed genetic weaknesses.

                                DIABETES

    The only other area that I would like to bring up is that 
when the gentleman talked about diabetes, I know you have 
towork within priorities, but diabetes takes a large portion, of 
Medicare, I think something like 18 percent. If you had additional 
dollars, would those dollars enhance diabetes research?
    Dr. Koplan. If we had additional funding, we could bring 
comprehensive diabetes programs to every state in the country. 
The comprehensive programs we have, such as examples we have 
from the State of Michigan, show that we can decrease cost and 
decrease the sequelae of diabetes, including amputation and 
loss of eyesight. The major cause of loss of limbs in this 
country is diabetes. A major cause of blindness in this country 
is diabetes. It has a huge effect on our health care costs in 
this country and the public health approach is a very effective 
one, a very cost effective one to improving the situation.

                            MEDICAL RESEARCH

    Mr. Cunningham. It would bring to those people better 
quality of life. Ms. DeLauro and I are both cancer survivors. I 
know you become an expert when that happens, and the different 
kinds of treatment, whether it is radiation or not. I just lost 
a good friend to cancer. But some are criticizing the 
Republicans for wanting to enhance the NIH budget for medical 
research. I just see out there the tip of the iceberg, we are 
right at the edge of medical research that can improve the 
quality of life and the life of people and in the end, in the 
long run save dollars for other programs.
    Would you encourage the increase of different budgets if 
you had the opportunity for medical research?
    Dr. Koplan. They are probably unlikely to give me the 
opportunity, but I would----
    Mr. Cunningham. We are going to do that.
    Dr. Koplan. Certainly I strongly support an increase in the 
research funding. I guess I see us and NIH in a hand-in-hand 
relationship. Without us to implement the new research that is 
found, then that research becomes a bit stale and just goes on 
the shelf and becomes a bit ivory towerish, but we need new 
information to apply and make advances in the field so we go 
hand in hand in what we need to do.
    I think we have lots of things we have learned that we 
haven't yet taken advantage of and put in place in the field 
and state health departments and local health departments, and 
one of the things I would like to do is close that gap between 
knowledge, the large amounts of knowledge we have invested and 
gained and what we can apply to a public health and prevention 
mode.
    Mr. Cunningham. Doctor, when I was a kid I bought--is my 
time up?
    Mr. Porter. We will have a second round.
    Mr. Cunningham. Okay, thank you.
    Mr. Porter. Thank you, Mr. Cunningham.
    Mr. Istook.
    Mr. Istook. Thank you, Mr. Chairman. Dr. Koplan, it is good 
to see you again and I am looking forward to coming to visit 
CDC in the near future. We don't have a date set but we will do 
that. Mr. Bonilla said we may do that at the same time, so that 
would be nice.
    I appreciate your comments, for example, on diabetes. As 
you mentioned, quite correctly, the high number of amputations 
that relate to that as well as of course there is traumatic 
amputation. We have worked with you and the amputee coalition 
on making some progress in that area and I wanted to express my 
appreciation for that. I also want to express my appreciation 
for some of the things you are doing through the environmental 
health science lab. Those are, I think, important directions.

                          ABSTINENCE EDUCATION

    I did want to focus my comments this morning, however, in a 
different area. I know there were releases from the Centers for 
Disease Control and Prevention in connection with some of the 
other related agencies, last year noting at long last some 
declines in the rate of out of wedlock teen births and 
pregnancies in this. And I don't want to get into a 
philosophical debate this morning. Of course different programs 
that promote prevention of pregnancy we have had for quite a 
long time. But in recent years, there has been an emphasis on 
programs that actually focus on abstinence and there is often 
difficulty to have a group that has been promoting so-called 
safe sex practices to also be promoting abstinence because of 
the mixed message that is inherent in there. There has been a 
number of people that have worked to increase grants available 
for abstinence training. There has been a lot of activity in 
the private sector on that, not as much from the government. 
But nevertheless, that activity appears to be bearing fruit and 
many of us are interested in putting more of our resources into 
that effort.
    I noticed Secretary Shalala in her comments with some of 
these statistics released emphasized that we have to stress 
with teens the will to postpone sexual intimacy. I have noted 
in some of the reading I have done that in some of the areas 
with the groups that are in charge of certain of these grants, 
there is a conflict right now that makes it difficult to have 
the focus on abstinence if that grant is being conducted by an 
organization that is also providing contraceptive services or 
even abortion services, and I had the desire to make sure the 
messages don't get mixed.
    Now this is what I wanted to ask about with you. As I 
understand it, CDC does have the authority for grants in this 
area to nongovernmental organizations, at this point has not 
chosen to pursue it but it may be under consideration. Can you 
expand on that point, please?
    Dr. Koplan. I believe we do fund nongovernmental 
organizations currently. In regard to abstinence, it certainly 
is something that we emphasize as a very, very effective means 
of birth control and STD reduction, and it is striking that 
sexual activity among teens has declined for the first time in 
many years and we picked that out from our youth risk 
behavioral surveillance, again one of these informational 
systems that I think is so important. That is good news.
    There is also data that show that condom use has increased 
among teens who are sexually active from the same information. 
The relative contribution of each is hard for us to sort out at 
this time. One of the things we do is we rely on local and 
state grantees, health departments frequently, to make a choice 
of how they are going to present things and we emphasize 
abstinence as one of the alternatives that they should be 
emphasizing. In the language of the laws in states or in the 
health departments, abstinence is a featured item in their 
programs.
    Mr. Istook. But these are programs, if I am understanding 
you correctly, that the grants are aimed at decreasing teenage 
birth rates or sexual activity or sexually transmitted disease 
rates and they are using the choice of methodology through the 
grants to the local entity as opposed to being grants that 
single out promotion of abstinence as the focus of that 
particular grant; is that correct?
    Dr. Koplan. We left that up to the state and local health 
departments, correct.
    Mr. Istook. What I certainly would encourage and would like 
to work with you on is having some of it emphasized to avoid 
the mixed message problem, that are solely devoted toward 
abstinence, just as we know that many of the grants when they 
reach the grantees frankly are used for the so-called safe sex 
messages and not really put into the abstinence.
    There was a hearing last fall, for example, conducted by 
the Commerce Committee, on the OI Subcommittee, that found a 
number of grantees were just not utilizing the abstinence 
portion of the message and therefore the grant money wasn't 
really getting through for that purpose. But we would like to 
work with you on that to make sure that one, the message gets 
through and, two, it is not confused by the fact that it has to 
be accompanied by the second portion, the prevention message so 
that it doesn't lose its power.
    In relation to that, is there any recognized sex education 
certification program involved in the CDC? Someone was telling 
me the only program that is currently recognized is one that is 
sponsored by Planned Parenthood, but none others are 
recognized? Is that accurate or do you know?
    Dr. Koplan. I believe you are correct, but I would have to 
get further information to confirm that for you.

                          OBESITY AND SMOKING

    Mr. Istook. We will follow up with you on questions for the 
record. Again, I appreciate your effort on the number of 
different points. I am glad I started an exercise program 
recently before I saw your figures on obesity. I do have one 
question on that.
    Have you noticed, is there any correlation between the rise 
in obesity and the decline in smoking? We don't want to 
encourage people to smoke in order to hold their weight down 
but certainly that is a common side effect when someone ceases 
that. Have you noted any correlation?
    Dr. Koplan. Not that would explain this level at all. There 
are studies that suggest a small increase in weight in people 
just when they quit smoking, but most of the weight gains you 
see here are in nonsmokers and the most distressing part are 
children and adolescents. Most of them are nonsmokers and we 
hope to keep them that way.
    Mr. Istook. Thank you, Dr. Koplan. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Istook. Mr. Dickey.
    Mr. Dickey. Congratulations, Dr. Koplan, on your decision. 
I would like to make sure I have the correct pronunciation of 
your name. Is it Koplan?
    Dr. Koplan. Koplan, please.
    Mr. Dickey. I heard about the recent report from the 
Institute of Medicine that recommends CDC implement injury 
programs in each state's health department. I know we had a 
very good experience with the fire prevention program in 
Arkansas and this is something we would like to see happen. Is 
this something CDC would like to do?
    Dr. Koplan. Yes, sir.

                        ANTIMICROBIAL RESISTANCE

    Mr. Dickey. Next question. I have a friend and a colleague 
in Congress who has a daughter who has acquired an infection 
with resistance to several different kinds of antibiotics. She 
was only 2 years old and it seemed like this kind of resistant 
infection could be risky in a little kid. Are there things that 
CDC is doing to address the problem of bacteria that are 
resistant to a lot of different antibiotics? Is there more the 
CDC would like to do? And you cannot answer this just yes or 
no.
    Dr. Koplan. I wouldn't want to, sir. This is a human 
problem, one that we are putting a large amount of resources 
and energy into and an increasing problem around the country 
that affects all of us and our families. Our approach has been 
on several fronts: One to decrease the unjudicious, unnecessary 
use of antibiotics, which unfortunately is widespread, and for 
that we are working with both consumers, patients, the 
citizenry in partnership with the American Academy of 
Pediatrics and the family practitioners groups. On the other 
side, we are trying to work with doctors, thepediatricians, 
family practitioners, internists so they don't use antibiotics when 
they don't need them or don't use the high powered ones when they can 
use a more modest one. That is one end of it.
    On the other side, we are working with manufacturers and 
private industry to encourage the development of newer 
antibiotics and we have gone through a period where antibiotics 
have not been generated as frequently, new ones, as much as we 
need them. In addition, we are doing careful surveillance of 
epidemiologic investigations to find out where there is 
antibiotic resistance and what patterns exist so we can 
identify them and help people choose the right antibiotics 
early for treatment.
    One key issue in this, and it is a striking one, is that 
these patterns are very narrowly defined. They are very 
circumscribed in an area. We have an active program that is 
going on in Chicago at Northwestern. We have active programs in 
Tennessee and Wisconsin, and what you find is a hospital a mile 
across town from another hospital will have a very different 
pattern of resistance than the other hospital. So that we 
really need lots of information on this to best guide treatment 
and also to control the problem.
    Mr. Dickey. This is a worldwide problem, isn't it?
    Dr. Koplan. Certainly is.
    Mr. Dickey. Do you have anything else that is more serious 
to worldwide health than this issue?
    Dr. Koplan. Unfortunately, there is a whole panoply of 
problems in Pandora's box, both worldwide and here, but this is 
a serious problem all over the world and it is one, as you have 
indicated, that crosses borders, that we go elsewhere and other 
people come here and bacteria don't know, they don't carry 
passports with them. So that if you develop a resistant 
bacteria in another country and come here with it, it enters 
our spectrum of bacteria, too. So the injudicious use of 
antibiotics in other countries then has an effect on what 
happens here as well. We work very closely with the World 
Health Organization (WHO) on this. Dr. David Hammond, who is a 
former CDC alumnus, is in charge of this and WHO and we are in 
regular coordination of doing programs together.
    Mr. Dickey. How much money is requested on this particular 
issue? Hi, Bill.
    Dr. Koplan. A little over----
    Mr. Dickey. I should ask Bill.
    Dr. Koplan. A little over $11 million for this.
    Mr. Dickey. Is that more than last year?
    Dr. Koplan. This is '99 funding.
    Mr. Dickey. Are you asking for more or less or the same?
    Dr. Koplan. In the total package for emerging infectious 
diseases, which includes hepatitis C, influenza, a wide variety 
of things, that total amount is $25 million.

                          OBESITY AND DIABETES

    Mr. Dickey. In your remarks you discussed obesity and 
mentioned the association between obesity and diabetes. Can you 
elaborate on the relationship between obesity and type 2 
diabetes mellitus.
    Dr. Koplan. Diabetes is fine.
    Mr. Dickey. It is not fine because I have to read this 
thing.
    Dr. Koplan. Diabetes mellitus, at the risk of a digression, 
it refers to--the mellitus is the sweet taste from--the extra 
sugar in the urine causes it to taste sweet. Should you be 
tasting urine, that is where the mellitus comes from. Diabetes 
is closely related, type 2 diabetes, to weight and it is 
almost, if not quite, a linear relationship with increasing 10 
pounds, 20 pounds, 40 pounds; that risk of your having 
diabetes, type 2 diabetes, as an adult markedly goes up.
    One of the most frightening things of all is we have begun 
to see type 2 diabetes, which is always a disease of aging, 
always a disease of adults, we have begun to see it in children 
and adolescents who are obese and overweight, and that is an 
extraordinary phenomenon and that risk to those children, heart 
disease, amputations, kidney failure, blindness is 
extraordinary. Again, it reemphasizes why obesity isn't an 
aesthetic issue, isn't a frivolous problem. It is a crucial 
issue.
    Mr. Dickey. We are informing people about obesity and it 
doesn't seem to have an effect. What do you consider the 
problem there and would money make any difference?
    Dr. Koplan. I would love to say yes. I don't know the 
answer yet. What would make a difference is gaining more 
information and I guess an investment in our prevention 
research would be helpful and that is to find out what are the 
behavioral issues, what are the societal issues that are 
causing this to go on. Is it just TV? Is it the increase in 
foodstuffs. Is it a decrease in physical activity? One of the 
things our research has shown is that in the year 1900 people 
ate more, had more caloric intake in 1900 than we do now but we 
have gained much more weight than they did then. It is a simple 
factor of exercise. We don't exercise at work. We sit all day. 
I sit all day. We don't get exercise in transportation because 
we drive our car to the place we go and we don't get it in 
house work. The only thing that is left for us these days is 
physical exercise that we force ourselves to do.
    Mr. Dickey. Isn't obesity requiring an expense in health 
care that is going up every year?
    Dr. Koplan. There is some very good and thorough economic 
studies in the last 5 years that demonstrate thecost of obesity 
and it is in the many billions of dollars to our health care system.
    Mr. Dickey. It seems to me what we have done is assume that 
if we get the information out there and we are able to project 
the truth of obesity, that things would change. It bothers me 
that we are not doing that and I don't know if the government 
has a place in that. I just wonder if we can--I mean, how can 
we get the----
    Dr. Koplan. Mr. Dickey, I guess I see this as a parallel in 
many ways with tobacco. There are obviously some crucial 
issues. But the parallel is if 30 years ago, if we were to talk 
about this related to tobacco, one, the public wouldn't 
recognize there is a health problem related to smoking. Two, we 
would have said there is really no role for public health and 
prevention for this. There is not much we can do about it. Once 
people do it, they do it. I guess I see a parallel in this. We 
don't have all those answers now. We recognize there is a 
health relationship although all of our public doesn't 
recognize it, but we have not yet come up with the 
interventions in public health solutions we need to effect the 
change. But I bet we will.

                          OBESITY AND SMOKING

    Mr. Dickey. I want to ask one more question.
    Is there a relationship between cigarette--thank you for 
tolerating me. Is there a relationship between cigarettes and 
obesity in the addiction area?
    Dr. Koplan. Could you explain that a little bit more to me. 
I am not quite sure of your question.
    Mr. Dickey. In cigarettes we have addiction and regarding 
eating and obesity we have an addiction. Have we drawn a 
corollary between those two activities?
    Dr. Koplan. I guess I wouldn't draw it quite the same way. 
In cigarette smoking, we have a chemical agent which is 
addictive. Plain and simple. In overweight, there is probably a 
much broader pattern of behavioral and societal issues that 
cause us to eat more than we want. Myself included.
    Mr. Dickey. Thank you, Mr. Chairman.
    Mr. Porter. Are you going to thank the subcommittee for 
tolerating you too.
    Mr. Dickey. No, I am not.
    Mr. Porter. Yesterday when we began our hearings, I 
announced that we would follow the same rule we followed last 
year in the order in being called on and part of that is we 
have a number of Members who are either Chairman or ranking on 
other subcommittees and if they request specifically to be 
moved ahead in the line because of their other 
responsibilities, we will honor that. Ms. Pelosi has so 
requested and I call on her.
    Ms. Pelosi. I thank you very much, Mr. Chairman. I thank 
also my colleague Congresswoman DeLauro for her courtesy in 
allowing me to go in her place at this time because we are in 
the process of having our Foreign Ops hearing. It is the first 
one of the year and we miss you there, Mr. Chairman, but know 
that you have responsibilities here. But when you come over 
there, we will put you ahead of the line as well.

                    ENVIRONMENTAL HEALTH LABORATORY

    Dr. Koplan, thank you very much for your leadership. 
Congratulations on your appointment. As you know, one of the 
issues that I am interested in at the CDC, I am interested in 
all your programs, but in particular today, the environmental 
health lab, which develops state of the art laboratory science 
that measures actual levels of toxic substances in people. 
Recent research found an association between exposure to 
pesticides and the risk of breast cancer. This research was 
made possible in part by the work of the lab, and I am pleased 
that with the support of our chairman, Mr. Porter, and Mr. 
Obey, working with the Senate, we were able to substantially 
increase funding in environmental health labs at CDC in fiscal 
year 1999 to $21 million from $7 million. I was disappointed 
that the President's budget had a decrease of $600 thousand, 
but hopefully we can find a way to make up for that and even 
meet additional needs at the lab.
    Can you tell us about the rapid toxic screen being 
developed at the lab and what could be done with additional 
funds?
    Dr. Koplan. Thank you, Ms. Pelosi. The rapid toxic screen 
is, I think, an extraordinarily exciting thing for all of us. 
It involves absolute state of the art science that will permit 
us to detect minuscule amounts of chemicals in a quantitative 
manner. Let me tell you how minuscule it is, parts per trillion 
of a variety of chemicals that we currently can detect. And so 
that what this new program is going to do is permit us to add 
those numbers of new chemicals that we previously had no way to 
detect in the human body. They will be added on line as we add 
more and more of these each year and we ultimately will have a 
large number of toxic chemicals that we can identify in the 
human body.
    Ms. Pelosi. What will be the lab's role in responding to 
the threat of chemical terrorism?
    Dr. Koplan. It will play a very active part. The same 
capability will permit us to rapidly determine what agents are 
being used and hopefully an event won't occur, but in the event 
of an outbreak.

                             HIV PREVENTION

    Ms. Pelosi. As you well know, HIV prevention is a major 
concern to my office and one that is shared by my colleagues 
here. It is estimated that the HIV infection rate is holding 
steady at 40,000 new infections each year in this country. That 
means one newinfection every 13 minutes. Every day, more and 
more new infections are affecting young women, women of color, people 
who are hard to reach with traditional prevention messages. The 
epidemic is increasingly complex, and seems to me that HIV prevention 
funding should be increased substantially rather than given relatively 
flat funding as it is in the President's budget. I am pleased that the 
$10 million is requested for the Know Your HIV Status campaign. Can you 
tell us more about the campaign and what could be done with additional 
prevention funding?
    Dr. Koplan. The campaign is geared towards increasing the 
number of people who know what their HIV infection status is 
and in particular those who are at high risk for infection 
within communities of color. As a basis for that, those folks 
who are positive would get appropriate referrals, counseling 
and care.

                        BUILDINGS AND FACILITIES

    Ms. Pelosi. I have a couple of questions about syphilis 
elimination and the relationship between periodontal disease 
and low birth rate. I don't know if I have enough time to ask 
them but I will submit them for the record and just ask you, I 
understand that the majority of your buildings are over three 
decades old. What are you doing to remedy your infrastructure 
needs and what are the risks of not attending to infrastructure 
needs at CDC?
    Dr. Koplan. The majority of our buildings are quite old, 
particularly when you consider that they are used for 
scientific purposes. We use a lot of duct tape in----
    Ms. Pelosi. I have seen it. I have been there.
    Dr. Koplan. And plastic sheeting and we are pleased that 
there is an increase in this year's budget that permits us to 
finish one infectious disease laboratory building.

                                SYPHILIS

    Ms. Pelosi. Can you give us some idea of the potential cost 
of not taking advantage of the opportunity to eliminate 
syphilis?
    Dr. Koplan. I think eliminating syphilis is a terrific 
opportunity we have now for a variety of reasons. The number of 
cases is at the lowest level in U.S. history. The number of 
counties is quite discrete of about 81 [Clerk's note--Later 
corrected to 31] counties. So it gives us a chance to target 
our efforts. I think a striking aspect of this, it is not just 
syphilis we are dealing with. These are also counties in great 
need of other health services and have other health problems, 
so what we are trying to do is both target them to eliminate 
syphilis, at the same time to strengthen them in their other 
services. So whether it is diabetes or heart disease or the 
other problems they deal with, they are better able to cope 
with them, and those are usually at much higher rates in those 
counties as well.
    Ms. Pelosi. You are saying $25 million additional per year 
over the next 5 years would accomplish this?
    Dr. Koplan. That is not in the budget but those sums would 
help us accomplish that.
    Ms. Pelosi. So you would like it----
    Dr. Koplan. I would say in my professional judgment that 
would be useful in affecting that end.
    Ms. Pelosi. Is my time up?
    Mr. Porter. Two minutes.
    Ms. Pelosi. Wonderful.
    Mr. Porter. We are on the eight-minute rule.

                              ORAL HEALTH

    Ms. Pelosi. Good. Last year there were reports of a 
connection between periodontal disease in mothers and the 
incidence of low birth rate babies. To me it just seemed like 
people who weren't taking care of their teeth were probably not 
taking care of a lot of other things. Could you provide me with 
any information on this connection more than just lack of care 
all around, and what program CDC is undertaking to promote 
these--to monitor these cases.
    Dr. Koplan. I suspect that your conclusion is the 
appropriate epidemiologic conclusion. They are both likely to 
occur in the same people rather than one being causal to the 
other. We don't have enough information to draw a causal 
relationship between the two. We have a very active program in 
oral health and dental care at CDC and its public health 
aspects, emphasizing good dentition in its relationship to a 
variety of health outcomes. On the other side we have a 
veryactive program in promoting prenatal care and healthy motherhood 
and early childhood development. These are natural items for us. We 
just haven't put them together before.
    Ms. Pelosi. So you don't have any information on the 
connection.
    Dr. Koplan. I don't.
    [Clerk's note. The following information was submitted for 
the record:]

       Periodontal Disease and Pre-Term Low Birth Weight Infants

    Several research groups have now linked periodontal disease 
as an independent risk factor for pre-term low birth weight 
infants (PLBW). One small study found a seven-times higher risk 
for delivering prematurely in mothers that had advanced 
periodontal disease. While clear, causal relationships have yet 
to be established, plausible biological mechanisms have been 
proposed to explain this relationship. We know that infections 
of the genitourinary tract can stimulate production of 
inflammation-mediating substances like prostaglandin E-2 (PGE2) 
that can induce premature labor. This demonstrates that 
infections remote from the developing fetus have the ability to 
influence the gestation time. Also, empirical observations and 
anecodotal reports have associated oral health with pregnancy 
for generations, mostly related to a decline in the oral health 
of the mother during pregnancy. Expectant mothers with severe 
periodontal disease have high-levels of gram-negative bacteria 
which can stimulate production of PGE2 and other inflammatory 
substances and lead to premature labor and low birth-weight. 
The NIH is currently funding research to further examine and 
characterize this relationship. Researchers are hampered, 
however, by the lack of an adequate system to identify and 
characterize individuals with oral diseases like periodontitis. 
CDC has a very active program in promoting oral health. We are 
currently working towards the development of a national oral 
health surveillance system using state and local data which 
will help to better characterize the prevalence and severity of 
periodontal disease, and other oral conditions like tooth decay 
and oral cancer.
    CDC also has an active program in promoting prenatal care 
and healthy motherhood and early childhood development. As this 
link becomes better characterized and if the surveillance 
program can be sufficiently developed to identify those mothers 
most at risk we can work towards incorporating oral disease 
prevention strategies into our prenatal and early childhood 
programs.

                     PREVENTIVE HEALTH BLOCK GRANTS

    Ms. Pelosi. Thank you very much. The preventive health 
block grant provides states with funds for preventive health 
services that help reduce injury and death and improve quality 
of life. Again, I was disappointed to see the budget cut of $30 
million. Could you tell us what kinds of programs could be 
maintained and improved were the funds to remain stable for the 
preventive block grant?
    Dr. Koplan. The preventive block grants are used for a wide 
variety of activities within states. It is up to the state's 
discretion and they include rape counseling, we mentioned 
before, but they also include environmental use and a variety 
of chronic diseases. Many states get most of their chronic 
disease activity funds, including cardiovascular disease 
control, which we think is a huge opportunity, through the 
block grants. So the block grants are used in a variety of 
different ways.
    Ms. Pelosi. I appreciate that. Thank you very much for your 
leadership and the work of CDC. I think it is about as 
important as any dollar that we spend. I hope you get what you 
want out of the appropriations process. Thank you, Mr. 
Chairman.
    Mr. Porter. Thank you, Ms. Pelosi. Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman. Welcome, 
Dr. Koplan. I want to just follow up on what my colleague Ms. 
Pelosi concluded on and considering that we only devote 1 
percent of our Nation's health care budget to prevention, what 
an unbelievable job that you all are doing. We are very, very 
grateful for the work of CDC and sometimes, and I said this 
last year, that if we were wise and smart and given what you 
can do, what kind of effect you can make, that we would have 
more eggs in the Secretary's basket. So we are trying to 
advocate on your behalf.

                             OVARIAN CANCER

    Let me move to two or three questions here if I can. One, 
you know the statistics as well as I. Ovarian cancer affects 
one in seven women in this country. I am a survivor of ovarian 
cancer and always remind myself every day as being very 
fortunate in that regard. What concerns me is that this very 
low level of understanding and attention that is afforded to 
the disease by medical research, provider of public health 
communities, the lack of education and understanding on ovarian 
cancer. We know if it is diagnosed early, if it is treated, we 
have a 90 percent survival rate and if not, we die. That is as 
simple and startling as I canput it.
    My question to you is, if you had the resources and I 
don't--this is prejudicial in some sense but would you, could 
you support within CDC a public health program that is focused 
on ovarian cancer, education on ovarian cancer and to have 
people in the medical community understand what is at risk and 
what is at stake here, what you might be able to do with 
something like this?
    Dr. Koplan. Certainly it is well worth exploring what would 
be a role of public education in this, what types of screening 
could be put in place. Unlike breast cancer, uterine cancer, 
cervical cancer, screening is much more difficult, as you well 
know, for ovarian cancer. We don't have ready tests available, 
so we really look to our research colleagues to come up with 
something that we can put in place in a public health mode for 
this. That is the real challenge of ovarian cancer for us in a 
public health prevention setting is those tools aren't quite 
there yet. But certainly from a public education concept, as 
you said, I think there are some things you can do.
    Ms. DeLauro. I would very much like to pursue that with 
you. I believe we will send a letter but if you will follow 
that up and we will sit down with you and talk about that. 
Thank you very much.

                             WOMEN'S HEALTH

    Let me move to another program which I think has had 
tremendous success, which is the wisewoman program. You let us 
know about its successes. My understanding is that more than 
5,000 low income, uninsured women have been screened for heart 
disease, diabetes, and other illness through the program. Let 
me also say that when the program was first authorized, we 
capped it, Congress capped it at three sites to be sure that we 
wouldn't draw funding from breast and cervical program funding 
but that funding has dramatically increased. We are now at 60 
percent above the funding level trigger in terms of having more 
sites, and it obviously hasn't eclipsed the breast and cervical 
cancer program.
    What I want to talk to you about or have you talk to us 
about, we ought to expand this program in my view, given its 
success. I would like to know how much per state it costs us 
here. Can you provide us some technical assistance in dealing 
with the limitation and the original statute, if this committee 
can be of any help in that direction, of moving forward and 
trying to expand the number of states that have this kind of a 
program?
    Dr. Koplan. Thank you. This is a very interesting program. 
I think it is an exciting one and it is an example in some ways 
of what Mr. Bonilla mentioned earlier, is how to get 
efficiencies in government. We have a screening program for 
breast and cervical cancer which is terrifically successful and 
of great value. What we try to do is add in a very cost 
effective way some other interventions to it. At the same time 
a woman is coming in, having other things done, there is 
frequently downtime unfortunately during a visit like that. Why 
not use it for some other effective health interventions, and 
one can give information about cholesterol, blood pressure, 
take measurements and get some feedback. The program is in 
place, as you know, in Massachusetts, North Carolina, and 
Arizona. It has been very effective. We have evidence that 
cholesterol levels have gone down. People have changed their 
habits based on this information. We have, thanks to you all, 
received an increase last year of approximately $2 million in 
funding for this but are limited to those three states. So we 
can put more into those states but we could easily go to other 
states to do it. An expansion of states would be helpful.
    Ms. DeLauro. What does it cost to expand to a state?
    Dr. Koplan. It is roughly--to add these programs into an 
active flourishing breast and cervical cancer screening program 
I would say somewhere between 750,000 and a million per state.
    Ms. DeLauro. I would like to very much work with you if you 
could provide us with technical assistance on this language.

                                LISTERIA

    Just finally, this only came to my attention yesterday and 
I asked Secretary Glickman yesterday in the agriculture 
appropriations committee about this listeria outbreak. I ask 
because--today's paper has another headline article outbreak. 
The long and the short of it, as I understand this, it was last 
August when this outbreak occurred. There had been 16 deaths. 
During this period of time the plant stayed open. I want to get 
a sense of where CDC was in this process, what the 
recommendations were. I have asked the Department of 
Agriculture and the Secretary to give me answers as to what 
their role was in this effort and how in fact a plant stayed 
open when we were at risk. And subsequent to this, I understand 
that we had one go-around and then we found again that some of 
the products that they were sending out were contaminated. So 
we had two episodes in this period of time and then during that 
time the plant was open. They will answer me about the plant. 
CDC and your role in this, what kind of recommendations and 
enforcement can we work out at this end to prevent 16 people 
from dying?
    Dr. Koplan. Sixteen people dying is a tragedy and our goal 
is none. But in past years, it could have been 160. Our current 
techniques do permit us to do this much more quickly than in 
the past. This process is a common one that I have been 
involved in for a decade now. What happens is when we look 
back, we can see a point usually where maybe that restaurant 
could have been closed, that plant closed, or that food taken 
off the market, but when you are goingforward in time, you 
usually don't have enough information to take that action and be sure 
that is the case, whether it is a restaurant or food product or 
whatever. This went quickly from our perspective. One of the key things 
in doing this was this new molecular test we have that permits us to 
identify common bacteria. It is a fingerprint of the listeria--and 
there are thousands of different kinds of listeria. We have a test that 
says it is this specific one so that when you see one from someone who 
ate a food product in Wisconsin, someone who ate it in New Haven, you 
say, wow, this is the same thing. It is not just this listeria, it is 
this particular kind. That advance has permitted us to target problems 
much more quickly and in this case it directed us to a particular plant 
much more quickly than it would have occurred in the past.
    At that point FDA and USDA stepped in to do their part in 
the plant. Our role is to identify the problem and target it, 
send the folks in. Again, there is that parallel with emerging 
infections, parallel with bioterrorism and this way of doing 
business.
    Ms. DeLauro. I have other questions. I will just put them 
in. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Ms. DeLauro. Mrs. Northup.
    Mrs. Northup. Thank you. Welcome, Dr. Koplan. I am eager to 
see what the progress CDC will make. I have a lot of respect 
for what CDC has done in the past.

                            TOBACCO CONTROL

    Specifically I would just like to make sure for the record 
that we are clear about Mr. Bonilla's questions regarding 
IMPACT and ASSIST. It is my understanding that ASSIST grants 
for years were much higher than IMPACT grants, the National 
Cancer Institute initiated those grants. They were to help 
anti-smoking efforts, among youth through community-based 
efforts and education-based efforts. After the ASSIST grant 
started in 17 states, the other 33 states wanted a similar 
effort. While it wasn't equal to the ASSIST program, but the 
IMPACT grants were started Last year we transferred ASSIST 
grants to CDC and it is my understanding that all we are doing 
now is increasing the IMPACT grants up to the same level as 
ASSIST. No state has both programs; isn't that right?
    Dr. Koplan. You have described it perfectly.
    Mrs. Northup. And in fact the 33 states that had the IMPACT 
grants really had minimal amounts of funding for their anti-
smoking efforts that were grassroots previously. So it is not 
as though we are combining and missing an efficiency here but 
we are equalizing the grants. Haven't we also extended these to 
our territories? Puerto Rico and the other territories?
    Dr. Koplan. We have in the District of Columbia. I am not 
sure about Puerto Rico and the territories.
    Mrs. Northup. I think actually we have.
    Dr. Koplan. I always learn something here.
    Mrs. Northup. In looking at your budget here----
    Mr. Dickey. Dr. Northup.
    Mrs. Northup. I have appreciated your work. I just want to 
bring to the committee's attention that almost any time we have 
the debate on how to deal with tobacco, the tobacco companies, 
the tobacco industries themselves say we should approach this 
through education, through a community basis as opposed to 
taxes. So I would think this sort of activity on your part 
would be the one area that would unify us all, since it 
reflects what the tobacco companies and the health community 
believe is good for decreasing tobacco use among our youth. I 
just thought I would clarify that.

                        PEER REVIEW OF RESEARCH

    I have a couple of questions about research in particular. 
I think I raised some of these questions last year but I will 
raise them again to you. I have been so impressed with the 
research standards that NIH uses. The peer review on all 
research that is done before the grants are awarded, after the 
grants are awarded, the results that are obtained. Quite 
honestly, I have had some experience in research that wasn't 
peer reviewed, it is not that the peer review catches mistakes 
as much as to ensure that the right results and the right 
conclusions are arrived at as it is done. If any entity would 
always use the same group and they know what they want the 
answers to be, they might tend to emphasize those answers 
unless they know that their fellow scientists are reviewed. And 
I just wondered how you would compare your quality standards 
and peer review, both in the awarding process and in the 
analysis after the fact would compare to NIH.
    Dr. Koplan. I think our quality standards are superb. We 
have two types of research, both done within our institution by 
researchers that is crucial to our public health 
responsibilities, and then we have a smaller amount of 
extramural research. We have some leaders in that. The National 
Institute for Occupational Safety and Health has decades of 
experience in funding outside investigators. It is one of its 
major missions and it does it through, just as you have 
described, high standard peer review, selection of those 
researchers, and monitoring of the research as it goes along. 
In some of our other programs we are only beginning to get some 
funding for external research. The committee was very generous 
last year in giving us some funds for prevention research and 
we are trying to implement in that program the exact same 
standards that you have indicated for peer review selection of 
programs.
    It is a little different in public health than in 
biomedical research because some of the groups that do the 
research aren't pure long-standing academic researchers. In 
some cases our research is done with state health departments 
with local health departments so it is not going to be one for 
one fit of what we do and, say, what the National Institutes of 
Health does, but nevertheless our intent and our current 
performance is at a very high level of both quality and 
integrity in what we do.
    Mrs. Northup. I certainly understand that you all have a 
role in surveying and monitoring and that that wouldn't be the 
same as research, scientific research, but the research on 
disease and so forth. I think that that is extremely important. 
If we operate based on scientific conclusions that are 
inadequate, or inaccurate I should say, obviously we could go 
in the wrong direction. So I would encourage you to make sure 
that those--that we work on that, to that goal all the time.

                          VIOLENCE IN SCHOOLS

    I wanted to ask you about your efforts in safety in our 
schools. I know that there is the violence against women 
program, and I wondered if any of those efforts would be 
directed towards young women in schools. In Kentucky we had a 
shooting that occurred. In Arkansas another shooting occurred. 
But I think there are also less dramatic and less reported 
incidents of young women who deal with violence who may be less 
prepared and less able to exercise self-protection, effect 
self-protection measures and I just wondered what your efforts 
were in those areas.
    Dr. Koplan. Thank you for your question. It is an 
interesting and important area. We have got a lot of activities 
going on in that. We have got collaborative efforts with the 
Department of Education and the Office of Juvenile Justice and 
Delinquency looking at interventions and monitoring the 
problem, documenting how much the problem is there. A key thing 
we are trying to do, I think, is support researchers in 
determining what are effective interventions to lower the 
response to conflict as being a violent one. And we have had 
some very successful approaches to that, working with 
schoolchildren of different ages to show them alternative 
approaches to conflict resolution in school which affects young 
women, young men in different ways so that there is a lot of 
active work going on there.
    Mrs. Northup. That was my time I suppose.
    Mr. Porter. I am afraid it was. Thank you, Mrs. Northup. 
Mrs. Lowey.
    Mrs. Lowey. Thank you, Mr. Chairman. I want to apologize, 
Dr. Koplan for being late. Many of us divide our time between 
two committees, but I thank you for the very important work you 
are doing I missed the conversation about obesity but there has 
been bipartisan discussions on this committee on teen obesity, 
and its link to teen pregnancy and domestic violence and if we 
understand it better, then we could make a huge dent in health 
problems in this area.
    I hope somehow that we could constructively work together 
and have some progress in that area and I thank you for all the 
work you are doing.

                           COLORECTAL CANCER

    Dr. Koplan, as you know, an estimated 55,000 Americans die 
from colorectal cancer each year. The good news is when 
detected early, this cancer can be treated successfully. And I 
have been very impressed with the CDC's national colorectal 
screening public awareness program. Can you give us your 
assessment on how the campaign is progressing and what plans 
CDC has to expand its efforts to combat the Nation's number two 
cancer killer. It is extraordinary to me that we have the tools 
and we have made progress but not sufficient progress.
    Dr. Koplan. One aspect of this is we work very closely with 
the American Cancer Society, who are neighbors of ours in 
Atlanta and who we can gain extra effect from doing things 
together on issues such as this, as you indicated, colorectal 
cancer a huge issue, a major cause of death and major cause of 
cancer. What we are trying to do is support comprehensive 
cancer control programs in states which will include breast and 
cervical, colorectal, other appropriate cancers where we can 
have a preventative role. Screening is shown to be really 
effective in this. We have got about 2.5 million to work on it 
so our role has largely been educational approaches, 
encouraging screenings, suggesting efficiencies for states of 
how to get these programs into place and then lots of 
partnerships with other players in this.
    Mrs. Lowey. Do you think that the work you do is really 
getting across barriers? Is it working in high-poverty areas, 
in areas where there are language barriers? Are we reaching men 
and women where there are significant barriers?
    Dr. Koplan. Absolutely. There are. I think that at the 
moment we are just touching on that and I suspect that those 
problems still exist and that this is not getting that far into 
it. There are marked discrepancies by economic status and by 
racial ethnic status in rates at which people get screened and 
there are subsequent courses as you have indicated and those do 
need to be addressed.

                          LABORATORY STANDARDS

    Mrs. Lowey. Regarding infertility treatment, I was pleased 
to see your agency's 1996 Assisted Reproductive Technologies 
Success Rate Report, which was released last week, and 
Iunderstand you recently published the proposed model standards for the 
labs and infertility clinics as well. All of us know people who have 
spent thousands of dollars and desperately want to have children and 
too often they are not successful. Can you tell the committee when you 
anticipate that those standards will be made final and when you 
anticipate being able to certify that voluntary accreditation programs 
meet those standards? Because I think that is really what's critical. 
People have to know that when they are paying that money for these 
services, that wherever they are going will give them a good chance of 
success.
    Dr. Koplan. Thank you. The final comments on the proposed 
standards just came in a couple weeks ago to us. We are putting 
them together and putting it out as a final--as a formal and 
final report which lists the standards. Hopefully it will be 
published in the Federal Register. We have no control over when 
that is, but we are basically almost there in terms of having 
the final product that goes to the Federal Register. When that 
happens, laboratories will have the standards that they have to 
meet to have a decent product and they are supposed to comply 
voluntarily with that and be able to list themselves as meeting 
those standards, and I think that is a very important factor 
for consumers to consider when they choose a place for those 
services done.
    Mrs. Lowey. Would there be any evaluation of those clinics? 
You are saying that the clinics will have to publish the 
standards.
    Dr. Koplan. The standards will be published and 
promulgated. I would think that the clinics would want to 
indicate that they meet those standards because that will give 
them credibility over competitors in performing these 
proceedings.
    Mrs. Lowey. Is there any oversight?
    Dr. Koplan. There is not oversight.
    Mrs. Lowey. We are making the first step. I would like to 
continue that discussion.
    Dr. Koplan. We currently put in over a million dollars of 
our own discretionary funding into this program to support it 
because we think it is important, but that is where the funding 
comes from for keeping this going.
    Mrs. Lowey. I just think back upon the time when a woman 
would go get a mammography and could not be assured that it was 
accurate and look what amazing progress we have made in that 
area. Dr. Kessler certainly led that charge and we have seen 
tremendous progress. So I just want to keep that in mind as we 
address this, and I hope we can continue that discussion as 
well.

                                 ASTHMA

    I know there was some discussion about asthma this morning. 
I was very pleased to see that the President's budget included 
$68 million to combat asthma. As you know, New York City has 
the highest asthma rate in the country and the problem is 
particularly bad among children. I have introduced bipartisan 
legislation to help us address this by providing for public 
education, improvements in the response of health departments 
and local schools and promotion of new federal guidelines on 
asthma prevention and treatment. Last year CDC reported that 
the number of asthmatics increased 75 percent between 1980 and 
1994. Can you account for any specific set of reasons for such 
a dramatic increase and can you tell us something about what 
CDC is doing to address this?
    Dr. Koplan. We don't have an easy answer as to why there 
has been this huge increase. It may be contributed to by social 
factors or environmental factors, but those are easy to say. We 
don't have an answer yet as to why the increases occurred. But 
that increase is profound and marked in a number of different 
places, including New York City. Amongst the approaches we are 
trying to take in this is to link with partner agencies, and 
including health care delivery systems in this, that play a 
huge role in how people get managed with asthma, but be 
concerned about the home, the environment and to try to 
eliminate some of those hazards that may be promoting asthmatic 
attacks in susceptible people.
    Mrs. Lowey. Have you seen any progress made in actually 
identifying asthmatics? I just wonder that so many of these 
cases, especially in the minority area--I see my time is up. We 
can continue the discussion.
    Mr. Porter. Go ahead and finish.
    Mrs. Lowey. I just wonder if so many of these cases remain 
unidentified far too long and there isn't enough education, 
there isn't enough direct action to address that.
    Dr. Koplan. Mrs. Lowey, I think probably most are 
identified because it is such a dramatic condition and when--it 
is not something, you know, you stay home--when someone has an 
acute asthmatic attack, they are in emergency, they are at the 
doctor and it is usually pretty well diagnosed. I think we have 
seen a very real increase and probably most are diagnosed.
    Mrs. Lowey. Thank you, Mr. Chairman. Thank you, Dr. Koplan.
    Mr. Porter. We will have a second round. We have about 15 
minutes. Do you have additional questions you would like to 
ask, Mrs. Lowey?
    Mrs. Lowey. I don't think so today, Mr. Chairman.
    Mr. Porter. Mr. Dickey, you do. We will divide this roughly 
in half then, and you and I will ask the questions.
    Mr. Dickey. Dennis wanted to say something. I feel sorry 
for him.
    Mr. Williams. I just wanted to add one footnote to Mrs. 
Lowey's discussion on asthma that I wanted to point out to her 
that in the Health Care Financing Administration budget,there 
is a new grant program requested, $50 million, to provide resources to 
states to improve the management of asthma for kids involved in the 
Medicaid program. So there is some efforts here in the budget to try to 
deal with this question.
    Mrs. Lowey. Thank you so much--I think more resources are 
needed because the increase is so extraordinary. You just 
wonder has it been undetected or are living conditions so much 
worse than they used to be and I really think it is important 
that we take some direct action. Thank you, Mr. Chairman. Thank 
you.

                              FOOD SAFETY

    Mr. Porter. Dr. Koplan, in December the FDA published a 
final rule to provide for the safe use of ionizing radiation to 
treat red meat products to control pathogens and extend shelf 
life. What are you doing to promote this as a method of 
controlling pathogens and are you finding resistance from 
consumers?
    Dr. Koplan. I am not sure we are playing a role in that. I 
will look into it and try to get back to you with more 
information on it.
    [The information follows:]

                  IONIZING RADIATION ON MEAT PRODUCTS

    The U.S. Department of Agriculture (USDA) is in the process 
of developing a regulation to permit irradiation of beef for 
pathogen control; a final rule has not been published. The Food 
and Drug Administration (FDA) does not have jurisdiction over 
meat products. Both USDA and FDA have extensive consumer 
education programs in place to inform the public about a wide 
range of food safety issues.
    CDC collaborates with USDA and FDA directly and as part of 
the public-private Partnership for Food Safety Education. 
Collaborative education efforts on food irradiation could 
potentially be done through the Partnership in the future. CDC 
is not actively involved in consumer education efforts 
pertaining to food irradiation.

         EFFECTS OF MASS MEDIA AND PUBLIC SERVICE ANNOUNCEMENTS

    Mr. Porter. I would appreciate that. When Dr. Broome 
testified last year, we discussed the lack of use of mass media 
in getting out health information to people and particularly 
young children. Looking at tobacco, we have $100 million--
excuse me--we have $27 million for increases in tobacco-related 
activities which would bring the fund for smoking and health 
funding at CDC to over $100 million. Are you building into this 
the purchase of media time as part of your tobacco efforts? 
Because it seems to me, children particularly, that you can do 
educational programs in the schools, but where you really reach 
them is through TV.
    Dr. Koplan. We consider our mass media public service 
announcements crucial parts of our total health promotion 
package, which also includes working with kids in schools and 
community work and a wide variety of different undertakings. We 
don't pay--currently we do not pay for public school 
announcement placement. We hope that the networks and media 
will place it at an opportune time for people to hear it and 
take advantage of it.
    Mr. Porter. Do they?
    Dr. Koplan. Occasionally.
    Mr. Porter. Occasionally. I am afraid if we don't require 
them to do it by law, they do it but they do it at times that 
aren't very good or in places that don't reach the audience 
that you want to reach. Shouldn't we be paying for that if 
necessary?
    Dr. Koplan. Paying--if paying for it got it at an 
appropriate time for the appropriate audience, that would be 
effective. It is very expensive to pay for air time for 
whatever the message is and that would have to be taken 
intoaccount on how we allocate different pieces of the budget.
    Mr. Porter. Dr. Koplan, I would urge you to look into this 
because it seems to me that while we may be using cost 
effective means, they are not really effective means of getting 
the message to young people. You can't reach them easily 
without using television and if you get the advertising council 
or others to help in that, fine, but there ought to be a way to 
have real impact and it seems to me that young people have to 
be your primary target audience. I don't know how else you 
actually reach them. I think it is important. I would like to 
follow this up next year and see what has been done in that 
regard.

                            TOBACCO CONTROL

    I understand California and Massachusetts have 
comprehensive tobacco prevention programs that are proven to be 
effective. What is being done to get other states to adopt 
programs like theirs and what should be done if nothing is 
being done?
    Dr. Koplan. CDC has worked hard with states to develop a 
package of assistance to them which suggests one of the 
elements they need to conduct an effective tobacco control 
program and, in many ways, that is modeled over some successful 
states that now have had several years of experience, in 
particular California and Massachusetts. A couple of other 
states, Florida is an example, is coming on line with also some 
increasing capabilities so that we have outlined that range of 
different approaches, the total sum of which becomes very 
effective in decreasing smoking rates, and we are kind of 
channeling what we have learned and the efficiencies we have 
learned from California and Massachusetts to these other states 
to help them develop that. So it is both technical assistance 
and funding.

                           POLIO ERADICATION

    Mr. Porter. There is a request in the FY 2000 budget for 
$17 million to eradicate polio globally. My understanding is 
that polio still exists in Africa and perhaps also in parts of 
Asia. And some of the places in Africa where it continues to 
exist have severe political problems, such as Congo, Liberia, 
and Angola. Can we get this job done by the end of next year 
when you have those kinds of problems or is it going to be 
something that is going to continue for a long period of time? 
I realize you can't tell me the political problems, but you can 
tell me the problems of getting to young people in those 
countries with vaccines.
    Dr. Koplan. Thank you. Yes, you have identified exactly 
where the remaining cases are, parts of Asia, Pakistan, the 
northern provinces and in the northern states in India, 
Afghanistan and in addition--and then Yemen and then parts of 
central and east Africa. Progress is being made in a number of 
those places and most of them do not have civil strife going on 
at the moment. However, as you said, Sudan, Somalia, Ethiopia 
have ongoing disorder. We have not changed the goal from the 
year 2000 for eradication and this has been discussed as 
recently as two weeks ago at WHO and the executive council 
there. It is still doable. Our past experience in smallpox was 
that we were able to continue an eradication effort despite 
civil war and stress going on, ironically in several of these 
same countries, Ethiopia, Sudan and Somalia. In some instances 
we were able to get a truce to actually deliver some of these 
programs during the course of it and places like the Carter 
Center in Atlanta have been very effective in trying to act as 
an intermediary in that. We are not at that point yet, but it 
will be a struggle and it will be just as difficult, as you 
indicated, but we are throwing increasing resources into it as 
is other parts of the world.
    About two weeks ago we sent our first cohort of 25 young 
epidemiologists off from CDC. We trained them for a week and 
then loaned them to WHO to be placed, thrown in the brink of 
addressing these problems in these countries. So our level of 
commitment is total in trying to get this done by the year 
2000.

                           PHYSICAL ACTIVITY

    Mr. Porter. Thank you. A final comment. We note that 
Georgia is the only state in the South and one of the few 
states east of the Mississippi to have a slightly lower rate of 
obesity than others. Is there any reason? Is it CDC's presence 
there that does it?
    Dr. Koplan. I have been personally very effective in 
promoting physical activity. People are afraid to sit still.
    Mr. Porter. You have done a great job. Can I make a brief 
comment. Aren't there recent studies that if you have any kind 
of movement or motion or get up and down, that is better than 
just sitting there without movement; while it isn't as good as 
exercise it helps?
    Dr. Koplan. Yes. This actually justifies all those people 
we complain about who are fidgeters before, they are actually 
doing themselves, if not us, some good when they fidget around. 
I think another aspect of it is less purposeful--not less 
purposeful but less exercise-related activity is also very 
useful. So the stair walking, the walking three blocks to the 
store rather than taking the car, the gardening, things that we 
don't perceive like we do running marathons and swimming miles 
and miles are still very effective means of both getting 
exercise and reducing weight.
    Mr. Porter. Thank you very much, Dr. Koplan. Mr. Dickey.
    Mr. Dickey. Dr. Koplan, I noticed you haven't moved much 
except for your right hand. Are you suffering today from 
obesity?
    Dr. Koplan. I am enjoying it, Mr. Dickey.

                   TOXICOLOGICAL CONTROL IN ARKANSAS

    Mr. Dickey. We have in Pine Bluff an arsenal at the 
National Center for Toxicological Control, NCTR, and we are 
very unique in that a whole lot of differentthings that we are 
doing would lend themselves to counterterrorism and biological fields. 
I have discussed this with Dr. Rosenberg. Do you know him personally?
    Dr. Koplan. I do.
    Mr. Dickey. He is a fine man.
    Dr. Koplan. If you say so.
    Mr. Dickey. He has been to Pine Bluff. That means he is 
okay. Can you think of anything in your past experiences that 
would indicate that you all might want to take a presence in 
Pine Bluff in some fashion?
    Dr. Koplan. I think it is certainly worth looking into it 
and we would be happy to visit it and see if there is a role we 
could be helpful.
    Mr. Dickey. We have chemicals stored from long ago--
actually munitions and chemicals and everything else. We have 
reacted to the dangers they may have to the community, and we 
are pretty progressive in that area. And then also we are 
consolidating labs in NCTR. This business about having 
vaccines, developing them, and then distributing them is a 
natural for us. And I think I have been discouraged a little 
bit, but I would like for you to think about that a little.
    Dr. Koplan. Thank you.

                                OBESITY

    Mr. Dickey. Have you ever gone on TV that you know of to 
warn against obesity?
    Dr. Koplan. Individual health figures and public health 
figures have done that in an organized public service campaign, 
not that I know.

                        PREVENTION EFFECTIVENESS

    Mr. Dickey. All right. One last thing and this is in view 
of the fact that I just asked you to consider a new mission in 
Pine Bluff, Arkansas, at the arsenal. I am amazed the areas 
that you all are covering or that we are covering through CDC 
and how many programs we have. Can you identify in this budget 
how many new programs there are, if any?
    Dr. Koplan. I can't give you a number now, but I would be 
glad to document what that number is.
    [The information follows:]
                       New Programs in the Budget
SAFE U.S.A.--$1.9 million
    The framework for Safe U.S.A. is built on a supporting structure of 
organizations, public and private that include the federal agencies 
working in injury control, and a number of private nonprofit groups 
such as National SAFE KIDS Campaign, National Safety Council, the Brain 
Injury Association, National Fire Protection Association, the American 
Trauma Society, American Psychological Association, and corporate 
partners, such as Browning Ferris Industries and Blue Cross/Blue Shield 
of Illinois.
    CDC would:
    assist in increasing the number of state health departments that 
have injury control programs and surveillance systems that provide data 
on nonfatal injuries;
    conduct research on injury prevention, including research 
demonstration, and evaluation projects to prevent child abuse and 
neglect;
    support the delivery of science-based programs such as smoke alarm 
distribution programs to reduce the number of fire-related injuries;
    support the implementation of youth violence prevention programs in 
schools; and
    support the expansion of the National Electronic Injury 
Surveillance System of the Consumer Product Safety Commission to 
collect information on all traumatic injuries seen in a nationally-
representative sample of emergency departments.
Tuskegee Bioethics--$2.0 million
    As part of the President's apology for the Tuskegee study on May 
16, 1997, a commitment was made to establish a Center for Bioethics in 
Research and Health Care at Tuskegee University. This initiative will 
support a public museum and the development of curriculum and related 
training/outreach materials, as well as securing a director and support 
staff to operate the Center.

    Mr. Williams. You meant the department as a whole or 
Centers for Disease Control and Prevention? Are you asking 
about the Centers for Disease Control and Prevention or the 
department as a whole?
    Mr. Dickey. Just the CDC.
    Dr. Koplan. Brand new programs that we weren't doing 
anything in it before? I can't think of any--all of them fall 
into the framework of things that we have done before.
    Mr. Dickey. Every one of these programs?
    Dr. Koplan. I believe so.
    Mr. Dickey. Every one. But I was saying something else. 
Every one of these programs that I see makes me sit here and 
think this is wonderful. What if we just concentrated onare 
good. I think I know what your answer is and I am not being critical in 
any way but are our efforts too broad? Are we trying to be--are we 
diluting our efforts? Is there any one effort that you think we could 
focus on and just eradicate?
    Dr. Koplan. I think it is a very good question and I think 
it is something we really have to ask ourselves regularly. 
There is a tendency to kind of get slushy at the margins and 
any work that someone's responsible for and I think we need to 
do the same thing. By the same token, what we deal with is 
public health is just broadened as a field over the last couple 
of decades, and there are a number of important health areas 
that we now find we have got capabilities and opportunities to 
do so. That is--having said that, it doesn't deny, I think, 
your point, and I think it is a very, very valid one, that we 
need to look very carefully at what we do and decide is this 
something that we have something unique to offer. Is it 
something that has a prevention role, where we can apply a 
prevention role, and is it something that we can have an impact 
on the community that improves people itself. If it doesn't 
meet those criteria and others like them, then we probably 
shouldn't be doing them.
    Mr. Dickey. To an observer, an outside observer, would it 
be safe to say that we should look at just the dollars that are 
spent in the various areas to see how you all rank them in 
importance?
    Dr. Koplan. I think that is obviously a fair approach but 
it is probably just a piece of the picture because there can be 
very important areas that we work in that have smaller amounts 
of funding. Cardiovascular disease is the largest cause of 
death in this country. It is a huge entity in which we have 
invested a lot in our research and we know a lot about how to 
prevent it but if you were to look at our budget on that you 
would see very little in it. It is hard to draw a link just 
easily. Many others, as you know better than I, many other 
factors go into how funding for a government agency budget gets 
put together.
    Mr. Dickey [presiding]. Well, I want to say this in 
closing. I am now the chairman. Do I look like the chairman 
right now? I am now the chairman.
    Dr. Koplan. You look like a chairman to me.
    Mr. Dickey. I am going to bring this thing to a close but I 
want to say one thing before I go. For all of you all down 
there, as you probably know, I not only admire you but I like 
you and I like what you are doing and I think the important 
thing about your work is that it is where the rubber hits the 
road. It is not academic. It is not ivory tower. It is not 
thoughts in the air. You are all really getting down to it and 
I am certainly appreciative of that. I don't want anything I 
have said or any question I have asked to indicate to you that 
I am not fully supportive of what you are doing. I can sense 
the people of America feel the same way even though you know it 
is not as political a matter as I wish it at times. I wish it 
could be. But I just want to thank you for your work and thanks 
for taking this task and congratulations again on your 
appointment.
    Dr. Koplan. Mr. Dickey, could I thank you personally. I 
know you have more than a passing interest in many of our 
activities and have shown and demonstrated it. I also would 
like to thank Congressman Porter. Please convey it back for me 
and other members of the committee here. I have had the 
opportunity to meet many of your colleagues, glad to meet you 
today and what I am struck by is how many of the people on this 
committee have real interests in the things we do and have 
substantial knowledge in it, as I have heard today, and that is 
terrific from our perspective. It permits a real partnership, I 
think, in what we are trying to accomplish.
    We thank you for your support last year before I came. I 
thank you for the terrific support I have had just the few 
months I have been here, and I really look forward to working 
with you all closely.
    Mr. Dickey. Good. The subcommittee is adjourned. Thank you.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                                     Thursday, February 11, 1999.  

       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
H. WESTLEY CLARK, M.D., J.D., M.P.H., DIRECTOR, CENTER FOR SUBSTANCE 
    ABUSE TREATMENT
DONALD GOLDSTONE, M.D., DIRECTOR, OFFICE OF APPLIED STUDIES
RICHARD KOPANDA, EXECUTIVE OFFICER, SAMHSA
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, HHS

                       Introduction of Witnesses

    Mr. Porter. The subcommittee will come to order.
    We continue our hearings on the budget of the Department of 
Health and Human Services this afternoon with the Substance 
Abuse and Mental Health Services Administration; and we are 
very pleased to welcome Nelba Chavez, Ph.D., the Administrator. 
And you have a lot of support with you. I have much less 
support on my side of the table.
    Ms. Chavez. Would you like to trade?
    Mr. Porter. Yeah, I think so. Why don't you introduce the 
people you have brought with you and then proceed with your 
statement, please.
    Ms. Chavez. Thank you very much, Mr. Chairman.
    I will begin by introducing, to my far left, Dr. Donald 
Goldstone, Director, Office of Applied Studies; Dr. Karol 
Kumpfer, Director for the Center for Substance Abuse 
Prevention; our newest staff person, who has been with us at 
SAMHSA since September, and he is very well known to the field 
of substance abuse, Dr. Westley Clark, Director for the Center 
for Substance Abuse Treatment. We have from the Department, Mr. 
Dennis Williams, Deputy Assistant Secretary, Budget, from the 
Center for Mental Health Services, the Director, Dr. Bernie 
Arons; and Mr. Rich Kopanda, Executive Officer, SAMHSA.
    Mr. Porter. Proceed.

                           Opening Statement

    Ms. Chavez. Mr. Chairman and members of the subcommittee, I 
am pleased to present the President's fiscal year 2000 budget 
request for the Substance Abuse and Mental Health Services 
Administration. The request is for $2.6 billion, a $138 million 
increase above the 1999 appropriation.
    Our budget proposal builds upon our past accomplishments 
and initiatives. It highlights three priority areas: improving 
access to quality mental health services, addressing the gaps 
in substance abuse services, and increasing knowledge in 
critical service areas. Focusing on these priorities will help 
prepare our Nation's health and human service systems to meet 
the needs of the 21st century.
    In the State of the Union Address, the President said, ``We 
must step up our efforts to treat and prevent mental illness. 
No American should ever be afraid to address this disease.''
    To help open doors to needed mental health care, the 
President is proposing an increase of $70,000,000 in the Mental 
Health Block Grant, the largest in the program's history. On 
average, States will receive a 24 percent increase in funds to 
expand their community-based programs and to build on the 
significant increase the Congress appropriated in 1999.
    The President is proposing a $30,000,000 increase for the 
Substance Abuse Block Grant in fiscal year 2000. This increase 
will help support and maintain State substance abuse prevention 
and treatment systems.
    While Block Grant investments are vital, they are only part 
of the comprehensive approach that we need. Mayors, town and 
county officials, the Congressional Black and Hispanic Caucuses 
and the Indian Tribal Governments have emphasized the need for 
Federal leadership in helping communities to address many of 
the emerging drug trends and related public health problems, 
including HIV/AIDS, at the earliest possible stages.
    As a result, we developed a new Targeted Capacity Expansion 
program. The goal of this initiative is to cultivate a system 
that is responsive to current and emerging needs. It 
accomplishes this objective by providing rapid and strategic 
responses to the demand for services that are regional or local 
in nature, but it also allows cities to come together and to 
develop innovative approaches to the problem that they see as 
the most important in their particular community.
    For example, the outbreak of methamphetamine use that has 
spread across the Southwest as well as dramatic heroin use 
reported in localized areas are but two examples of the need 
for this initiative.
    The President's proposed budget adds $55 million for 
Targeted Capacity Expansion in fiscal year 2000. It is 
anticipated that between 90 [Clerk's note.--Later corrected to 
60] and 100 [Clerk's note.--Later corrected to 90] new awards 
will be made under this initiative, paying particular attention 
to what many mayors and county officials have said to me and 
have said to many of our staff members, that they are faced 
with issues involving substance-abusing women. Many are also 
having to address the risk of HIV/AIDS with individuals who are 
addicted to drugs.
    We are also very concerned about issues concerning the 
dually diagnosed and the elderly.
    During the last few years, SAMHSA's programs have 
demonstrated dramatic outcomes. For example, an evaluation of 
our treatment programs found a 50 percent reduction in drug use 
among clients one year after treatment. Our Service Research 
Outcome Study produced similar findings five years after 
treatment. We have achieved successful results that parallel or 
exceed the outcomes of patients receiving treatment for other 
chronic illnesses like diabetes, hypertension, and asthma.
    The story is the same for mental health. Our programs for 
adults have documented improved health and well-being, reduced 
homelessness, and increased employment for individuals with a 
serious mental illness.
    For children with serious emotional, behavioral ormental 
disorders, our programs have not only improved functional ability but 
also improved their grades, improved living conditions, reduced school 
absences and reduced costs. Many of these children in the past have 
ended up either in institutions and/or placed out of State.
    As a result of this Federal investment, millions of people 
with mental illness or a substance abuse problem now have the 
opportunity to live productive and fulfilling lives in their 
community.
    Let me tell you one story about a local man who provided a 
very vivid picture to all of us. He said to us, ``If you had 
seen me 18 years ago, down and out, and hustling for a fix, 
stealing, grubbing on the streets, you wouldn't believe I was 
the same man.'' He continued, ``With the help of comprehensive 
treatment that provided medical care, counseling, and a place 
to stay, as well as a caring support system, I have made it 
from the underside. My life is now right, right up there with 
other people who have made it. I am on the professional staff 
of a national health agency where I serve as a grants 
administrator.''
    Even with these results, we are living in an America where 
mental disorders and addictions are stigmatized and health 
insurance plans discriminate in their coverage for these 
medical conditions. There obviously is much work ahead of us in 
the area of improving substance abuse and mental health 
services. It is clear we must continue to pursue the answers to 
questions like why people become involved in substance abuse; 
why treatment is effective for some, but not for others; how to 
improve access to quality care for those individuals who have 
both a mental and an addictive disorder; and, how we can make 
treatment and prevention more relevant to individual needs, 
taking into account cultures and situations.
    We must also invest in understanding the impact of the 
recent shift to managed care coverage and the changing 
demographics regarding the delivery of substance abuse and 
mental health services. These are but a few of the questions we 
are addressing through our Knowledge, Development and 
Application grants.
    In fiscal year 2000, the President has proposed $267 
million for SAMHSA's KD&A program. As you know, these grants 
are used to improve systems performance and service quality. 
While research is incredibly important and all of us have 
benefited from it, what our KD&A program does is to give life 
to much of the research that is being done, and research 
knowledge is what we have used to build many of our KD&As.
    For example, in response to Congressional interest, we are 
investing in the delivery and improvement of mental health 
services in schools for children, especially young children who 
are at risk for violent behavior. We have launched an 
initiative to determine the effectiveness of methamphetamine 
addiction treatment for various populations, an addiction that 
is very difficult to treat.
    And, in prevention, we are working in a number of targeted 
areas, including underage drinking, particularly on college 
campuses, and family focused prevention programs, especially 
programs for children of substance abusing parents.
    At SAMHSA, we are deeply concerned that today we have 
8,300,000 American children in this country who are living with 
at least one parent who is an alcoholic, is using drugs, or is 
in need of substance abuse treatment. These are not all 
children that are black. These are not all children that are 
Latino. These are not all children that are on welfare. These 
are children that live in families similar to those represented 
by individuals in this room today. I believe that we need to be 
very concerned about this issue, because 12 percent of these 
children are under 2 years of age.
    These children represent the tidal wave that I believe is 
coming in the 21st century, because they face a higher risk of 
substance abuse, addiction and the development of a variety of 
physical and mental problems. To address this high-risk 
population, we are developing prevention interventions 
specifically designed for them and their families as part of 
our Strengthening Family Initiative.
    In closing, SAMHSA's achievements continue to demonstrate 
the effectiveness of Federally supported, drug, alcohol, and 
mental illness prevention and treatment programs.
    Mr. Chairman, our strategy is to maintain a balanced 
approach to improve access to quality mental health services, 
address the gaps in substance abuse services, and increase the 
application of knowledge in critical service areas.
    Mr. Chairman and members of the Subcommittee, thank you for 
the opportunity to appear before you today. We will be pleased 
to answer any questions you may have.
    [The information follows:]

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                            ADVANCE FUNDING

    Mr. Porter. Dr. Chavez, thank you for your excellent 
statement. I am sorry more members weren't here to hear it.
    I begin with a question that you may well want Dennis to 
answer. But your budget request this year proposes to forward 
fund $100 million for the Substance Abuse Block Grant. Can you 
tell the committee what the need for this forward funding is? 
Is there a problem we don't know about? And if there is, please 
tell us so we can check it out. Why are we forward funding $100 
million?
    Ms. Chavez. Mr. Chairman, thank you very much for your kind 
comment regarding my statement. I agree with you that Mr. 
Dennis Williams should answer that question along with Mr. 
Kopanda.
    Mr. Williams. Mr. Chairman, as you know, the budget and the 
budget caps for discretionary programs are very limiting.
    Mr. Porter. I am aware of that, yes.
    Mr. Williams. And the budget seeks many different ways to 
try to make funds available for important programs. In this 
case, committing in advance $100 million for this program next 
year is one way of indicating the priority afforded the program 
and still living within the budget constraints.
    Mr. Porter. Okay. Well, if that is the case, why aren't you 
proposing to forward fund part of the Mental Health Block Grant 
as well? I mean, why this one?
    Mr. Williams. I don't think there is any particular reason 
that distinguishes between the two. Mental health was a program 
that has not received quite the support in recent years that 
drugs have. And the President wanted to indicate this year in 
the 2000 budget that mental health is a special priority.
    Mr. Porter. Do you think this is a good way to appropriate?
    Mr. Williams. All things being equal, if resources were 
unlimited, probably not. The fact is, we face a situation where 
resources are limited; and the President seeks the best way to 
try to accommodate that and still give resources to important 
programs.
    Mr. Porter. Dennis and I got into the President's budget in 
a previous hearing, so we won't go there now.
    Ms. Chavez. Mr. Chairman, let me respond to that as well. 
There is a commitment on the part of SAMHSA to work towards 
closing the treatment gap. This is one of the goals that has 
been established. By the year 2002 [Clerk's note.--Later 
corrected to 2007] we hope to have reduced the treatment gap in 
this country by 50 percent. This is one of the reasons that the 
advanced appropriation is requested.
    Regarding mental health, I must say that Mr. Dennis 
Williams is correct. We have not seen an increase in mental 
health for years and we continue to see the problems 
compounding. It's a great concern to all of us.
    Mr. Porter. Well, first, I guess we will go there for a 
minute. First of all, I think we all share the same goals, and 
we realize the problems. Frankly, what I said to the Secretary 
when she was here yesterday was that I think we should all sit 
down and agree on a bipartisan basis and on the basis of an 
economy that is performing very, very well that the caps ought 
to be lifted on discretionary spending to reflect reality and 
that the process last year by which we forward funded, used 
offsets that were totally unreal and declared things 
emergencies that were not emergencies is nonsense. Let us be 
honest. We can't go through that again.
    And just so I can lobby you for a second, because you may 
have occasion to talk to the President about this, I think it 
is time for Republicans and Democrats alike to reflect the 
reality of the situation, look at the needs, look at what was 
done last year, and raise the budget caps in a realistic way.
    I don't know how we can--when we look at this, we look at 
about $42 billion, including the President's budget, and not 
including, by the way, the forward funding and the unrealistic 
and unlikely revenue increases that the President has included. 
We look at about $42 billion worth of suggested spending over 
last year that simply can't be absorbed in the system and 
certainly can't be dealt with at all with budget caps in the 
place that they are.
    So I just hope we can sit down, and I am certainly sending 
that message to my side of the aisle, and I hope we can get 
honest and real about this. Because I think that things that 
are very important, like the programs that you administer for 
people that are most at risk are on the table in this instance. 
And we do have the resources to help address those problems, 
and I think we should do so.
    Ms. Chavez. Thank you, Mr. Chairman.

                       CLOSING THE TREATMENT GAP

    Mr. Porter. You see, I got my sermon in anyway.
    The Office of National Drug Control Policy established a 
goal of closing the drug treatment gap by 50 percent by 2007. 
How much increased SAMHSA funding will it take to reach this 
goal?
    Ms. Chavez. I did a calculation, Mr. Chairman, a while 
back. And if we are really serious about closing the treatment 
gap, in my opinion, based on my calculation, and please 
understand I am not a mathematician, I had to depend on what 
Donald said to me and some of the other folks, I came out with 
$8 billion to be able to realistically address the treatment 
gap as we now estimate it.
    When we discuss the treatmentgap, we are talking about 
those individuals that are most in need of treatment. We are not 
addressing individuals, especially young people, that may need 
treatment because he or she is beginning to use marijuana and drink 
alcohol. In all probability, it is going to be very difficult for a 
parent to be able to find a slot for that child because that child is 
not a hard core addict.
    Those are very basic figures. But if we are going to close 
the gap, Mr. Chairman, I think we also have to look at 
balancing the whole system. What I mean by that is that we need 
to look at the States' responsibility, Federal responsibility, 
local responsibility, and the cities' responsibility, in my 
opinion. I have been spending a lot of time with mayors, and 
mayors are very concerned about what is happening in their 
communities. They feel that in some areas our dollars are not 
reaching them when it comes to some of the issues that they 
have to deal with on a day-to-day basis. If we are looking at 
closing that treatment gap, then I think we must work together. 
This is where ONDCP, which is very important in terms of the 
10-year strategy that they have developed and that we have all 
participated.
    Another issue that I believe is very important in terms of 
this strategy and looking at treatment, it can't be done just 
in the quick strategy that I have outlined to you in terms of 
who the participants are.
    There is another issue that we don't deal with, and that is 
the very critical piece that mental illness plays in some areas 
and that you are seeing in many communities that are having to 
deal with individuals and families, that are coming into a 
treatment system that is not prepared to deal with them because 
they are coming in with a multitude of problems, including 
mental illness, substance abuse, and alcoholism. These are some 
of the areas that we are greatly concerned about in looking at 
what are some of the best practices that are out there.
    We have regional drug problems as well. The maps that we 
have put together show how one drug, methamphetamine, can tell 
us something about the regional issues that we are dealing 
with. They also show suicides and age data. There are a 
multitude of problems that I think are critical, that we pull 
together in terms of the kinds of strategies that our staff is 
trying to deal with on a day-to-day basis and with very limited 
staff to do it and very limited resources.
    Mr. Porter. This is quite good. I did get a chance to look 
it over. And I think it is very, very well done.
    Ms. DeLauro.

                 MENTAL HEALTH SERVICES TO THE HOMELESS

    Ms. DeLauro. Thank you. Thank you, Mr. Chairman. Before Ms. 
Northup came in, I was going to say ``It's just you and me, 
Babe.'' I am delighted there are more of us, and thank you very 
much for your statement, Dr. Chavez, and for all of you being 
here.
    As an adjunct to what you were just saying, last year 
congressional action required HUD to spend at least 30 percent 
of its homeless assistance funds for permanent housing. Now 
this is obviously an important function. I agree with that. But 
it leaves a lot of the shelters providing for homeless people 
with less money to be able to do the job.
    For example, local programs, in my district that would 
provide mental health services along with other services to the 
homeless are going to lose almost $3 million and may run out of 
money later in the year. We are trying to address that issue.
    Let me ask, what actions can or does SAMHSA take to ensure 
critical addiction and mental health services will be able to 
continue to operate if HUD is no longer able to provide those 
services? Is there any sense of any gap that needs to get 
filled here? And how it is going to get filled by SAMHSA, or by 
others in terms of trying to deal with these kinds of problems?
    Ms. Chavez. Congresswoman, let me begin to address that, 
and then I will turn the question over to Dr. Arons.
    One way to address homelessness is through the increase 
that is being requested for the Mental Health Block Grant, 
where, as I indicated earlier, States will have an average 
increase of 24 percent. But as you know, we are dealing with a 
very small base when you look at the block grant.
    The other area is through our PATH Homeless program. We are 
also requesting an increase there. But again, it is a very 
small increase of only $5 million which must be divided based 
on a formula. Large States are going to get the majority of the 
increase.
    The Center for Mental Health Services has been able to 
accomplish much in addressing homelessness. Homeless programs 
do work. We have been able to demonstrate that people do get 
better and, more importantly, that they don't remain homeless.
    My concern, and let me turn it over to Bernie, what we are 
getting, and I don't know if you are seeing this in your area, 
but I would like for you to comment on that, we arebeginning to 
get a lot more reports about homeless families as compared to 
individuals. We are beginning to see like 37 [Clerk's note.--Later 
corrected to 39] percent of the homeless shelter users are families 
with children. Are you beginning to see that as well?
    Ms. DeLauro. That is absolutely right.
    Ms. Chavez. We don't know very much about that in terms of 
what kind of array of services, et cetera. We have done a lot 
in terms of the individual. But now we have got families with 
little children. We have seen that before. But it is 
increasing. So, Bernie.
    Dr. Arons. Congresswoman DeLauro, let me just put the 
question into context. At the Center for Mental Health 
Services, we think we are beginning to see an impact from the 
work that we have been doing across the Nation. One of the 
areas we do see an impact is improving services to individuals 
who are homeless and have a mental illness. We know many of 
them also have an addictive disorder as well. In fact, 66 
percent of those served through the PATH program have co-
occurring disorders.
    Even though we see an impact, we believe we are spending 
tax dollars in a sound, efficient and conscientious manner. We 
also know there are tremendous unmet needs. I don't know that 
we will fill the gap that you mentioned, the unmet needs 
regarding the individuals who are homeless, but that is one of 
the areas we still see tremendous unmet needs.
    We are proposing to increase the PATH program and the 
mental health block grant program. We know those programs 
target services to the homeless. We know that we have 
demonstrated that the services do work. The myth used to say 
that people on the streets don't want services and won't avail 
themselves of services. We know through our Access programs 
that people do want services. They will engage in services 
where they live. They have to be comprehensive.

             MENTAL HEALTH BLOCK GRANT/DATA INFRASTRUCTURE

    Ms. DeLauro. Don't misunderstand. My comment was not that 
you are not filling the gap. I find that we do things here 
almost in a vacuum without realizing the consequences. We tell 
HUD to go ahead and do something here, which leads to cutbacks 
on what they had been doing in the past to try to deal with 
this issue, and make no plans to provide those services 
elsewhere.
    I can go to Columbus House, Davenport House in New Haven, 
and they are doing a great job, a wonderful job. But then, all 
of a sudden, we are saying, HUD must meet this new percentage 
and you are left with less funding for the effort that you were 
undertaking in terms of the mental health services. And we know 
some of the homeless have had a mental illness problem, and a 
lot of that stems from taking people out of institutions, and 
putting them on the streets, without providing any services for 
them to live well in society. So we compound our problem with 
doing this.
    But I often wonder about how are we then making up the 
difference when we keep throwing more people into the system. 
You all internally have to figure that out. We have to think 
about what is the human and financial consequences of that 
spillover, if you will. We need to consider the implications 
when we say okay, HUD, you need to direct 30 percent toward 
permanent housing. Which, as I said, is a good goal. But what 
in the heck happens to these folks without the kinds of 
assistance that they need? And you know we clearly want to try 
to work in those areas.
    Let me move to the Mental Health Block Grant and ask if any 
of the funding is going to be used on developing data 
infrastructure to demonstrate how many people are served by 
public mental health programs, what populations are underserved 
and which systems are underfunded. And correct me if I am wrong 
on this, I understand SAMHSA spends about $13.7 million on data 
collection on substance abuse compared to about $670,000 for 
mental health. Is that----
    Ms. Chavez. Let me address that. Both block grants have a 
set-aside, which is 5 percent of the total. So obviously, since 
the Substance Abuse Block Grant is larger, you have a larger 
set-aside. The law is specific in terms of how those dollars 
are to be spent: data collection, technical assistance and 
evaluation. That is how we spend our dollars.
    Dr. Arons, do you want to respond to that?
    Dr. Arons. Yes. It is very important we begin to do better, 
to measure and assess, develop performance measures for how we 
are doing with the funds that we spend and the funds that we 
spend through the States especially.
    The block grant set-aside is used to help States develop 
that data infrastructure that you mentioned that will assist 
them in better measuring for their own purposes as well as for 
the Nation how we are doing as far as closing that gap and 
meeting that need.
    At the moment, we have 16 States that are piloting a 
performance measures program where we have identified 28 
measures that will help address whether we are doing the right 
thing with these funds. And we hope to expand that to all 
States as soon as we see the success of those 16 States.
    Ms. DeLauro. Is that the buzzer?
    Mr. Porter. We will have another round. We are going on the 
8-minute rule.
    Mr. Porter. The gentlelady from Kentucky, Mrs. Northup.

                            SYNAR PROVISIONS

    Mrs. Northup. Thank you.
    I want to welcome the SAMHSA people here today. I have 
obviously had a chance to work with you in the past on the 
Synar provisions. I just want to start by reiterating thatmany 
States depend on SAMHSA and its implementation of the Synar amendment 
in order to make progress in youth use of tobacco products.
    In Kentucky, those people that advocate grassroots' 
approaches to solving that problem are lonely indeed. It is not 
a popular cause. And the public health community and the 
nonprofit community that has--that really is a wide array of 
people that have come together to work on issues surrounding 
tobacco use, especially among our youth, depend on the pressure 
that exists from Synar.
    And I have to say I have been very impressed with what your 
approach includes. It is such a broad approach in both 
substance abuse and tobacco. And I think your expertise--it 
always surprises me that the President, when he says he is 
serious about tobacco, and tobacco use mainly, including our 
youth, that we don't use some of the funds that he proposes to 
generate from his approach to up the funds of SAMHSA that has 
such experience in this area.
    I know that I am sure you advocate for your agency and for 
what you can accomplish, and I want to thank you for that and 
reiterate that I think it serves an important, important role.
    I would also like to ask you a couple of questions about 
mental health. First of all, let me go back to Synar and 
start--follow up and say, are you on target in the enforcement 
of the Synar regulations? In other words, are the States 
complying? Are there States that are out of compliance? And 
what are you doing about that?
    Ms. Chavez. First of all, before I respond, let me just 
say, I have said this to you privately, but I really would like 
to say it publicly, how much we appreciate your advocacy in 
this area. It is an issue that, coming from Kentucky, is very 
hard to take on sometimes; and you have done that. All of us 
commend and salute you, because we need advocates like you.
    Mrs. Northup. It is a labor of love.
    Ms. Chavez. I know. But we need advocates in tobacco, and 
we need them in mental health, alcohol and drugs as well. If we 
could all work together, what a difference we could make in 
this country, right?
    Mrs. Northup. That is right.
    Ms. Chavez. Let me just address the Synar Program 
implementation, and we can send you more information on it.
    I want to, first of all look at some of the positives. And 
the positives are where we were in terms of prior to 1997 or 
prior to 1997 or 1996 and where we are today, where, you know, 
States had from a 60 to a 90 percent noncompliance rate. There 
has been significant progress made in that rate. Now, about 12 
States are below 20 percent, which is very good.
    And the States right now, I think most of the States are 
going to be in compliance. I am sure that we will have some 
States that will be problematic. I don't have all the 
information with me at this point, but we will be very happy to 
respond to you.
    This is a very serious issue. We certainly are doing as 
much as we can within the statute. But we take it beyond that, 
in that all of our Knowledge Development and Application 
Prevention Programs very clearly advocate the nonuse of 
tobacco.
    As important is that many prevention programs are not just 
focusing on drugs, but alcohol and tobacco as well. If you are 
going to address alcohol use you have got to address tobacco 
use too. You have got to deal with all drugs. We are in fact 
doing that.
    Dr. Kumpfer, I don't know if you want to add anything.
    Dr. Kumpfer. Well, certainly the KD&A programs, the 
knowledge, development and application prevention programs, all 
address tobacco as well as alcohol and drugs; and a number of 
them already have statistically significant reductions in 
tobacco, such as the student assistance program that is in New 
York and others that are part of our eight exemplary models 
that we are now disseminating through our six regional Centers 
for the Application of Prevention Technology to get those out 
to the States and to help the local communities in the States 
with the best practices that really do work to reduce drug use.

                              BUDGET CAPS

    Mrs. Northup. Well, I do think we are making progress on 
drugs, although there is always--there is a correlation in that 
tobacco usually precedes the use of drugs. But I would point 
out that we have yet to see CDC results that show there is a 
decline in young, young people, both teenagers and young 
adults, using tobacco.
    I know that there is one survey that shows a slight 
decline. But it will be the first one in years, and we will see 
if that is upheld by the CDCs.
    Let me turn to mental health, if I may. I am going to just 
reiterate in a little different way what the Chairman said and 
not address the caps. We may have to raise the caps on at least 
in some areas. But, eventually, you have to establish a cap, in 
my opinion, or there is sort of unlimited money you can spend. 
You are not required to make the very tough trade-offs of what 
is essential and what is not essential. And, you know, I 
believe we failed in that way, too.
    The caps may be wrong. But when I see us funding what I 
believe are nonessential programs, and you can just take this 
back because it is not directed to you, but, for example, the 
summer employment program where, last year, the local program 
could only fill 240 slots of its 400 slots it had, much less 
the Federal program. The private sector couldn't find the 
employees they needed. We couldn't open up our swimming pools 
because we couldn't find lifeguards that would lifeguard. Yet 
we are going to fund a summer employment program when the 
private sector is crying for these kids.
    Yet, we have mental health services, not only an emerging 
need, but as an emerging area where we know there are answers. 
We know there are targeted drugs that will help people become 
able to lead independent lives, become able to deal with those 
problems that plague them. And we don't put the money there. 
You know, that was the whole purpose of the caps.
    And, you know, Mr. Chairman, we may up the caps to 
anything, but we have to also find the discipline to admit that 
there is some needs we had in 1979 that don't exist today and 
that we can direct money into different channels.
    With that said, I would also like to ask you whether you 
track the amount of Medicaid money that is available that is 
used to address mental health services. Certainly our mental 
health, mental retardation community bills a lot of their 
services through Medicaid. And I just wondered if we are 
funding mental health services at a higher level based on what 
Medicaid pays for those services?
    Ms. Chavez. Dr. Arons.
    Dr. Arons. Well, I certainly would agree we have effective 
programs, and effective treatments that work which aren't 
getting to people who need it; and we can see this in a variety 
of ways. We can see it in general programs, as I mentioned 
before, the homeless on the streets. We can, unfortunately, see 
it in very particular situations, some of our young people who 
aren't getting the treatment they need and some of the 
increases in even some of the rare but unfortunate tragic 
incidents like has occurred in Paducah not long ago.
    We do keep track of these funds. We have recently produced 
a report on expenditures for mental health and substance abuse. 
It includes Medicaid spending. Total spending in the country is 
about $80 billion. The Mental Health Block Grant is a very 
small portion of that overall spending.
    Mrs. Northup. I think you are misunderstanding me. I want 
to know about the increase of Medicaid funds that go to address 
mental health.
    Dr. Arons. Right.

                         MENTAL HEALTH SERVICES

    Mrs. Northup. In other words, I mean whether you all track 
that or not. In Kentucky, there is some money that goes to 
physical health services. What about mental health?
    Dr. Arons. Right. We do track that. There has not been a 
significant increase in the portion of Medicaid funding going 
to mental or addictive disorders, for that matter, but we do 
track that and can get specific information on that.
    Mrs. Northup. I would be interested in that.
    One of the concerns I have is whether or not we are going 
about the billing of those services well. I mean, the truth is 
the people that need the most profound level of care are not 
people that show up for the 2 o'clock appointment every 
Wednesday. They are on the streets. They are often homeless. 
They are the most difficult to serve.
    If you are an agency and begin seeing Medicaid billing as 
certainly one of the offsets to your cost, then providing 
services to people that need mental health services but maybe 
aren't the most in significant need, these might not be the 
services that you prioritize.
    And so I have wondered whether we should look at the 
funding for mental health services that comes through Medicaid. 
Because many of the people that have mental health problems 
that would use your services qualify for Medicaid. But whether 
or not there should be, besides the grant program, a way to 
fund people in those programs more effectively--is very 
important.
    Dr. Arons. If I could comment just on one approach that we 
are taking. We are working with HCFA and with Medicaid to try 
to target exactly the people you mentioned. We are working with 
them to look at these assertive community treatment services 
for people who are not likely to come in for the 2 o'clock 
appointment, people who need to have folks come out and visit 
them, call them. And we are working with the Medicaid agencies 
throughout the country to make sure they have available funding 
for those very tough services to deliver.
    Ms. Chavez. Could I follow up very quickly, Mr. Chairman?
    Mr. Porter. The gentlelady's time expired some time ago.
    Mrs. Northup. I am sorry.
    Mr. Porter. But go ahead, Dr. Chavez, and answer. I was 
going to Mr. Jackson, but he left the room for a moment. But 
please go ahead.
    Ms. Chavez. Allow me to respond quickly, and then we will 
get more information to you because we do have some 
information. What I hear you saying is that we are beginning to 
see more people falling into this gap. They are seriously 
mentally ill and may have many other problems; yet they are not the 
ones coming to the mental health center at 2 o'clock for the 
appointment or taking their medication when it is prescribed.
    What we are seeing, then, is--what we are beginning to see 
more and more is that insurance coverage for mental health and 
for substance abuse services for people that have been 
employed, just employed people has been declining--okay, so if 
we take the employed people--from 10 percent in 1989 to about 
4.5 percent in 1986. So what we are saying, then, is that we 
have about 41 billion [Clerk's note.--Later corrected to 41 
million] Americans that are not insured.
    Let us now deal with the issue of substance abuse and 
mental health, because what we have talked about earlier is 
that these are not the individuals that are more likely to get 
a comprehensive system of care. This is what the Mental Health 
Block Grant tries to do. As I said earlier, it is a very small 
piece, but this little piece is used to expand and to develop 
systems.
    The problem that we are beginning to see is the advent of 
managed care, what is happening in terms of mental health and 
substance abuse. We have done a lot of work in this area, and 
we will be very happy to share it with you.
    Mr. Porter. The Chair would advise members that there 
appears to be one vote, and we will vote and come back if you 
will stand in recess briefly. And the Chair will also advise 
members that we have the Agency for Health Care Policy and 
Research also before us today. And we will have a second round 
with SAMHSA, and then we will work on AHCPR.
    The subcommittee will stand in recess briefly for this one 
vote.
    [Recess.]

                     YOUNG PEOPLE IN DRUG TREATMENT

    Mr. Porter. The subcommittee will come to order.
    Dr. Chavez, your charts begin with this one; and this one 
seems to me perhaps to be the most worrisome of all. And if you 
look at it and talk about serious emotional disturbances among 
young people, if I understand correctly, you have got one out 
of every five young persons with some kind of diagnosable 
disorder; is that correct?
    Ms. Chavez. Yes, sir.
    Mr. Porter. And then you have a chart later as to how many 
people are in drug treatment. How many of these young people 
are in treatment? Is there any way of already determining that?
    Dr. Goldstone. I do not have that number immediately 
available, but we do have at least admission data for all 
substance abuse treatment facilities in the country that we get 
through the States. They do break it down by age groups, so we 
can provide you with that number.
    Mr. Porter. Substance abuse? I am talking about mental 
illness.
    Dr. Goldstone. That we don't have.
    Dr. Arons. We estimate about one in three get the treatment 
that is indicated for young children with serious emotional 
disturbances.
    Mr. Porter. Do we have any way of tracking those young 
people into adulthood in finding how long they suffer from 
these disturbances? What happens to them, in other words?
    Dr. Arons. There have been some studies that follow these 
folks.
    Again, I think the broader circle, the 20 percent with any 
sort of diagnosable disorder, is very comparable to other 
illnesses. There are some very mild conditions as well as more 
serious conditions.
    The group we try to focus a good part of our activity is 
concerning the smaller circle, the 5 to 9 percent with serious 
emotional disturbances and who have extreme functional 
impairment. We see the impact in schools. We see it in their 
home life and so forth. As they get older, we see young people 
who continue to have difficulty. Some go on to have other 
disorders and some we know will get in trouble with the law if 
treatment doesn't become part of their services.

    BEST STATE PROVIDERS OF MENTAL HEALTH & SUBSTANCE ABUSE SERVICES

    Mr. Porter. If I were to say to you can you name the five 
States that do the best job in dealing with substance abuse or 
the five States that do the best job in dealing with mental 
illness, or I do it the other way around, say which of the five 
worst, do those come to mind real quickly or is this something 
that--in other words, I don't want you to necessarily say that, 
but do we know States that do a really good job and are models for 
others and do we know others that do a really poor job and really have 
to have the attention to bring them up to any kind of effective 
treatment for mental illness or drugs or both?
    Dr. Arons. I think we try to take the approach as a Nation 
we need to do more regarding treatment of mental disorders. 
There are some States trying innovative ideas. We hope our 
funds from--the children's comprehensive services program will 
help give the States and communities the kind of stimulus 
needed to try new things, and we are finding it is working.
    Of the States that have received grants in the children's 
mental services program, many of them are changing their laws, 
adopting new practices; and we see improvements throughout. Of 
course, there is still a long way to go. We are constantly 
working with all the States in trying to improve those 
services, including developing peer-to-peer technical 
assistance where States can help one another. They may hear 
that better, but we try to avoid the kind of ranking that you 
mentioned.
    Mr. Porter. I don't mean we should; but, clearly, there are 
significant differences in the States and their ability and 
results in terms of dealing with these problems; am I correct?
    Dr. Arons. Yes.
    Mr. Porter. And in all of this, they are the front line. 
They are the ones who are dealing or their cities are dealing 
with the individuals who need the help; isn't that correct?
    Dr. Arons. Yes.
    Dr. Clark. Mr. Chairman, the Center for Substance Abuse 
Treatment through our exemplary treatment program is attempting 
to identify programs that are in the trenches that are 
exemplary that we can replicate so we can educate through our 
relationship through the States and the block grant. We have 
this past fiscal year funded five exemplary programs in 
jurisdictions like Arizona and California, Maryland and New 
York that we believe can help us understand some of the 
dynamics of young kids between the ages of 12 to 19 that have 
substance abuse problems. Also most have concomitant 
psychiatric problems.
    Ms. Chavez. Mr. Chairman, may I add something?
    Mr. Porter. Is Mr. Chairperson politically correct? I am 
just not sure.
    Ms. Chavez. I don't know.
    I have been listening to all the comments that have been 
made, and I guess I have to put my old community hat on in 
terms of activities I accomplished in the community. You raised 
a very good question when you were asking about good States and 
bad States.
    If you look at the Mental Health Block Grant, for example, 
the statute is very clear that these dollars be allocated for 
children who are seriously emotionally disturbed. But many of 
these communities are strapped for mental health dollars. 
Having run one of the largest mental health programs, I am very 
much aware of what happens in these programs, and they are 
strapped. And, consequently, what happens is you try to do the 
best you can with those block grants that are there.
    But one of the things that is very clear is that it is 
restricted to those children that have a seriously mental 
disorder. What does that mean? An example: This happened 
somewhere in the Midwest a couple of years ago. A child was two 
years old and his mom walked into the school cafeteria and put 
the child in the oven. The child survived, but think about the 
implications in terms of the kind of long-term treatment that 
that child is going to need. Would that child be able to get 
into one of the systems out there that is funded with block 
grant dollars? I don't think so because, according to the 
criteria, she is not yet seriously emotionally disturbed. 
However, we are going to pay an incredible price for that when 
that child is eight or nine years old. And it is not going to 
cost $2,400 a month or a year or whatever. We are talking big, 
big dollars.
    So do we have systems for children? No. We have some 
systems designed for children; but basically what we have been 
doing is that we have been taking a lot of these adult systems 
and we have been dumping them on children. So if you are asking 
which are the best child treatment programs, we would guess.
    What we have been able to do through the children's 
initiative is to begin to develop some infrastructure. But we 
are only spending $76 million in this country for children that 
are seriously mentally ill.
    Mr. Kopanda. I might just add that in both the mental 
health and substance abuse areas, we have been working closely 
with the States to develop performance indicators and output 
and outcome measures to help assess how well they are doing. 
The States have been very cooperative in dealing with this 
issue and reporting voluntarily in their block grant 
applications. This will help us assess relatively speaking how 
they are doing. We are doing that not to be punitive but to see 
where additional work is needed and where better approaches can 
betranslated to the States.
    Mr. Porter. Not at all. In fact, we are responsible--those 
are dollars that you are and we are responsible for, just like 
any dollars; and they have got to be well spent and get good 
results or we ought to look at the entire thing anew.
    Ms. Chavez. We are getting good results in terms of what we 
have doing with the block grant and the children's mental 
health dollars. All I am saying is it is so restrictive if you 
look at the magnitude of some of the issues, when you start 
looking at this diagram that is here and then you look in terms 
of what is happened with suicides.
    Mr. Porter. I have gone over my time here.
    Ms. DeLauro.

                             MENTAL ILLNESS

    Ms. DeLauro. I just have one question. The National 
Household Survey on Drug Abuse, as I understand it, found 63 
percent of people with severe drug problems did not receive 
care in 1997. My question is, do you have numbers for those 
with mental illnesses who do not receive needed treatment? Do 
we have some idea of what the situation is out there?
    Ms. Chavez. Let me ask Dr. Goldstone and Dr. Arons to 
respond to that.
    Dr. Goldstone. I wish this were two years from now, and I 
could give you exact figures.
    I think the reason I was asked to respond to the question 
is that, as you may know, we have expanded the household survey 
to make State as well as National estimates of substance abuse 
problems. However, we propose next year to put in new measures 
which will look at mental disorders both in adolescence and in 
adults so that we will not only be able to tell you better 
about the problems of co-occurring disorders. We may also, 
because of the size of the survey, be able to give you separate 
and distinct estimates on the nature of mental disorders both 
in youth and in adults across the country.
    Nothing this large has ever been done to look at mental 
health problems in the United States. It is a wonderful 
opportunity. We will put--if you put two years of data 
together, which for mental health disorders where you don't see 
the kinds of trends and changes that you see in substance abuse 
from year to year, we will have about 140,000 for a two-year 
period respondents, actual people who have been interviewed and 
responded to this; and we will have 50,000 youth between the 
ages of 12 and 17 so that we will be able to do things with 
data to look at mental health problems as well as the substance 
abuse problem that we have never been able to do before. We are 
just not there yet.
    Dr. Arons. Just to add to that, we very much look forward 
to this additional information. We do know from some past 
surveys--the ECA study and the national co-morbidity study--
that, unfortunately, people in need are not getting the 
services that are available. We know it from seeing people on 
the street. We know it, unfortunately, from those rare but 
terribly traumatic incidents that result in the killing of 
Officers Gibson and Chestnut. We know it in all sorts of ways.

                                 PARITY

    Ms. DeLauro. I think I just ask issue of parity because we 
know that in the private insurance market, there has 
traditionally been a disparity between coverage for the 
physical illness versus mental illness, and that continues. How 
much does that get in the way of your efforts of trying to deal 
with the issues of mental illness? Is there a way in which 
there could be some sort of a cooperative effort with what you 
are doing and a private insurance?
    Are we able to get mental illness covered so that we 
address this problem in a very serious way, whether for 
children or for adolescents or for adults. Does the full burden 
of responsibility, if you will, fall on the Federal Government 
if you can't have any sort of a cooperative relationship with 
private insurance to ensure it is available for people who 
might need it?
    Anyway, I am just trying to think creatively about how the 
hell we deal with this issue. I guess you guys do that all of 
the time.
    Dr. Arons. We absolutely need to deal with this issue. We 
are doing work in the private sector--we do do such studies. We 
recently have done a study and are working to increase the 
information around the issue of parity, around trying to work 
with the private sector to make sure there is the same coverage 
for mental and addicted disorders as there is for all health 
disorders. And we know that, with the kinds of responses that 
insurance companies make, that we know that we could do this 
around a 1 percent increase in premium. It is time to take that 
step, and we are working with all sorts of people to make that 
step.
    Ms. Chavez. Let me just very quickly--we are tracking this; 
and one example I can just give you is major companies like 
Delta Airlines, for example, expects that their expenditures 
for mental health services and their expenditures for substance 
abuse prevention and treatment for their employees will return 
$10 for every $1 that they invest in terms of productivity, 
injuries, disability claims, health care, et cetera.
    Many companies that we are tracking are beginning to pull 
and in some areas have already pulled information regarding how 
important this is within the private and theprivate sectors.
    Ms. DeLauro. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Ms. DeLauro.
    Mrs. Northup.
    Mrs. Northup. I think I went over in my first round, and I 
will just submit a few questions.
    Mr. Porter. Well, if I can say so, I think this is for the 
subcommittee going to be a rather frustrating year. We have of 
necessity compacted our hearings a great deal this year because 
last year we went into June and this year we have to finish by 
the middle of April. That means that we don't get nearly as 
much time as we have got to talk to you.
    There has only been three of us here today, and I think we 
can go on and ask questions for another two hours and find no 
end to the information that we gain and some insights as to 
what needs to be done and how the money is spent, but we can't 
do it because we don't have time.
    Let me just thank all of you. Dr. Chavez, you are doing an 
excellent job.
    Ms. Pelosi and Mr. Jackson have just arrived, but we have 
AHCPR to go to in the last half-hour of our hearing, so I don't 
know how we are going to cover much ground. If either of you 
have a pressing question that you really want to ask Dr. 
Chavez, please do so; but we are going to have to give some 
time for the Agency for Health Care Policy and Research as 
well.
    Ms. Pelosi. Mr. Chairman, may I just make a comment that, 
again, heeding the admonition of our Chairman, apologizing for 
coming at this point, I just want to commend Dr. Chavez for her 
excellent work.
    I will submit some questions for the record that relate to 
managed care, preventing youth violence, mental health and 
substance abuse issues in relationship to women, substance 
abuse and the HIV epidemic, homeless programs. And, of course, 
an update on the agency's support for the City of San 
Francisco's innovative treatment of demand program.
    I will submit questions in writing, Mr. Chairman.
    Thank you very much. Your agency is so very, very 
important; and I look forward to getting these answers but, 
more importantly, working with you and supporting your request.
    Ms. Chavez. Thank you, Congresswoman Pelosi.
    Dr. Clark from San Francisco is our new Director for the 
Center for Substance Abuse Treatment. He was with the Veterans 
Administration (V.A.) and is also working on the Treatment on 
Demand Initiative in San Francisco.
    Ms. Pelosi. We are delighted to see you as well as all of 
your colleagues here.
    Mr. Porter. Thank you, Ms. Pelosi.
    The gentleman from Illinois, Mr. Jackson.
    Mr. Jackson. Mr. Chairman, let me submit my questions for 
the record, if I can ask unanimous consent.
    Let me also associate myself with all of the common 
courtesies to the panel that Ms. Pelosi indicated. At this 
time, I have no questions.
    Mr. Porter. Thank you, Mr. Jackson.
    Thank you, Dr. Chavez. We very much appreciate your coming 
to testify.
    Ms. Chavez. I would like to thank you and the members of 
the Subcommittee for the outstanding work that you always do. 
Thank you.
    Mr. Porter. We will do our best.
    [The following questions were submitted to be answered for 
the record:]

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                                     Thursday, February 11, 1999.  

               AGENCY FOR HEALTH CARE POLICY AND RESEARCH

                               WITNESSES

JOHN M. EISENBERG, M.D., ADMINISTRATOR, AHCPR
LISA SIMPSON, DEPUTY ADMINISTRATOR, AHCPR
RITA KOCH, OFFICE OF MANAGEMENT, CHIEF, FINANCIAL MANAGEMENT STAFF
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, OFFICE OF BUDGET, 
    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                       Introduction of Witnesses

    Mr. Porter. The subcommittee will come to order.
    We continue our hearing with the Agency for Health Care 
Policy and Research, and we are pleased to welcome Dr. John 
Eisenberg, the Administrator.
    Dr. Eisenberg--I am going to call you John because we were 
just at a conference together that Harvard and the Commonwealth 
Fund put on that was a very, very good one. It is good to see 
you again. Why don't you introduce the people you brought with 
you and then proceed with your testimony?
    Dr. Eisenberg. I will do that.
    Let me introduce Lisa Simpson, who is the Agency's Deputy 
Administrator; and you know Rita Koch from last year. She is 
the Agency's Chief of our Financial Management Staff. And I 
heard in the previous hearing you know Dennis Williams well.
    Mr. Porter. Dennis who?

                        AHCPR'S PLANNING PROCESS

    Dr. Eisenberg. Let me start by thanking you for staying 
late and let us do our testimony. Also, I want to thank you for 
the committee's recognition of the importance of this Agency's 
research agenda last year in approving the President's budget 
request in fiscal year 1999.
    Last year Mr. Chairman, was my first appearance before the 
Committee, and you asked us how our research helps to improve 
health care and how that helps to improve the health of the 
public. That question has become a touchstone for AHCPR. In 
fact, in our planning activities, in planning our agenda, in 
planning our budget, that has become the core of our planning, 
and we ask that question of ourselves all the time. How is this 
going to make a difference? It is the ``so what'' question. So 
what if we fund this research?
    What I would like to do today is to describe how some of 
our past research has made a difference, how it has improved 
health care and also how we fashioned this year's budget, so 
that we can do an even better job of meeting this challenge in 
fiscal year 2000.
    In addition, of course, the Government Performance and 
Results Act has helped us to focus our attention by providing a 
clear blueprint for the way in which we can evaluate these 
initiatives, the ones that we propose for fiscal year 2000.

                      AHCPR'S PIPELINE OF RESEARCH

    One of the ways of thinking about our research agenda is a 
pipeline--and I think we have a graphic of that pipeline over 
there--with three key elements, three key segments in the 
pipeline which drive the way in which we think about how we are 
going to make a difference to the health of the public.
    The first stage is to do research and to sponsor research 
that helps to discover new knowledge about priority health care 
issues for the Nation. And then, having done that, how we can 
use that new knowledge to develop new tools and new talent for 
the next century. And, having the new knowledge and having the 
tools, how we can use both of those to translate that research 
into practice which makes a difference in people's lives.

                    AHCPR'S RESEARCH AND ITS IMPACT

    Let me give you an example. One product of that pipeline is 
the Consumer Assessment of Health Plans, or CAHPS as we 
describe it. CAHPS grew out of research that the Agency 
sponsored about four years ago on what people care about, what 
they want to know when they make a decision about a health 
plan, what is it that are the attributes of health plan quality 
that people are really looking for when they have the choice 
and when they make that decision.
    Having funded that research, we then funded researchers to 
develop tools that would design and then test this quality 
measurement tool so that it was validated, enabling people to 
choose the best plan, given what they said that they were 
interested in.
    Then, having that tool, we went to the third stage this 
year; and in 1999 that research is being translated into 
practice so that 90 million Americans, four years after the 
initial research, are able to select a health plan based on the 
quality of the plan according to the Consumer Assessment of 
Health Plans.
    Last month, for example, Medicare beneficiaries had their 
first chance to use the national CAHPS data as part of the 
information given to Medicare beneficiaries as they make their 
own choices. The same holds for the National Committee on 
Quality Assurance, the Federal Employees Health Benefits Plan 
and a number of private sector organizations who are using 
CAHPS.

               AHCPR'S IMPACT ON PATIENTS AND CLINICIANS

    That is one example. Let me give you another one. Another 
example of the pipeline is how our research led to the 
development of new technology, a new tool, that would help 
emergency room physicians make decisions about people who come 
in with chest pain.
    A person comes in with chest pain. This new decision aid, 
which is integrated in with an electrocardiogram, helps to 
advise the physician about whether the patient is likely to 
have a heart attack and therefore should be admitted to the 
hospital. The early track record of this tool is very, very 
promising. In fact, if it were extended to the entire Nation, 
it has been estimated that 200,000 people would avoid a 
hospital stay: that 100,000 people would be able to avoid a 
stay in a critical care unit; and, at the same time, we 
wouldn't miss people who needed to be in the unit. In fact, the 
projected savings from this would be $700 million per year.
    This is being translated into real practice by a private 
sector corporation, a well-known company, that is developing 
and marketing this tool to translate it intopractice so that it 
can be used across the country.
    Now, in addition to helping clinicians and patients make 
decisions, which is what I described, we also want to be sure 
that the research helps people who are making decisions in 
health care systems or people like you who are making health 
policy decisions.

         AhCPR'S IMPACT ON HEALTH CARE SYSTEMS AND POLICYMAKERS

    For example, the research that has been sponsored by AHCPR 
has led to a program by Medicare's peer review organizations, 
the PROs, a total of 73 projects in 42 different States, that 
will help to prevent the recurrence of strokes. This is a 
project that helps to increase the number of people who are 
taking blood thinners after they have had a stroke so that the 
likelihood of a stroke in the future is decreased. HCFA has 
estimated for us that their adoption of this research, putting 
it into practice, has saved an estimated 1,300 strokes per year 
in the United States.

                          FY 1999 INITIATIVES

    Now, before I discuss the President's fiscal year 2000 
budget, I would like to comment on some of our fiscal year 1999 
initiatives to describe the way in which we want to keep with 
this theme of translating research into practice and being 
sensitive to what the needs of the users are, the users of our 
research.

            CENTERS FOR EDUCATION AND RESEARCH THERAPEUTICS

    You might recall that the Food and Drug Modernization Act 
directed us to establish centers for education and research in 
therapeutics, and this year we are initiating that. The request 
for applications is out, and we are asking for applications 
that will help to improve the country's ability to use 
medications appropriately and to avoid errors and misuse of 
pharmaceuticals.
    In fiscal year 1999 we plan to spend $2 million to fund 
four early programs. An article in the ``Washington Post'' from 
an expert estimated that this relatively small investment would 
have the potential to save a substantial portion of the $20 
billion that the GAO estimates is spent in the care of 
individuals who suffer from the misuse of medications.

                     IMPROVING HEALTH CARE QUALITY

    We have also begun to implement the Department's initiative 
to improve health care quality, a major priority for all of us 
in government. A part of this initiative is the issuance of 
five requests for applications in the past several weeks. These 
applications are aimed at improving the care of Americans 
through improving the quality of care that we are able to 
provide them.

                    NATIONAL GUIDELINE CLEARINGHOUSE

    I am also pleased to report that the National Guideline 
Clearinghouse, NGC, which is a web-based compendium of 
guidelines, went live on the Internet on December 15. We 
developed this as a public-private partnership with the 
American Medical Association and, the American Association of 
Health Plans to make the best guidelines available to all 
Americans.
    It has over 500 guidelines already in the system being 
reviewed or on the web from 67 different guideline developers 
and the response has been very gratifying so far. In fact, in 
the first two months, NGC has already been used 70,000 times. 
Our biggest week was last week when 16,000 hits came to this 
guideline clearinghouse, so that the people can compare 
different ways in which the evidence suggests that care should 
be provided.

                            FY 2000 REQUEST

    So let me turn to fiscal year 2000 which builds upon this 
theme of trying to translate research into practice and being 
sure that we are sensitive to the needs that the American 
health care system has for better information to guide decision 
making.
    We have asked for an increase in our budget of $35 million 
[Clerk's note.--Later corrected to $35.2 million] to 
$206,000,000 [Clerk's note.--Later corrected to $206,255,000] 
in the fiscal year 2000 budget. The increase follows the three 
priorities that are on the chart and that I have emphasized, 
the three parts of the pipeline: new research on priority 
health care issues, new tools and talent for a new century, and 
translating research into practice. Let me describe each.

                    NEW RESEARCH ON PRIORITY HEALTH

    In fiscal year 2000, we request $10,000,000 [Clerk's 
note.--Later corrected to $10,055,000] for the first priority, 
which is to fund health care research that will close the gap 
between what we know in science and what we do in practice. 
That gap is large, and it has got to be closed to improve 
health care quality. We need to discover new ways to measure 
care and especially to measure the quality of care, and we need 
to discover the factors that lead to high and low quality, the 
factors that lead to high and low access and the factors that 
lead to high and low cost of health care.

                 NEW TOOLS AND TALENT FOR A NEW CENTURY

    The second priority is new tools and talent for a new 
century. In fiscal year 2000, we are requesting $13.2 million 
to invest in the tools that we are going to need to monitor the 
quality of care in the United States, and to invest in the 
talent we are going to need to translate this research into 
usable tools in order to improve the quality of care.
    Compared to any other industry in America and its ability 
to ask the most fundamental questions of itself like how are we 
doing, and health care lags behind. We don't have the 
information and we don't have the tools to understand quality, 
to track quality, to forecast the future. Science just has not 
yet been able to provide policymakers with the kinds of tools 
that you need in order to answer the most basic questions that 
you get asked all the time, like is health care quality getting 
worse or is health care quality getting better. Unfortunately, 
the state of the science today doesn't allow us to answer that 
question.
    In partnership with health care decision makers, people who 
are on the frontline, we are going to expand ourMedical 
Expenditure Panel Surveys and The Health Care Costs and Utilization 
Project. These are large databases that allow us to create and then 
test the new system of indicators that would answer the questions that 
I just asked, how are we doing in quality? Are we getting better? Are 
we getting worse? For whom? Which populations? Which parts of the 
country?
    They allow us to track and understand the kinds of changes 
that are occurring in quality of care at the national level, at 
the regional level, at the State level and even at the 
community level.

                   TRANSLATING RESEARCH INTO PRACTICE

    Finally, priority three is translating this research into 
practice, making research make a difference and answering the 
``so what'' question. This past decade has seen remarkable 
challenges for us in translating the formidable breakthroughs 
in science into real care that makes a difference for 
individuals in each of your districts. The challenge for us is 
not only to uncover new knowledge, but also to use it to 
develop tools and to ensure that they are translated into 
improved practice.
    So, we request $13.5 million to shorten the time lag, 
currently estimated to be between six and 10 years, between new 
scientific advances being discovered and getting them into 
practice. We think that the end result will be quantifiable 
improvement in the health care system that we can measure, as 
well as improved health care quality, quality of life, and 
averted deaths and even in dollars that are saved.
    Mr. Chairman, I want to thank the Committee for supporting 
the President's budget request for our Agency in fiscal year 
1999 and our request for the Committee's consideration of the 
President's proposal of $206 million [Clerk's note.--Later 
corrected to $206,255,000] for AHCPR in fiscal year 2000. Thank 
you.
    Mr. Porter. Dr. Eisenberg, thank you for your testimony.
    [The prepared statement follows:]

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                         AHCPR's authorization

    Mr. Porter. I have a basic question; and that is, when was 
AHCPR first created?
    Dr. Eisenberg. In 1989.
    Mr. Porter. 1989. My understanding is that it has been 
authorized probably twice, the last time through 1995, and has 
not been authorized since.
    Dr. Eisenberg. That is right.
    Mr. Porter. Any indication that our authorizing brothers 
and sisters are going to do anything about reauthorization?
    Dr. Eisenberg. In the Senate, there was a bill introduced 
last year to reauthorize the Agency. There were hearings on the 
bill, but it did not have a vote.
    We understand there is continued discussion this year about 
introducing bills on both sides to reauthorize the Agency, and 
we are looking forward to working with the Congress to see that 
happen.
    Mr. Porter. Has the Administration submitted a bill?
    Dr. Eisenberg. The Administration hasn't submitted a bill, 
but has had discussions with the staffs who are working on the 
bills that are coming out of the Congress.

                      ONE PERCENT EVALUATION FUNDS

    Mr. Porter. Another housekeeping kind of question and that 
is, you are funded in large part through a tap; and the 
President's budget increases the tap from 1 percent to 1.5 
percent. According to our figures, 87 percent of your funding 
would come through the public health service tap rather than 
your own line item.
    Dr. Eisenberg. That is right.
    Mr. Porter. What is your feeling about that? Does that 
bother you?
    Dr. Eisenberg. Well, of course, from our Agency's narrow 
perspective, the most important issue is that we have the 
funding in order to do the research. Beyond that, all I can say 
is that I sympathize with the problems of the budget caps and 
the difficulties of putting a budget together that meets the 
administration's priorities.
    From our perspective, I can repeat that we were happy to 
see the total amount, and hope that that amount will, in fact, 
be appropriated.

                      TIME TO ADOPT NEW KNOWLEDGE

    Mr. Porter. Okay. I understand that part.
    Your budget justification says that research has 
consistently shown that it takes six to 10 years for clinical 
practice to adopt a new knowledge and provide that knowledge to 
the majority of patients in this country. You propose somehow 
to speed up that timetable. How do you do that and what is a 
reasonable timetable to shoot at here?
    Dr. Eisenberg. I think the first approach is to find out 
why it takes so long, what are the barriers. In many instances, 
the barrier is that the information didn't get out to the 
practicing physician, and in some, because systems are notin 
place to facilitate the change, or because there are financial 
incentives or disincentives to disseminate the new knowledge. Let me 
give you two examples to address it, and I can generalize from that.
    One project that we sponsored in Minnesota was aimed at 
accelerating the adoption of beta-blockers and aspirin as drugs 
to be used after a heart attack. Investigators whom we funded 
determined that just dropping information on physicians wasn't 
likely to work by itself, that we needed to do two other 
things. One was to have systems changes in the institutions so 
that they facilitated the use of beta-blockers and aspirin. 
Beta-blockers are a drug that slows down the heart, basically.
    In addition to system changes, things like computer 
reminders and efforts in the hospital to link the pharmacy with 
decision making by the physicians were effective. In addition, 
what is very important is to get the opinion leaders in the 
institution to provide clinical leadership so that the 
physicians understand that the new change is needed.
    Having just those two changes, in addition to the 
information, increased the use of beta-blockers in that area by 
a good 50 percent and increased the use of aspirin as well in 
these hospitals compared to the control hospitals where this 
wasn't done.
    In Alabama, we sponsored a similar project which looked at 
an innovation that had been discovered some few years ago but 
hadn't been adopted. We know that women who are at risk of 
premature delivery also have risk that their newborn will have 
a lung disease. But if you give steroids to the woman when she 
is having premature delivery, you can decrease the amount of 
lung disease in the kids. But only about 20 or 25 percent of 
the kids in this area were getting that treatment.
    Investigators at the University of Alabama instituted a 
program to get the information out by using opinion leaders, 
and other experimental innovations to see if they could speed 
up the adoption of the corticosteriods. They were able to do 
that. They increased the use by, as I recall, 35 percent in 
their demonstration areas in the use of this new drug.
    So the answer is that getting good evidence out to 
physicians is important, but making it easily accessible using 
computers and other mechanisms, getting opinion leaders and 
getting systems to enhance the quality of care through system 
change, as well as just education are some of the mechanisms 
that the early research suggests will work. Our sense is that 
we both need to use what we have learned to get the material 
out to physicians and induce change, but also to find new ways 
in which we can encourage adoption more quickly.
    Mr. Porter. Thank you, Dr. Eisenberg.
    We are operating under the four-minute rule now. Ms. 
Pelosi.
    Ms. Pelosi. Mr. Chairman, because our colleague Mr. Jackson 
has been here longer, I want to defer to him this round.

                  RACIAL AND ETHNIC HEALTH DISPARITIES

    Mr. Jackson. Thank you for yielding.
    Mr. Eisenberg, I just have one question. Besides the 
specific budget request, can you elaborate how AHCPR's programs 
propose to close the disparity gap?
    Dr. Eisenberg. Yes, I would like to.
    In a number of different ways. The first issue is to 
identify where those gaps are, and one of the reasons why we 
feel it is important to expand the Medical Expenditure Panel 
Surveys is because it would help us to understand where those 
gaps exist. In fact, in your previous conversations with SAMHSA 
about some of the substance abuse issues and some of the gaps 
there, we have had conversations with them about collaborating 
because we think the MET survey would help answer some of those 
questions about gaps and delivery of care.
    So, first, we need to identify where the gaps are and where 
they are greatest. Second, we believe that there are certain 
areas where it is very clear that even when insurance is equal 
across different parts of the country, access to care is 
decreased for certain populations; and even when access is the 
same, that the quality of care is poor.
    We have got to figure out why that is. Is it racism? Is it 
barriers to access because of transportation or other issues. 
There are a number of different candidates, of course. We want 
to figure out what those barriers are so that we can intervene. 
That is the research side. Those both fall into the first 
priority, new research, to identify what the issues are.
    On the tools part, the second priority, there are two major 
issues where we have great concern and we think that we could 
make a contribution. The first one is that the measures of 
quality that we have in this country are measures for the 
population as a whole. We don't have very good measures of 
quality for components of the population. Yet, we know that 
people's preferences, and the way in which people define their 
quality of life, is very different for different parts of the 
population. It is even different for the two genders. We have 
got to have better ways of measuring quality that are sensitive 
to cultural differences, culturally competent quality measures 
is what we are calling them.
    Secondly, also in the second priority area of tools, is the 
issue of who the work force is going to be, who the talent will 
be. When we think about closing the gap, we think in partabout 
doing research on problems facing vulnerable populations, independent 
of who is doing the research. But it is also the case that we need to 
have more minority researchers in health services. There is a huge gap.
    We have an initiative to try to recruit more minority 
health services researchers through our training centers, but 
also to provide early career support for them so that they get 
through that awkward period when they are trying to get their 
first grant.
    The final issue is translating the research into practice, 
which is always a challenge. Here we are working very closely 
with the user community, that is, the people who are delivering 
care so that we can start by identifying what their needs are. 
Then we must make sure that we have partnerships that are 
developed at the beginning so that the research can get 
translated.
    We are focusing mostly on asthma and diabetes in this 
year's budget because we think those are two areas where these 
gaps are very large, and we want to work closely with the 
administration's racial disparities agenda so that we can try 
to help to close those gaps. So we have picked a couple of 
diseases where we think there is a big challenge. That is the 
plan, but it is a big challenge, as you know.
    Mr. Jackson. Thank you, Mr. Chair. I believe my time has 
expired, Mr. Chairman.
    Mr. Porter. It actually hasn't, but are you yielding back?
    Mr. Jackson. I yield back.
    Mr. Porter. All right. Mrs. Northup.

                            FEAR OF LAWSUITS

    Mrs. Northup. Yes. Thank you, Doctor. And I have a number 
of questions. I am sure I won't get through them all, but I 
will try to move as quickly as possible.
    I want to ask you about some of the research you are doing 
on new best practices, more effective means of approaching 
health care that also might be financially more feasible. I 
just wondered if you run into much opposition based on the fear 
of lawsuits. I am aware of situations in my own family where 
less is sometimes more. I often wonder why any doctor or any 
health provider would promote less considering the exposure 
they might have to a lawsuit if there isn't a good outcome.
    Dr. Eisenberg. Well, that is an issue we take very 
seriously and are trying to deal with in several ways. The 
first way is that, for physicians, the best defense is good 
evidence that the physician has followed practices for which 
there is a relationship between what he or she has done and 
good outcomes.
    And for that reason, we are sponsoring research that is 
just that. It is evidence-based medicine, research that tries 
to show what does make a difference. Because what we have heard 
from the legal community is that, whereas sometimes the lawsuit 
is, of course, risked by a physician, when the physician is 
challenged for the practice, the best defense is to say that 
there has been good research that shows that this works. I must 
say a civil action notwithstanding. But we do know that good 
evidence is the best defense that a physician can have.
    The second is that much of this evidence that we are 
gathering is to be used for improving choice and improving the 
quality of care that is provided for clinicians. It raises a 
very fundamental issue about the degree to which the data ought 
to be maintained and protected so that the confidentiality of 
the patient is protected and the confidentiality of the 
provider is protected.
    The PROs do have the ability to keep the data confidential; 
and I think that is something that we ought to be thinking 
about as we move forward, the degree to which these data need 
to be confidential if they are going to be used to help 
physicians and hospitals with the quality improvement.
    The final thing I will say is that, at this very moment we 
are sponsoring or cosponsoring a conference on how this 
information can get used to make better decisions about which 
services to provide. The legal community, the medical community 
and health services community are coming together to try to 
reach a common understanding of what evidence is.
    And then one last comment I will make--I know I am using up 
all your time--we are going to try to reduce errors in medicine 
through this mechanism, too.

                       HEALTH INSURANCE COVERAGE

    Mrs. Northup. Let me point out to this Committee, because I 
think this is important, that I saw on page 83 of your 
justification that you found that a greater percentage of 
workers are being offered insurance by their employers in 1996 
over 1987. However, a smaller percentage of those employees are 
actually accepting the policy.
    And I think that this is really important, because I have, 
again, experienced a number of companies that share the cost of 
insurance and co-payments with their employees. And when you 
increase the cost of insurance, there is a direct result where 
the employee just turns it down because they simply don't want 
to make that--share in that cost. They don't want a higher-
priced premium.
    I don't know whether you did the research, but it also was 
discovered that Federal employees who have the widest array of 
choices have voted with their pocketbooks and have chosen 
cheaper policies that have fewer coverages because that is what 
is most important to them. So as we confront the dilemma of 
mandates, I think it is important that your information help 
boost our information.
    Dr. Eisenberg. Yes. It is very important.
    In consideration of the time, I will just make one brief 
comment which is that the Consumer Assessment of Health Plans 
is being evaluated so that we can see what difference it makes. 
What we are finding in the early results of how it is being 
used, is that people who have a choice are often making 
decisions to go with the lowest cost plan if there isn't 
evidence of difference of quality among the plans.
    As CAHPS becomes available and they see that there is 
difference among plan quality, people who are switching plans 
do seem to be using the CAHPS results to make choices on 
quality as well as decisions based on cost. I think that that 
is good, because the cost will always dominate if people don't 
understand what the differences in quality are.
    Mrs. Northup. Okay.
    Mr. Porter. Thank you, Mrs. Northup.
    Ms. Pelosi.

               HIV COST, SERVICES, AND UTILIZATION STUDY

    Ms. Pelosi. Thank you, Mr. Chairman.
    Thank you very much, Dr. Eisenberg.
    First of all, I want to associate myself with the question 
asked by my colleague, Mr. Jackson, about the disparity; and I 
appreciate your answer. But it will be our relentless mantra. 
Our great leader, Mr. Stokes, is no longer with us, but 
unfortunately the problem is, and therefore the issue will be 
with us. I am glad Mr. Jackson is taking a lead on that.
    In December, the first results of your HIV Cost Services 
Utilization Study, HCSUS, were published, and they indicate 
that many individuals with HIV infection are not receiving 
medical care at least as often as every 6 months and that 
people with HIV are more likely to lack health insurance than 
the general population.
    It is my understanding that future articles based on the 
HCSUS study will provide us with a wealth of information on the 
quality of care received by people with HIV. Can you tell us 
more about the kinds of information we can expect from HCSUS 
study?
    And also, my next question, I will combine, the funding of 
the HCSUS survey expires this year. Do you plan new efforts in 
this area, possibly a similar data collection tool to examine 
the cost of use and access of care for other chronic diseases? 
What is unique about the kind of research represented by HCSUS?
    Dr. Eisenberg. What is unique about HCSUS is that it is a 
survey in which the information about individuals who are 
infected with the HIV virus is collected from the individual 
and from their providers. So, we can get data about the 
clinical and the personal issues that they face, as well as the 
cost issues.
    To your point about what kinds of information is going to 
be coming out, we believe that there is a treasure trove of 
information here. The first article was recently published and 
pointed out, for example, that it is not as expensive a disease 
as we used to think it is. The average cost is $20,000 per 
person who has HIV. That either tells us it is not as expensive 
because we found less expensive ways of treating it or, that 
they aren't getting the care they should be getting. Further 
research is going to address that kind of a question with 
regard to HIV.
    What will we do next? We are talking with the people who 
are carrying out the HCSUS study, a group at Rand, at the 
University of California, Los Angeles, and San Diego 
principally, about the prospects for our continuing funding. We 
are looking forward to getting proposals from them that we can 
evaluate. We would also see if we can find sister agencies who, 
as they have in the past, would be willing to co-fund it with 
us, depending upon the merits of the application.
    But, in addition to that, we are looking at a lower cost 
option, which will take advantage of a national network of HIV 
providers. We want to fund this project this year and in coming 
years to gather data from a community-based perspective. This 
would be a less expensive option to gather the data and would 
give us a broader array, about 10 times as many patients.
    So we will be evaluating those two options, but we are 
committed to collecting information on what is happening to 
people who have HIV.

                                 ETHICS

    Ms. Pelosi. Thank you.
    I was interested in, having read your presentation around 
the three priority areas, and I just wondered, as you are 
presenting the new tools and talent and priorities, et cetera, 
are you doing anything in the area of ethics as a tool for how 
we deal with this issue?
    Dr. Eisenberg. In two ways. One of them is the ethics of 
health services research. The ethics of research has heretofore 
mostly focused on randomized trials and informed consent. But 
there are some very important issues in health services 
research, how we use large databases and issues of 
confidentiality that we are very concerned about. We want to do 
research on ways in which we can improve the ethics of 
research.
    But the flip side is also the case, that is to say, 
research about ethics. We have a collaborative program that we 
started 6 months ago with the NIH ethics group. We hired 
someone, in collaboration with the NIH, to focus more on the 
kind of ethics that AHCPR focuses on, having to do with the 
delivery of care, how we deal with the constraints of 
resources, what people call rationing, how we deal withdoctor/
patient interactions and communication, the confidence between doctors 
and patients and the very special relationship that exists there.
    We also had an expert panel meeting with about 15 of the 
leading experts in medical ethics in the country to ask them 
what they thought we ought to be studying, where are the gaps 
in knowledge in ethics related to the delivery of care. The 
agenda is huge. Part of what we would like to do in 2000 is get 
started on that agenda because it is very challenging.
    Ms. Pelosi. Where is that? One? Two?
    Dr. Eisenberg. It would be in priority one right now. I 
wish I could tell you we are far enough along to put it into 
priority two, but we are not.
    Ms. Pelosi. Thank you. I appreciate your answer.
    Our time is expired. I will submit for the record a 
question on the funding.
    Mr. Porter. Thank you, Ms. Pelosi.
    Dr. Eisenberg, I apologize for the shortness of this 
hearing. You are probably happy, but we are not happy, because 
you are doing such a wonderful job at the agency, and we really 
need to know more about what you are doing, and the time that 
we have available just isn't long enough, obviously. So we do 
apologize. We appreciate the job that you are doing, and thank 
you for coming to testify this morning.
    Dr. Eisenberg. Thank you. We appreciate it.
    Mr. Porter. We have to go to more conferences where I can 
hear more.
    The subcommittee stands in recess until 10 a.m. on Tuesday, 
February 23.
    [The following questions were submitted to be answered for 
the record:]

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                                      Tuesday, February 23, 1999.  

              HEALTH RESOURCES AND SERVICES ADMINISTRATION

                               WITNESSES

CLAUDE E. FOX, ADMINISTRATOR
THOMAS G. MORFORD, DEPUTY ADMINISTRATOR, HEALTH RESOURCES AND SERVICES 
    ADMINISTRATION
MARILYN H. GASTON, ASSOCIATE ADMINISTRATOR, BUREAU OF PRIMARY HEALTH 
    CARE
PETER VAN DYCK, ACTING ASSOCIATE ADMINISTRATOR, MATERNAL AND CHILD 
    HEALTH BUREAU
JOSEPH F. O'NEILL, ASSOCIATE ADMINISTRATOR FOR AIDS AND DIRECTOR, 
    OFFICE OF SPECIAL PROGRAMS
DENA PUSKIN, DIRECTOR, OFFICE FOR THE ADVANCEMENT OF TELEHEALTH
WAYNE W. MYERS, DIRECTOR, OFFICE OF RURAL HEALTH POLICY
VINCENT C. ROGERS, ASSOCIATE ADMINISTRATOR, BUREAU OF HEALTH 
    PROFESSIONS
WILLIAM R. BELDON, DIRECTOR, DIVISION OF DISCRETIONARY PROGRAMS

                       Introduction of Witnesses

    Mr. Porter [presiding]. The subcommittee will come to 
order.
    We continue our hearings for the budget of the Department 
of Health and Human Services with the Health Resources and 
Services Administration. We would like to welcome Dr. Claude E. 
Fox, the Administrator.
    Dr. Fox, this is your second appearance, I believe, before 
the committee. Why don't you introduce the people who are with 
you, and then proceed with your statement.
    Dr. Fox. Thank you, Mr. Chairman. We are pleased to be here 
today. I will start from the right. Mr. Bill Beldon is from the 
Department Budget Office. Dr. Dena Puskin, who is the Director 
of our new Office of Telehealth, Telemedicine. Okay. Dr. Peter 
van Dyck, who is the Acting Associate Administrator for 
Maternal and Child Health. Dr. Joseph O'Neill is head of our 
HIV/AIDS Bureau. Mr. Tom Morford is Deputy for the agency. Dr. 
Marilyn Gaston is the Associate Administrator for the Bureau of 
Primary Health Care. Dr. Vincent Rogers is our relatively new 
Director or Associate Administrator for Health Professions. Dr. 
Wayne Myers is also new since last year. He is the Director of 
the Office of Rural Health. Did I get everybody?

                           Opening Statement

    Mr. Chairman, we are pleased to be here to talk about the 
HRSA 2000 budget. Just in the way of opening comments, there 
are a lot of barriers to care in this country. I guess if we 
had a thread that runs through HRSA, it is ways to improve 
access to care for Americans. Access may not just be the 
failure to have insurance. It may be the fact that you don't 
have healthcare providers in your community. It may be that you 
live in a rural area or an urban area. There are a lot of 
reasons for failure of access. I guess everything we do in one 
way or the other, even organ transplantation, is an attempt to 
address the access issue.
    The HRSA budget, I am just going to run down quickly the 
areas where we have changes. I want to begin with the community 
health centers. We now serve some 9 million people through 
community health centers. We have $945 million. We are asking 
for a $20 million increase in the budget for the consolidated 
health centers. We plan to add 28 sites and about 125,000 
people through this budget.
    I would point out that currently, because of the racial 
disparities around the health issues in America, 65 percent of 
our patients at community health centers are minorities. So we 
really reach into those communities.
    There is also an economic benefit to many of the programs. 
I think the community health centers would be no exception 
through the direct healthcare we provide. We also support 
through this budget the National Health Service Corps that 
reaches out with about 2,500 providers. What weconsider from a 
bureaucratic standpoint, a rapid response team as far as being able to 
go into communities and provide healthcare professionals in a 
relatively short period of time to meet again, the needs of under-
served communities.
    The HIV/AIDS area, we are asking for approximately $100,000 
[Clerk's note.--Later corrected to $100 million] there. As you 
know, there has been a significant decrease in the HIV/AIDS 
death rate over the least several years. I think, and we think 
in large part, to the Ryan White program and the kind of care 
that is provided through this agency.
    We are asking this year for an additional $16 million in 
our grants to cities that will let us expand services to some 
additional communities there. We are asking for some $45 
million in title II. The majority of that, some $35 million 
will go for the ADAP program. We hope to add over 4,000 new 
patients there, which will bring that total to about 60,000 
[Clerk's note.--Later corrected to 82,200] patients receiving 
drugs through ADAP.
    We are looking to add some $36 million in title III, our 
early intervention and our primary care. This really lets us 
follow up on our Congressional Black Caucus commitment last 
year, where we put out planning grants. We want to follow that 
up now with care grants to a number of communities. We are 
looking to increase services to about 10,000 people with those 
dollars. Then finally, an increase of $2 million in the 
pediatric, maternal and infant area, again, that serve pregnant 
women, infants and children.
    In the health professions area, we have two critical issues 
we are dealing with there. One is diversity and distribution. 
The HRSA programs, on the programs we fund in health 
professions, of the graduates of the programs we support, three 
to six times as many go into under-served areas as programs 
that are not supported by HRSA dollars. So we feel like we do a 
good job. We also know in a number of the programs like Allied 
Health and some of the others, we do an outstanding job in 
bringing in minorities to health professions.
    The dollars this year are in the area of increasing funding 
to the Centers of Excellence, historically black colleges, 
Hispanic-serving institutions, our health career opportunities 
program, which allow us to both double the number of Centers of 
Excellence that we are funding, and increase the number of 
students that we support, minority students and others by at 
least 2,500, if not more. So we think we can make significant 
increases there.
    We also are asking for $40 million in a children's GME 
program. As you may be aware, 55 of the children's hospitals 
are freestanding and collect virtually no Medicare GME dollars. 
At the same time, these hospitals provide an average of 50 
percent of their care to kids that are either Medicaid or 
uninsured. Because about 25 percent of pediatric residents are 
trained in children's hospitals, we feel a need to provide 
support there. So we are asking for $40 million, this is new 
money, to establish a formula grant program to provide to the 
freestanding children's hospitals. Again, we think this will 
help them.
    The average GME reimbursement for most hospitals is $33,000 
per resident. The average GME reimbursement for children 
hospitals is $400 per resident. There is a huge discrepancy.
    In the area of maternal and child health, we are asking for 
the same amount of money in the maternal and child health block 
grant. Again, we are doing a number of things that are not 
going to be done by the Children's Health Insurance Program, 
supporting individuals that are not covered there, and 
developing systems that are not funded by that program. We also 
want to continue the support for the Healthy Start initiative 
that we think is crucial to good maternal and child health.
    We are asking within the maternal and child health area for 
a new program, funding for universal newborn hearing screening. 
We know that currently today 85 [Clerk's note.--Later corrected 
to 80] percent of infants are discharged from hospitals without 
being screened for hearing problems. Yet know that one to three 
out of 1,000 well babies, with no risk factors, having hearing 
difficulty and will have hearing difficulty. It is much higher 
among preemies. But the bottom line is, the technology is here 
now. There was a consensus panel several years ago at NIH that 
recommended universal newborn hearing screening. The Academy of 
Pediatrics published an update policy statement in the Feb. 
1999 issue of Pediatrics endorsing universal newborn hearing 
screening and early intervention. The technology has now made 
it accessible and cheap. So we are going to recommend $4 
million that will help us to work with States to begin 
universal newborn screening and to make sure that those infants 
that are identified with hearing defects indeed have follow-up.
    We have a set of what we call critical care programs we are 
recommending funding for. Several of these are continuation 
funding for the children's EMS program and for traumatic brain 
injury. We have two areas that are new. One is poison control. 
The number of poison control centers in this country generally 
are not supported by Federal funds. They have been on the 
decline. Most of them have some significant needs as far as 
infrastructure. This Congress asked us to look at this issue. 
We had an advisory committee that made a set of 
recommendations. Last year you provided almost $1 million to 
CDC to put together a 1-800 toll-free number for poison 
control. We were working with them on that.
    One of the other things we want to do is a follow up of a 
series of recommendations that were made out of this 
advisorycommittee. It was to begin to develop some uniform patient 
management guidelines that can be available to all the poison control 
centers. We are asking for $1.5 million to do that.
    We are also asking for $1 million in the area of emergency 
medical trauma services. I was previously a State health 
officer, and dealt with a lot of EMS issues. I guess it 
appalled me when I got to the Federal level and realize we have 
now virtually no funding for trauma EMS. We would like to have 
$1 million to begin to do an assessment of the States, figure 
out where we are, the whole issue of community's response to 
terrorism, to other issues that--I come from a rural community 
that really depend on EMS trauma system. Injuries are the 
number one leading cause of death between age one and 34. So if 
we could have a little bit of money, we feel like we can begin 
to do good assessment of what is out there, and I think come 
back with a recommendation on where to go from there. So that 
is part of our critical care programs area.
    In the Office of Rural Health, we have $25 million there 
that is a continuation of funding from last year, to work on 
our Critical Access Hospital program to help rural hospitals 
both survive and get into the Medicare cost reimbursement 
program. We formed, as I mentioned, an Office of Telehealth. We 
have had a telemedicine activity with the Office of Rural 
Health in the past. We felt it needed to be in addition to the 
rural emphasis, we needed an urban focus, because there are 
some problems in urban areas as well. So we formed an office 
that cuts across all of HRSA.
    Our intent, and it is very different from what NIH is 
doing, is to look at the infrastructure and to help everybody 
out there, if possible, have a Chevrolet and not have a few 
people with a Cadillac. We really want to help with working, 
providing technical assistance to various entities about what 
to buy, what is out there. Not what specific equipment, but how 
to put the systems together in a way that is most cost 
efficient. Again, it is I think an excellent technical 
assistance project that will help our grantees in other parts 
of the community as well.
    We are asking for in the area of family planning, a $25 
million increase there. You may be aware that the title X 
program provides care to some 450,000 clients, primarily women 
[Clerk's note.--Later corrected to 4.5 million]. We are asking 
for funding that will increase the number of clients served 
annually by 500,000.
    These dollars are used mainly to support women who don't 
have other funding sources. There is a real need as a part of 
their care, to make sure these women get breast and cervical 
cancer screening, that when they have sexually transmitted 
diseases, that they are treated and followed up. There has been 
an emphasis on male involvement. We think this $25 million will 
be quite well spent.
    The final area is our program management area. We have a 
single line item in HRSA that funds everything as far as all of 
our administrative costs. It funds our rent, funds our heat, it 
funds our telephones, it funds our computers, it funds our 
training, it funds our regional offices, it funds all of our 
personnel. That is our program management account. We have 
reduced our FTEs over the last several years some 300. But we 
are asking for a $3 million increase this year. Actually, if 
you look at our costs just for the cost increases of all the 
personnel across the agency for the cost of living and other 
costs, the mandated costs are like $5 million. So we think this 
is minimal. But again, this account supports all of the 
administrative costs to the agency except for those areas where 
we have a trust fund, like the Vaccine program or the National 
Practitioner Databank.
    Finally, we have done a lot around performance planning. We 
have reduced and consolidated our performance measures. We have 
added some performance measures in the area of children's GME, 
the rural hospital flexibility grants, telehealth, and family 
planning, where we have not had any. We are going to apply it 
well there.
    That is our budget in summary. I look forward to any 
questions you or the committee might have.
    [The prepared statement follows:]

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    Mr. Porter. Dr. Fox, thank you very much for your excellent 
testimony. I would tell the subcommittee members that we will 
operate under the six minute rule, and expect to have a second 
round. I will also say that you now have microphones in front 
of you, which is brand new. Mr. Jackson arrived right at the 
right moment, and Mr. Cunningham as well.

                      RACIAL DISPARITIES IN HEALTH

    Dr. Fox, your testimony leads me to reinforce my belief 
that leadership makes a huge difference. You are doing a 
wonderful job at HRSA. I commend you for the kind of leadership 
that you bring to your position.
    Let me be devil's advocate here for a minute. The $70 
million that is in the President's initiative to eliminate 
racial disparities in health, I have no doubt that it is 
important, but I have some need to understand why this money is 
in the community health centers, where 65 percent of the 
population served is racial or ethnic minorities. Presumably 
that is not particularly where the problem is, although there 
certainly may be problems there. Can you explain that a little 
more to us and tell us why the money is in that account?
    Dr. Fox. Sure. Well, to begin with, we are only reaching a 
fraction of the number of people out there that need health 
care. You may be aware that there has been about a 25 percent 
increase over the last I think three or four years in the 
number of uninsured in this country that are coming to all 
providers. We have seen a 49 percent increase coming to 
community health centers. We are only reaching 9 million 
people. There are some 43 to 46 million out there that are 
uninsured. So we feel like that the dollars to the community 
health centers certainly do in large part reach the minority 
populations, but we are only reaching a fraction, we are only 
reaching a fraction of the number of people that need to be 
reached.
    The whole agency is around racial disparities, Mr. 
Chairman. We know that in the area of HIV/AIDS, probably 50 to 
60 percent of the money we spend is on minorities. Title IV of 
Ryan White is 84 percent. So we have a number of areas where we 
spend a lot of our emphasis in that area. We are proud of that. 
But we are not reaching the people we need. We have much more 
need for community health centers, for National Health Service 
Corps than we have dollars available.
    Mr. Porter. So that this would be the place where we can 
make the most progress in reaching out to serve more?
    Dr. Fox. I don't want to say the most, because again, we 
have a variety. Again, in health professions, we target 
minorities and under-served populations. But it certainly is an 
area for primary care, where I think we could make a huge 
difference if we had the dollars.
    Mr. Porter. Well, this is an area that the subcommittee has 
made a very high priority as well. So I think we are tracking 
very well in that regard.

                            FAMILY PLANNING

    You mentioned that the $25 million in Title X would allow 
us to increase outreach there by about 500,000 poor women, 
presumably. Have you made an estimate of how much under-service 
we have in that area across the country?
    Dr. Fox. We can get that for you. I know again, there is a 
tremendous need in the title X clinics. Those clinics are 
administered, I think probably a third of them are in health 
departments. In fact, when I came up through the public health 
system and spent a lot of my time seeing patients who came in, 
funded off of title X. These women had virtually nowhere else 
to go.
    I will point out that although I can't give you the exact 
figures, I know over the last 10 to 15 years, funding for the 
title X program has not kept pace with inflation. So we are 
really behind the eight ball as far as funding for those 
services. Again, we can get you the demands, but I know we are 
not meeting the demands there.
    Mr. Porter. I would like to see the figures because I think 
this is a program that does reach people who otherwise are just 
lost in the system, and gives them their only access to primary 
care anywhere along the line.
    [The information follows:]

    According to data from the National Survey of Family 
Growth, 2,145,354 poor women at risk of unintended pregnancy 
(defined as under 150 percent of poverty, between the ages of 
15 and 44 years, sexually active, fecund and not currently 
pregnant, postpartum or seeking pregnancy) did not make a 
family planning visit to a doctor or clinic in 1995, the latest 
year for which data are available. If the definition of poor is 
extended to under 250 percent of poverty, this figure doubles 
to 4,251,050 women. We can also assume that large numbers of 
men are under-served; only 2 percent of Title X clients are 
male. Unfortunately, until the next cycle of the National 
Survey of Family Growth which will include men for the first 
time, we have no way of estimating their number.

                        CHILDREN'S HOSPITALS GME

    Mr. Porter. You mentioned the need to provide for 
children's hospitals because they don't get Medicare funding 
and since managed care is not looking to help, you propose to 
provide $40 million. Children's Hospital in Chicago has a 
tremendous problem. As you say, they are getting $400, and they 
need $33,000. But our estimate of the cost for children's 
hospitals across the whole country was something like $280 
million, not $40 million. Where did you get this figure, and 
how many hospitals are going to be served by this?
    Dr. Fox. I think again, this is a start. These are for the 
55 that are freestanding. There are obviously I believe 100, 
approximately 100 children's hospitals nationwide. We are 
targeting the freestanding ones because they generally don't, 
because they are not associated with another facility, do not 
share in the Medicare GME. So we think they have specific 
problems. Most of them run a net operating loss I think of 
about minus six percent. The average percent of care is about 
half their care is to either Medicaid or uninsured. As you 
said, as the managed care system has continued to evolve in 
Medicaid, those funds are being decreased over time. So it is a 
start. We are not saying it fully funds what they need. But at 
least will give them more health than they are able to get 
today.
    Mr. Porter. Do I assume correctly that this is not 
authorized?
    Dr. Fox. Right. There will have to be some type of 
authorizing legislation.
    Mr. Porter. Yes. I think it needs authorizing legislation.

                       UNIVERSAL NEWBORN HEARING

    Now you talked about hearing screening for newborns. My 
recollection was that Congressman Walsh had a proposal in that 
area, but that it did not in the final analysis get adopted. Am 
I wrong about that?
    Dr. Fox. I am not familiar with that, Mr. Chairman.
    [Clerk's note.--Congressman Walsh indeed introduced 
legislation last year, but it was not enacted into law. This is 
a separate activity from the $4 million proposed in the 
President's budget.]
    Mr. Porter. We had it in the House bill. I think in the 
final conference, it wasn't included. Don't you need an 
authorization there as well?
    Dr. Fox. Well, I don't believe we do. Again, we are not 
proposing here to pay for the screening. What we are proposing 
is to work with the States. There are only nine [Clerk's 
note.--Later corrected to 10] States that now mandate 
screening. Most States do not. Even those States that do, we 
know the kids that are screened, only about 60 percent of them 
never get the follow ups.
    So what we are going to do is what we do with the maternal 
and child health block grant and the additional funds now, is 
we are going to help States with putting the screening 
together, figuring out a way to get it paid for, making sure 
that those children, those infants that are identified with a 
hearing defect or a potential defect, that they get to 
remediation, and that those systems, just like we do with 
newborn screening when a child is found to have PKU, we make 
sure that they get the treatment, that they stay in treatment 
and it is not just identified, but the problem is ameliorated 
somehow.
    So that is what the $4 million is for, not to actually pay 
for the screening. We are going to look to State Medicaid or 
insurance or whatever, the payers that are out there to cover 
the actual cost of the screening.
    Mr. Porter. I want to get Congressman Walsh together with 
you on this, because he has been working on this very hard. 
Apparently you see it as the same problem he does.
    Dr. Fox. Right. We would love to.

                            DIVERSITY--COES

    Mr. Porter. Ms. Pelosi.
    Ms. Pelosi. Thank you very much, Mr. Chairman. I too want 
to commend Dr. Fox for his leadership and for his presentation 
today as well, and welcome all of the witnesses. I associate 
myself with the chairman's question about the disparity and 
appreciated your response to the disparity in access to health 
care, and am glad that you focused so much attention to it in 
your statement.
    I just had a quick question before my other questions. That 
is, you said diversity is a critical element in funding, and 
HRSA emphasizes support for historically black colleges and 
universities, and Hispanic-serving institutions and other 
institutions that train substantial numbers of minority 
students, and that is important because we have to have 
minority healthcare providers. But when you say emphasizes,what 
do you mean? In other words, you are encouraging us to support them 
more?
    Dr. Fox. We actually provide direct grants. We not only 
provide direct grants to these universities and schools to 
support their faculty, to support their students, but we have 
even done things like recently we have actually gone around to 
historically black colleges and also to the tribal colleges, 
and gone in doing grant training exercises. We have actually 
had some staff go in and work with them on their own technical 
expertise to put grants together so that they can actually not 
only compete for these funds, but other HRSA funds.
    So we directly fund these institutions, their faculty, 
their students. We also provide technical assistance to them in 
other ways.
    Ms. Pelosi. So this is over and above, separate from the 
increased funding that we got last year in our committee that 
we worked with the Hispanic Caucus?
    Dr. Fox. Right. We are asking for $15 million more in 
health professions to deal with the diversity issue.
    Ms. Pelosi. That is wonderful. I am very pleased to hear 
that.

                    HEALTH CARE ACCESS FOR UNINSURED

    The administration has proposed $25 million in the Fiscal 
Year 2000 budget for health care access for the uninsured. My 
understanding is that this initiative is intended to help 
community health centers, public hospitals and other 
organizations to better collaborate among themselves and 
improve health care for their clients.
    Could you tell us more about the target population of this 
initiative, and how the program will interface with other HRSA 
programs?
    Dr. Fox. Certainly. Well, we actually, this program will 
interface quite well. I started two years ago, when I arrived 
at HRSA, having come from the State level, we spent a lot of 
time trying to think about how can we make the HRSA program as 
seamless as possible at the community level, and what kind of 
things we can do to make sure that the right hand knows what 
the left is doing, and that we are working together. So I think 
from the conceptual standpoint, it fits together real well.
    We really anticipate that the target population for this 
program will be those individuals that are too poor to buy 
private insurance, but have too much money to get Medicaid or 
other public funding. They are going to be the ones in between, 
perhaps the working poor, who can pay a little bit on a sliding 
fee scale, but can't pay the full freight. That is really the 
group of folks that we are trying to target. We think there are 
a lot of them out there. As you know, there are a lot of kinds 
that are under-insured, that are not eligible for CHIP. So this 
is the group we are targeting.
    The intent of this program is not to create a new system, 
but again, at the community level to encourage communities, and 
there are some that have done some positive things in this 
area, but to encourage the communities to look at what is out 
there and to figure out a way to pull it together in a way 
where the whole is greater than the sum of the parts.
    It is also consistent with what I think we are charged to 
do by Congress under the Critical Access Hospital program. I 
come from a rural town of 2,500 population. You may have a 
health department on one corner and a community health center 
on another corner, and a hospital here, and a home health 
agency here, and HUD coming in here, and Head Start here, and 
not any of them are talking or working together. Now that is 
not true across the board, but that is the kind of scenario we 
would like to bring them together and see.
    For instance, in a rural hospital, could perhaps we provide 
respite services through AOA, adult daycare? Those are the kind 
of things where I think just better coordination of what is 
there may actually increase the survival of each one of those 
safety net providers, and I think allow perhaps some additional 
people to be seen.
    This program is not--we are not trying to say with this 
program there is not a need for additional service funding. But 
what we are saying is it is really a dual approach that is 
needed. One is to figure out how better to make sure that the 
pieces out there are aware of each other and work together, and 
then to identify the service deficits and fund those.

                               RYAN WHITE

    Ms. Pelosi. I thank you. On the subject of collaboration, I 
wanted to move onto Ryan White care. I thank the administration 
for seeking additional funds. I am concerned that the proposed 
seven percent increase will not allow us, though, to keep pace 
with the growing epidemic of AIDS. There are more people living 
with AIDS, as you know, than ever before.
    Increasingly we read reports of growing numbers of people 
who are failing to control their HIV infection, even the best 
care available. What role does Ryan White Care program play in 
delivering care and services to people with HIV, and how do the 
different titles of the act, including ADAP, work together to 
provide necessary care for people with HIV? Maybe Dr. O'Neill--
well, it is up to you to respond.
    Dr. Fox. Okay. Let me make a comment and then ask Joe to 
talk about it. We recently reorganized the agency. I guess it 
has been two years ago now, recently in bureaucratic terms. We 
pulled all the titles of Ryan White under one bureau that Dr. 
O'Neill has responsibility for. I think that to begin with, 
that has really made possible the communication across the 
titles, and try to look at it as a program, that again, we are 
trying to think about thepopulation and how the titles together 
can serve the population. So I think it has set the stage for some 
things that are very positive.
    We know that within the program there is a lot of primary 
care being provided. I will ask Joe to comment on any of the 
specifics. But I think that we do have, as we have people who 
are surviving with HIV, as you already alluded, we actually 
have a growing number of people who need services. So there are 
a growing number of people that need drugs, that need primary 
care. We have done some things I would be glad to discuss 
further with the committee to try to use the taxpayers' dollars 
well, particularly in the ADAP program. But we have now 12 
States that have capped enrollment on ADAP. We have 10 States 
that have waiting lists. We have five States that have capped 
expenditures. So we do know that, you know, we still have some 
need out there that we are not meeting.
    Joe, do you want to comment?
    Dr. O'Neill. I think the most important change that has 
happened in the last couple of years around the reorganization 
has been to let the Ryan White Care Act operate as a unified 
national program, rather than as four or five independently 
moving pieces. That really I think is for the benefit of people 
living with HIV/AIDS around the country, because it is such a 
complex illness, both medically and socio-economically that the 
flexibility that the various operating pieces of the act give 
us to target particular communities to maintain local, the very 
important local control in areas where that is important.
    I am actually, and we can give specifics later or on the 
record, but there are a number of very clear things we can 
point to as really administrative successes in terms of pulling 
the programs together and beginning to operate this way. I 
would point out, for example, that we are very close to having 
a much more uniform data collection activity across all the 
titles, which should make our grantees very happy. We are much, 
much further along in terms of being able to evaluate the 
program as a national program. Before we meet next year, we 
will be able to give you some very good statistics about the 
kind of things that we have all been looking for. These would 
be statistics and information about who is being served by the 
Care Act, and data supported by places like Harvard University 
and the Rand Corporation and national researchers, who can 
really give us a much better understanding of the unmet need 
here.
    Ms. Pelosi. Thank you. My time has expired, but I might 
just say a quick sentence, that I am glad you emphasized the 
local control. I hope that it will continue to include 
flexibility in title I. Thank you so much.
    Mr. Porter. Thank you, Ms. Pelosi.
    Mr. Miller.

                           SPRANS/HEMOPHILIA

    Mr. Miller. Good morning.
    Dr. Fox. Good morning.
    Mr. Miller. You have a lot of different programs under you 
that are really very popular with the American people and with 
us here in Congress, and you do a very fine job.
    I am a little baffled by the administration, this $4 
billion area and you have got a $33 million increase. You 
mentioned about how programs are not keeping up with inflation. 
It bothers me or I am missing something, and maybe we can 
figure it out. That is not even a one percent increase. You 
have all these new programs and increases of important 
programs, but obviously we are slashing somewhere. So I would 
like to follow that up.
    Just one comment about one. There are some big programs 
obviously and some small programs. One small program I always 
look at, and I see that is always staying flat funded, is under 
the SPRANS program, which is hemophilia treatment centers. I am 
familiar with them. I know how they got developed, and I am 
glad they continue. It is not a very big part at $5 million out 
of $4 billion, but I am glad it continues, though it is flat 
funded, I mean as almost all these other programs.

                         PRIMARY CARE TRAINING

    So you had to set some priorities. I see you have done away 
with primary care training. I mean medical schools are under 
dramatic pressures from Medicare, from managed care. I don't 
have a medical school in my district, but I have one nearby I 
follow closely, University of South Florida. I know the 
struggles they are having. Then all of a sudden we are yanking 
away $79 million. I guess that is not important. Geriatrics, I 
have got more old people in my district than anybody in 
Congress. That is very important. But that program is being 
zeroed out.
    How did you justify that? I know you have to accept the 
number that Secretary Shalala gives you and the President gives 
her. But there are some very important programs here that are 
just not being funded very well. As a fiscal conservative, I am 
glad you are maybe eliminating programs. But I am not sold they 
should be eliminated.
    Dr. Fox. Mr. Miller, to point out one that we did receive a 
fairly sizeable increase from the Congress last year in which 
we very much appreciate. We obviously are aware of the budget 
caps and the constraints on the budget this year. Some tough 
choices were made in some of the programs like the health 
professions area, where there were some decreases. The 
administration felt that the market would come into play and 
support some of that. Some of these programs were quite small, 
and they felt that perhaps there were funding sources that 
could be made available from foundations and other entities. 
But you know, the bottomline is we made the judgements within 
the resources we felt would be available. Those are some tough choices.
    Mr. Miller. I know when Secretary Shalala was here, we were 
talking about NIH, for example, which gets a lot of support 
from this whole committee. Most of these programs are not 
partisan issues. NIH got less than an inflationary increase. 
There was an editorial in the Wall Street Journal by Al Hunt 
saying well, when Senator Kennedy quizzed the President, he 
said well, the President's response was well Republicans will 
take care of that in Congress. We will just fund our pet 
projects. It makes you think the whole process is not working 
very well if we end up saying well, we are not going to fund 
primary care or we are not going to fund geriatrics because 
someone else will find the money for it.
    Are these programs just not worthwhile? I guess you decided 
they are not worthwhile. You zeroed them out totally. Right?
    Dr. Fox. No, sir. We are not saying they are not 
worthwhile. In fact, if you look at some of these programs like 
the primary care area, we have a project in the chairman's 
district, Rush College of Medicine has a project with Cook 
County, where 70 percent of the graduates of that program went 
into under-served areas. So these programs do have a good 
result. Again, we feel like that in some areas the dollars may 
need to be elsewhere. Again, it is a series of tough choices. 
It certainly has nothing to say that the programs are not 
effective or not worthwhile.
    Mr. Miller. Like training in primary care medicine and 
dentistry, $79 million this current Fiscal Year, and zero next 
year. That is a big hit on medical schools, I would think.
    Dr. Fox. Well again, it is a significant change, and one we 
are concerned about. The dentistry area, we obviously have some 
concern of what is going to happen with the CHIP program and 
with the additional kids coming in the system there.

                     NATIONAL HEALTH SERVICE CORPS

    Mr. Miller. I suspect there is a game being played again, 
and it just bothers me.
    Let me switch to something else on that. GAO made a report 
on the National Health Services Corps. What has been the 
follow-up on that, some of the criticisms of the GAO about that 
program?
    Dr. Fox. Well, let me say that the National Health Services 
Corps, in my opinion, is a very good resource for communities, 
and one that we would like to see continue and move forward. At 
this point, we know that the one-year retention on the corps is 
about 65 percent.
    We recently also looked at longer-term retention. We are 
looking right now to try to see on a five-year basis what the 
retention is. We do not have those numbers yet.
    But what we do know is when we go past the one-year point, 
at least two-thirds of the people who have been in the Corps 
may not stay in that area, but they still continue to work in 
an under-served community. They may not work in that community 
where they were initially placed, but they work in an under-
served community somewhere.
    So I think that says that not only do we know with the one-
year we retain a significant number, but we also retain them at 
least as far as a service standpoint somewhere. Again, I come 
from a small rural area. I will tell you that if we had zero 
retention, which we do much better than that, but if we had 
zero retention, the benefit that the corps provides to those 
communities who would not have a physician, would not have a 
dentist, or would not have a mental health provider without 
them, to me is tremendous.
    So we have done a lot to try to increase retention. We are 
putting teams out there now. We are trying not to just put a 
physician out there by his or herself, but put them out there 
with a healthcare team. We are trying to set up a buddy system, 
where again, people can have some support and hopefully 
encourage encouragement from their colleagues to stay out 
there. We are working both better on our selection process for 
the corps, as well as what we are doing with the medical 
schools in trying to make sure that we are capturing students 
who are most likely to stay.
    So we have done a lot, we think, in trying to improve 
retention. The retention, I think again overall is much better 
than it has been.
    Mr. Miller. Well, my time has expired. I just want to 
conclude by saying I am just disappointed with the 
administration. It is not your problem, unfortunately. There 
are a lot of good programs here that need to be funded 
properly. The administration just gives you less than a one 
percent increase for a $4 billion program with all these good 
programs. That does not give you the flexibility to do what is 
right. So it becomes almost a useless budget proposal from the 
administration.
    Dr. Fox. If I could make one final comment. We are not 
denying the need, Mr. Miller. We certainly know it is there. 
But I think that again, within the budget and the dollars, the 
budget caps that are available, I think there were some tough 
choices that were made.
    Mr. Porter. Thank you, Mr. Miller.
    Mr. Jackson.

                    HEALTH PROFESSIONS ZERO FUNDING

    Mr. Jackson. Thank you, Mr. Chairman. Thank you, Dr. Fox, 
for your testimony. Mr. Chairman, all of my questions have 
centered around the zeroing out of the funding for health 
professions programs, particularly the primary care medicine 
and dentistry, which Mr. Miller has already articulated. So I 
don't want to exercise too much of ourtime with questions that 
have already been asked and answered.
    Suffice it to say, I think that Congressman Miller has 
raised some very serious concerns that I think we all have to 
pay very close attention to with respect to I guess in 1998, 
the actual, was it $77 million, in 1999 enacted $80 million, 
and then they zeroed it out in 2000, which is a substantial hit 
to primary care medicine and dentistry programs. I am very 
concerned about that.
    Dr. Fox, at the appropriate time, if you could try and 
assuage many of our concerns about where these resources will 
go as we have seemed to have scaled them down, it would be more 
than appreciated.
    I thank you, Mr. Chairman. I have no further questions.
    Mr. Porter. Thank you, Mr. Jackson.
    Mr. Cunningham.

                             BORDER HEALTH

    Mr. Cunningham. Thank you, Mr. Chairman.
    Dr. Fox, I would like to thank you for your work. It is 
always nice to come to a hearing and hear other Members on both 
sides of the aisle laud someone's participation and endeavor. I 
have got some questions.
    California, about one in every nine Americans lives in the 
State of California. It is a lot warmer there today, Doctor. I 
froze this morning. [Laughter.]
    We have got a tremendous problem as most border States have 
with undocumented in some cases. In some cases there are legal 
immigrants in our hospitals that all have the common bond of 
uninsured. I know Governor Wilson at the time asked for 
additional funds to cover this. I am sure Gray Davis, our 
newest governor, is going to be asking for the same kind of 
thing.
    Do you reasonably feel that we can gain these additional 
funds since there is such a demand? We are averaging 50,000 new 
uninsured per month in the State of California. You can imagine 
the drain that that puts on us.
    Dr. Fox. Well, the border health issue is a tremendous 
problem. In fact, we have a border health initiative within the 
agency. One of the things we have done since I came is to try 
to sit down not only with our sister agency, CDC and SAMHSA, 
but also within the agency, and try to see one, what we are 
doing at the border now, and two, what we need to do.
    We have actually redirected some of our internal resources 
to try to concentrate on the border because of the tremendous 
health problems there. There are still some unmet needs, as you 
have already alluded.

                              CHIP PROGRAM

    A lot to be done. One of the problems in the CHIP program, 
particularly in California, is the public charge issue and the 
hesitancy of parents even where the child, the infant is an 
American citizen, to bring that child in. I think California, 
if I remember the numbers correctly, had about 250,000 children 
that are eligible for CHIP. At this point, only 50,000 have 
actually signed up. We think again, this is for a variety of 
reasons. But one, because of the public charge issue.
    So there is a tremendous problem we know in the Colonias in 
Texas and Arizona, as well as the border in California, a 
number of needs both in the area of maternal and child health 
and primary care. Just to say I agree with you, we have tried 
internally to kind of put our money where our mouth was and use 
some additional resources. We have to target that, although we 
do not have enough to do what needs to be done. But we are very 
concerned about it. We would be glad to work with you any way 
we can.
    Mr. Cunningham. Thank you, Dr. Fox. If our great chairman 
could send some extra money, do you think that the 
administration could go along with an add where the dollars are 
being taken away from the teaching hospitals, that we can plus-
up the dollars where they were zeroed? The children's hospital 
in San Diego is not in my district, but I know that it treats a 
lot of different folks in there. Also, we have a lot of look-
alike health centers that reach out and meet a lot of people 
even though they do not receive Federal funding from the health 
centers program.
    I would also like to tell you, Doc, I am pro-life, but I 
also went to a family planning clinic who I had been told is 
the evil empire. I witnessed a lot of women and children being 
taken care of in there. I would think that this committee can 
at least come together on a resolution that says we can focus 
on those areas that can help in that endeavor. My eyes were 
opened a little bit I think, and I would recommend some of my 
colleagues visit some of those planning centers. Mine in San 
Diego is doing a pretty good job.
    But the hospitals, like Children's and so on like that, it 
is going to be a tremendous blow to the children out in San 
Diego.
    Dr. Fox. One of the things we do in the agency is not only 
direct services, but we try to help with outreach. For 
instance, we are working with some of the States in trying to 
look at ways to get the kids in and get them on CHIP. I mean 
the more kids that are on CHIP, the less the drain on all the 
health care system that is providing care now at no cost or 
very little cost. So let me just say in general, I think any 
dollars the committee feels inclined to give the agency, I 
think we will do our best to use any way we can.
    Mr. Cunningham. Well, I don't want you to use it any way 
you can. I want you to use it for a specific purpose.
    Dr. Fox. I guess I am talking about the issues of both the 
border health and the other ones that you alluded to. Again, I 
think we have some activities in that area, and wecan very much 
increase our activities.

                             POISON CONTROL

    Mr. Cunningham. I don't know how much time I have left. I 
don't see a red light. But the administration budget contains 
funds to help a network for poison control. I had a little girl 
die in my district with e coli. Many of the other hospitals 
were not aware that there was even a problem. I know hepatitis 
in a border State is the same thing. Could you briefly explain 
what the administration program is going to do in that?
    Dr. Fox. There are a series of recommendations, of which 
only two at this point are we asking for funding. The advisory 
committee that we had look at this recommended a 1-800 line, a 
national line, so that there is just one number that every 
American has to know. It would then link to the poison control 
centers where they were calling from. We are actually doing 
this with the CHIP program as well. So it is technically 
feasible to do. So that is the first thing. That is already, 
Congress has provided some dollars. We are working with the CDC 
on getting it up and running.
    The second is the funding that we are requesting here for 
some uniform management guidelines around certain conditions, 
so that there are some things that can be put out, that can be 
developed about what do you do when, that again, poison control 
centers could use. This is the $1.5 million that we are asking 
for here. We think this again would help them with being 
current with all the toxic substances that are out there, and 
what do you do when you have a child come with XYZ.
    There is a need for some online data collection that we are 
not doing, to know what is happening, what is coming in out 
there. That is not something we are recommending now, but was a 
recommendation of the advisory committee. There is a 
recommendation for a task force to look at efficiencies in the 
poison control system and ways that those can be addressed, 
again, that would help them use their money well. There is an 
issue of just general support for poison control centers. There 
is no Federal dollars going in to supporting poison control 
centers. Their numbers have actually been declining over the 
last five to 10 years.
    So we are recommending two of, I think it was six 
recommendations that came out of this advisory committee. It is 
a real problem.
    Mr. Cunningham. I would ask another question, but Jay 
Dickey wouldn't understand it, so I will yield back my time. 
[Laughter.]
    Mr. Porter. Thank you, Mr. Cunningham.
    Mr. Bonilla.
    Mr. Bonilla. Thank you, Mr. Chairman.
    Good morning, Dr. Fox.
    Dr. Fox. Good morning.

                     HEALTH CENTERS BUDGET REQUEST

    Mr. Bonilla. Folks, I am going to also echo what Mr. Miller 
has. The feeling by many on this subcommittee that the numbers 
that are given to good programs like health centers and to 
health professions are way under what they should be and the 
President somewhat--perhaps his strategy is, don't worry about 
it, those guys will take care of it.
    But, nonetheless, that sends a bad signal to the healthcare 
people out there that are desperately trying to keep the lid on 
things back home.
    For example, the health centers budget covers, right now, 
roughly 400 [Clerk's note.--Later corrected to 400,000] 
uninsured people and it's proven to be one of the most cost 
effective programs that's out there. And, I am not going to 
really try to put you on the spot in a big way today, Dr. Fox, 
because I visited with some heads of agencies and other parts 
of the government over the last several weeks and they had all 
but privately concurred that sometimes these numbers games are 
played and they're played by people, with all due respect, that 
are above your paygrade.
    And, I wonder, what was your professional budget 
justification for health centers as submitted to the Secretary? 
If you would share that with us, I think it would enlighten us. 
And, in addition, what was the Secretary's professional budget 
justification as submitted to the OMB and why? And, I am 
speaking directly about the health center budget that we are 
trying to increase more than the 2 percent that the 
administration is trying to provide.
    Dr. Fox. Well, again, you understand that respectfully my 
position is to come and convey to you the administration's 
position on what the budget is. And, again, there were some 
tough choices made there.
    You were asking specifically about the health center?
    Mr. Bonilla. Yes, sir.
    Dr. Fox. The health center budget? The request that we had 
put in for the department I think was approximately $100 
million [Clerk's note.--Later corrected to $106 million] above 
what we had before. We actually had an $80 million request 
increase in National Health Service Corps and I think it was--
Dr. Gaston says that I am understating it a little bit.
    Dr. Gaston. Two hundred and sixty-six. [Clerk's note.--
Later corrected to two hundred and six]
    Mr. Bonilla. Increase?
    Dr. Gaston. For health centers.
    Dr. Fox. For health centers that we sent to the department.
    Mr. Bonilla. So, clearly, you and the Secretary understand 
the significance of this program in providing uninsured folks 
out there with the health care they need inmany rural areas, as 
you are describing, and impoverished areas. And I appreciate that and 
the fact that you understand that these numbers are not what they 
should be.
    Dr. Fox. Well, again, you know, we are very frustrated with 
the budget caps and the limitations and, you know, I guess I 
said already that we know there's a lot of need out there that 
is not being met, whether you are talking about Board of Health 
or community health centers or whatever. But, again, this was 
the administration's position based on the dollars they felt 
would be available.
    Mr. Bonilla. And one of the other concerns I have as well 
is the administration's request for additional funds for new 
programs, one of which I will get into in a second, which is 
unauthorized and which takes away from ultimately the overall 
budget for health centers and health professions and that is 
frustrating.
    I don't want to go without thanking Dr. Fox and Dr. Gaston 
for their help during the flood crisis we had in Texas with our 
facility, the United Medical Center in Del Rio, and I certainly 
appreciate the attention that you paid to that. It was a 
horrible situation. We had 700 people lose their homes, we are 
still trying to get them their permanent homes rebuilt, and, 
needless to say, many of the medical facilities and other 
essential services that were affected by that. And I appreciate 
not only your attention during that time but also consistently 
with the increased need we have for funding at our health 
centers near the border.

                          HEALTH CENTERS NEED

    I want to ask now, Dr. Fox--my understanding that the $50 
million increase that is already granted to health centers is 
really only a quarter of the need and, even when the $100 
million increase we provided last year for this year is 
completely sent out, in your opinion--maybe you have answered 
this already because you say we need a lot more but--how short 
are we falling with just the increase provided in this fiscal 
budget?
    Dr. Fox. Well, again, if you look at the fact that we 
have--I guess people argued the figures--43 to 46 million 
people in this country that are uninsured, many of those do not 
have anywhere to go. We are serving 9 million through community 
health centers and about another 2 million through the Corps. 
So, we are serving about 11 million. So, I mean, how many of 
the people are in a care system--perhaps getting some partial 
care from their local doctor now? That's hard to say. But, I 
think that you can say that there are many people out there in 
the community that don't have anywhere to go, that don't have 
access to care.
    Again, this is a prime reason for the HRSA program to exist 
because we do fill gaps--we don't only fill gaps but we 
certainly do fill gaps for those populations and, again, we 
certainly think this meets part of the need.

                   HEALTH PROFESSIONS BUDGET REQUEST

    Mr. Bonilla. It's certainly not all of it and I appreciate 
that you acknowledge that.
    Like the health centers program, Dr. Fox, or the health 
professions program has provided increased and improved access 
to vital health for the care of many Americans across the 
Nation. You noted in your budget justification on page 123 that 
health professionals trained under this program meet the large 
need of some of these underserved areas.
    Unfortunately, the President once again has a pattern of 
not supporting this program, perhaps thinking that we are going 
to take care of it in the end. I am dismayed, again, that in 
essence if you talk about the bottom-line numbers in terms of 
what might be locked in for a new program and what may not be 
provided, it's about a $90 million shortfall.
    Let me ask you the same question as I did on health 
centers. What was your professional budget justification for 
the three health profession clusters as submitted to the 
Secretary?
    Dr. Fox. I will have to look and see. I will tell you for 
the primary care and medicine we actually asked for a million 
increase over the Fiscal Year 1999. The interdisciplinary 
community-based linkages which includes the geriatric and 
allied health, we asked for an $18 million increase. And, for 
the public health area, we asked for a $50 million [Clerk's 
note.--Later corrected to $42 million] increase.
    [The information follows:]

    We will provide the specific information you requested as 
we have in the past. However, per OMB Circular A-11, generally, 
details regarding internal Administration budget deliberations 
should not be disclosed. In reviewing this privileged 
information, please keep in mind the following. Neither the 
Operating Division request to the Secretary nor the HHS request 
to OMB is inhibited by the consideration of other national 
priorities or government-wide budgetary limitations. We fully 
concur with and support the request levels in the FY 2000 
President's Budget. The information you requested is provided 
below.

                        [In thousands of dollars]
------------------------------------------------------------------------
                                     FY 1999             FY 2000
                                     revised   -------------------------
                                      Pres.       HRSA to
                                      budget        DHHS     DHHS to OMB
------------------------------------------------------------------------
Training in Primary Care Medicine       77,210       81,500       80,410
 & Dentistry.....................
Interdisciplinary, Community            50,889       71,985       52,889
 Based Linkages..................
Public Health Workforce                  9,107       51,099       41,607
 Development.....................
------------------------------------------------------------------------

    Mr. Bonilla. And, again, that was, in essence, denied and I 
just want to go on the record on that. And I want to also 
express once again my appreciation for your understanding of 
the needs in these areas. I know I am out of time and again, 
thank you, Dr. Gaston, for your help specifically and all of 
you here today.
    Dr. Fox. Thank you.
    Mr. Porter. Thank you, Mr. Bonilla.
    I will remind the subcommittee we will have time for a 
second round, I believe.
    Ms. Lowey.

                    INCREASING COORDINATION EFFORTS

    Ms. Lowey. Thank you, Mr. Chairman, and I join my 
colleagues, Dr. Fox, in welcoming you and your colleagues here 
before us. I apologize: my plane was on the runway for about an 
hour and a half but I did read your comments. Several of us 
have been talking about community health centers and you talked 
about increasing coordination among community-based providers, 
such as community health centers, teaching hospitals, public 
hospitals, and I strongly support this.
    I have an interesting community that goes from Westchester 
to the Bronx to Queens and see a shaking of heads so you must 
be from one of those areas. Westchester Medical Center, for 
example, Queens Hospital Center have contacted us with regard 
to how they could better coordinate to meet the great need out 
there. Could you give us some idea about how you are 
encouraging coordination with these dollars and how they could 
best benefit from it?
    Dr. Fox. Well, again, we actually have a program now that's 
a part of the Bureau of Primary Health Care, where we are 
encouraging community networks. So, this has been an ongoing 
activity and we have felt for some time that for our community 
health centers to survive that there are a lot of the things we 
need to do. But, one is they have got to get together with the 
other people in the community and talk and work together and 
figure out strategies together that they can both use to 
provide the care. So, that's already been on our radar screen.
    I guess what we envision with this money initially would be 
more of an identification of trying to both act as a catalyst 
to get communities that perhaps haven't done this to do it and 
communities that have--and that are part of the way along that 
spectrum--to facilitate and encourage that to happen.
    I will just give you an example. In the county where I was 
actually located when I was the health commissioner, we co-
located the community health center and the health department.
    Ms. Lowey. Yes.
    Dr. Fox. What we did was we built the new health department 
building and we put in enough space for the community health 
center so they are now in the same building. And, so, the 
patients come in one time and get what they need. They don't 
have to come in twice. These are people who have transportation 
problems, who can't afford to pay $10 for a cab.
    I know that in Denver there's an example of a project that 
has pulled together the hospitals, the trauma center, the 
health department, the community health centers, and the 911 in 
looking at common enrollment, again, so people don't have to 
come back 20-something times to get enrolled in the system--
which sounds absurd but it happens--and to make sure, again, 
that people that are coming in are getting everything they need 
when they get in. So, there are several, we think, examples of 
good projects like that.
    We have a models-at-work program that Dr. Gaston and the 
Bureau of Support that we actually have used to identify 
communities that have done a good job in improving access to 
care. And, if you would like, Dr. Gaston will, perhaps, comment 
on that further.
    Ms. Lowey. Yes.

                             MODELS-AT-WORK

    Dr. Gaston. Thank you for that question. That's certainly 
an important aspect in dealing with this environment of today.
    As Dr. Fox mentioned, we have for the past few years been 
encouraging that and through a number of mechanisms: by 
providing technical assistance to communities that want to do 
it; by supporting consultants so that they can help; and by 
making funds available for administrative needs and the 
necessary planning. There's a lot, as you know, that has to go 
on to bring partners together that don't have much experience 
working with each other.
    We are proud of the fact that, of the over 600 health 
centers in the country, 50 percent of them are definitely 
participating fully in networks and we anticipate that this 
initiative this year will help us to get even more. So, we are 
very happy that we are able to move as rapidly as we are.
    Ms. Lowey. Thank you and I look forward to continuing to 
work with you in that regard.

                            FAMILY PLANNING

    I am sorry Mr. Cunningham left because I did want to thank 
him for his comments regarding the San Diego Planned Parenthood 
clinic and I want to thank you, Dr. Fox, for your work in that 
regard. And I would like to say to Mr. Cunningham and my 
colleagues on the other side of the aisle, as Chair of the Pro-
Choice Task Force in this Congress, I have fought hard for the 
full range of reproductive health care. However, if we are 
really going to reduce the number of abortions--I was very 
pleased to hear Mr. Cunningham's comments about the San Diego 
clinic because increased access to contraceptives is an 
important way to reduce the number of abortions--I was extraordinarily 
pleased to see the Administration's proposed $25 million increase in 
Title X family planning services.
    As we know, family planning does reduce the number of 
abortions, and I think this is really important, by preventing 
unintended pregnancies. As a result of our investments in 
programs like Title X, and because of the policies of this 
administration working in partnership with communities--the 
pregnancy rate has dropped to its lowest level since 1973. But, 
we all know that we have much more to do. We have to continue 
to ensure that women have access to direct services--like 
exams, cancer screening, contraception--and Title X is so 
critically important.
    Can you share with us what you feel that increase will mean 
to women who need reproductive health care?
    Dr. Fox. Well, I have several comments. One, I think, 
obviously we have a two-fold strategy around pregnancy 
prevention in the agency. One is to encourage those that are 
not sexually active to delay it and not begin it, particularly 
teenagers. But, for those that are--and many of the women that 
come into the Title X clinics--to be able to have access to the 
full range of contraceptive services so that they do not have 
an unwanted pregnancy.
    These dollars will do several things. One, they will allow 
us to target some groups that are very difficult: homeless--and 
yes, there are homeless women who get pregnant and have 
babies--substance-abusing women. We know that again there are a 
number of at-risk groups that are not getting family planning 
care now. Part of this money will be used to increase male 
involvement, which has been a perpetual problem, in how to get 
the fathers, how to get the men in and have them--it's not just 
the women's problem, we have got to include both. And, so 
almost $5 million would go toward that.
    And then, finally, to make sure that those women that come 
in--sometimes this is their absolute only source of care--and 
that we can provide them with breast and cancer screening in 
addition to the contraceptive services, again, rather than 
having to refer them to the health department or the community 
health center for their sexually transmitted diseases to be 
treated, we can treat those there.
    So, to provide for what health needs we can to those 
patients when they come in because again the women we serve and 
the few patients we serve in here often have absolutely no 
insurance and no Medicaid and it would go for a variety of 
services like that.
    Ms. Lowey. I thank you and I think the buzzer went off.
    Mr. Porter. Thank you, Ms. Lowey.
    Mr. Istook.

                      ORGAN TRANSPLANT REGULATIONS

    Mr. Istook. Thank you, Mr. Chairman.
    Gentlemen, ladies, it's nice to have you here this morning.
    I would like to touch on two topics: one, regarding the 
organ transplant regulations, and secondly, revolving around 
abstinence education and the funding for that.
    On organ transplants, obviously we all know that there was 
a major difference of opinion between Congress and the 
administration on this last year. I understand, Dr. Fox, that 
Secretary Shalala has basically delegated to you at least some 
of the contact work with people such as the United Network for 
Organ Sharing and so forth that have grave concerns about the 
regulations. I don't want to turn this into a debate upon the 
respective positions and medical practices that underlie them.
    But, I am concerned on whether there is an effort going on 
to try to dictate regulations in this area in the absence of a 
consensus. I think what happened last year certainly indicates 
that there is major division within the organ transplant 
community. And, I don't want to get into, you know, where the 
majority lies. But, that absence of consensus to me seems very 
indicative of the problem of trying to compel a solution from 
the Federal level.
    What I wanted to ask you, Dr. Fox, is what is the status 
right now of any meetings that you may have scheduled not with 
people that are proponents of the administration's position but 
with those who have had concerns about it--such as UNOS and 
others within that community? Do you have meetings and sit-
downs scheduled with them to try to go through this right now?
    Dr. Fox. Mr. Istook, two things. One, as you know, in the 
summer, we had a series of meetings with UNOS of some 40 hours. 
We have continued since that time both at the project officer's 
level--and a group of my staff were down in Richmond just this 
last week, spending several days down there--so we have 
continued some discussions at that level. We are also in the 
process of reinitiating the meetings. In fact, the Secretary 
has communicated back to Dr. Bill Pfaff--the current president 
of UNOS--that we want to sit back down and begin that 
discussion again.
    I have said publicly and I will say here again today, you 
know, we need to work it out. We want to work it out. And, I 
think that, quite frankly, there are--you know, we have, 
perhaps by having an 8-page regulation that we think left some 
flexibility--I think the transplant community feels perhaps the 
reverse. And, so, I think that what we have got to do is sit 
back down and clarify both where we are and where we both are 
willing to go.
    We think that the regulation, by saying that it allows both 
UNOS to have as its performance goals the things that are in 
the regulation and also they are the ones--the OP10 or the UNOS 
board--who will put together the actual performance measures by which 
those goals are obtained, so we think there's some flexibility there.
    I think there are issues. For instance, in the area of 
kidneys, the transplant community has felt that the issue of 
medical urgency should not apply equally to the organs, since 
on kidneys you have a what's called a ``rescue technique'' with 
kidney dialysis. We have agreed and I think the question at 
this point is whether or not that needs to be explicit in the 
rules. And it's those kinds of issues that we want to work with 
them on and we are in the process of sitting back down and 
initiating the discussions.
    As you know, we had the comment period, it ended, we have 
been analyzing those comments, and we do--she has communicated 
back to UNOS that we want to sit back down and begin those 
discussions again.
    Mr. Istook. I would certainly recommend to you that, you 
know, it's hard to have discussions that are constructive. When 
people know that the only thing between them and the 
regulations with which they have concerns is the act of 
Congress and so long as the administration's public position is 
to say that, ``well, we intend to go ahead with the regulations 
or some form of them as soon as we can get out from under the 
congressional restriction,'' I think would be a much better 
signal if the administration said we are going to scrap those 
regulations and start over so that people know that those 
discussions are leading to a new regulation as opposed to just 
butting their heads up against the wall. I would certainly 
encourage that.

                          ABSTINENCE EDUCATION

    Let me also turn some attention, as I mentioned, on 
abstinence education and, Dr. van Dyck, I know that you are 
involved with the maternal, child and health of that. I have 
seen the figures published that basically say we spend 
something like $4 billion in Federal funding on prevention--so-
called ``safe sex'' practices to prevent or protect, to prevent 
pregnancy or prevent acquiring an STD from sexual activity. 
Yet, the amount that we expend upon the true form of 
protection--which is abstinence education--is about $50 
million, a very huge difference in the ratio.
    There have certainly been recent medical reports talking 
about the upswing in privately-funded as well as government-
funded abstinence education generating some of the positive 
results that we have seen. Because of this, I am very concerned 
with what's happening in the abstinence education programs that 
are Federally funded and whether they are actually fully 
compliant with the intent of Congress.
    I know there were oversight hearings in September before 
the Commerce Committee. A number of things were brought to your 
attention at that time. For example, the appearance that Rhode 
Island has ignored one of the mandatory features of the 
enactment, basically that abstinence education must say that 
the standard is sexual activity should be confined within 
marriage.
    My question is, what have you done since the hearing in 
September before the Commerce Committee to address the concerns 
that they raised with Rhode Island and other States that don't 
seem to be using these monies for the intended purposes?
    Dr. Fox. Well, again, I will let Dr. van Dyck comment 
specifically. But, just to tell you generally, I think we have 
certainly tried to be attentive to the intent of Congress and 
to make sure that these monies were administered consistent 
with the guidelines that Congress has asked us to provide. The 
grant dollars have gone out. We have been working with the 
States. Dr. van Dyck, I know, is more directly involved in this 
than I am so I will ask him to comment.
    Mr. Istook. Sure, which is why I wanted to know since those 
things were brought to your attention in September what has 
happened since then in those situations. I have only mentioned 
one of several.
    Dr. van Dyck. Yes, sir. During the September hearing or 
within a month or two following the September hearing, the 
grant reviews were being undertaken. The information you gave 
us during that hearing was carefully looked at, was 
incorporated into the grant review process, and, as the letters 
went to States notifying them of their grant award, conditions, 
recommendations, strengths and weaknesses were all listed for 
each State.
    In fact, there was not one State that passed completely on 
the first round of grant application. Every State received at 
least some recommendation or condition that we felt would make 
the grant stronger and would make it more compliant with the 
Federal legislation. I believe that you are receiving very 
shortly a list of those pages of grant conditions--which you 
asked for during the Secretary's hearing and those are in the 
process of coming to you.
    Mr. Istook. Right.
    Dr. van Dyck [continuing]. And I think after you read 
those, you will feel really pretty good about our attention to 
the issues that you raised during that Commerce Committee 
hearing.
    Mr. Istook. I will look at those with interest. Thank you 
very much.
    Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Istook.
    Mr. Dickey.
    Mr. Dickey. Thank you, Mr. Chairman.
    Mr. Porter. You would like to ask for your privilege?
    Mr. Hoyer. Would it be possible--I have another hearing----
    [Laughter.]
    Mr. Porter. No, you are entitled to do it if you have 
another hearing.
    Mr. Hoyer. I am entitled, Mr. Dickey.
    Mr. Porter. Yes. Mr. Hoyer.

                  COMMUNITY INTEGRATED SERVICES SYSTEM

    Mr. Hoyer. There it is. Okay.
    I thank you, Mr. Chairman, and, Dr. Fox and ladies and 
gentlemen, I apologize for being late to the hearing. We have 
another hearing across the hall with the Treasury, Postal 
Subcommittee, of which I am the ranking member.
    I want to ask only two questions, Doctor. As you know, I 
have been very interested in coordinated services and I want 
you to tell me--can you give the status of the work done over 
the past year on the community integrated services system that 
I know you have been involved in and then I will have a follow-
up question after that with reference to----
    Dr. Fox. You are alluding to the CISS program that is in 
the Maternal and Child Health Bureau.
    Mr. Hoyer. Yes.
    Dr. Fox. Again, I will make some general comments and Peter 
may want to add to this, since he deals with it on more of a 
daily basis.
    Those dollars have been used for several things. One, we 
have used them working with States in the area of child care, 
the agents of children and families, and the individual State 
child care programs in trying to look at the help issues that 
are coming up in various child care settings. The States have 
found this very useful and have asked us to continue that. So, 
a portion of those dollars have gone in that area.
    We have used a portion of the dollars for our looking at 
the issues around the services that are available and need to 
be available as a result of the CHIP program, the Children's 
Insurance Program. Part of those dollars, again, have been used 
at the initiative of the agency in the broader area we are 
dealing with but this one is a specific piece and that's the 
area of oral health and trying to look at what are the oral 
health services that are available, the dental care issues that 
we think are going to be a tremendous problem for States in 
trying to expand health insurance to children, particularly 
where now even most of the Medicaid kids out there do not get 
oral health services.
    And, I think there are some other networking issues that 
the dollars have been spent on but I think that the child care, 
the oral health, and the CHIP have been several of the major 
ones.
    Dr. van Dyck, do you want to comment further on this?
    Dr. van Dyck. No, I think those are the three main ones.
    Mr. Hoyer. Doctor, this is $12 million? Is that the level 
we are talking about?
    Dr. Fox. It's a subset of the Maternal and Child Health 
Block Grant.
    Dr. van Dyck. It's 12 and three-quarters percent of the 
dollars in the block grant above $600 million. So, that's about 
the correct amount, yes, sir.

                  HEALTHY SCHOOLS, HEALTHY COMMUNITIES

    Mr. Hoyer. Okay. Now, let me ask you a question then about 
Healthy Schools, Healthy Communities Program, Dr. Fox. I must 
thank you for your support of this program.
    School-based health centers, in my opinion, are fundamental 
in serving children who otherwise would not have access to some 
health care resources, which you, of course, mention in your 
statement which I have read quickly while sitting here. You 
have requested $105 million, which is a level funding from 
1999. Is this enough, in your opinion, to support this 
successful initiative and will it meet the needs of this 
underserved population? And does HRSA have any plans to expand 
the program to reach more children?
    Dr. Fox. We actually have several school activities. As you 
know, we support some school health activities through 
Maternal, Child Health and then the other funding that comes 
through the consolidated health centers we actually have a 
formula that we use based on the increases, whether we put a 
portion of that money in the homeless projects, a portion in 
the migrant health centers, and a portion into school health.
    Obviously, there is a need for more dollars than is 
currently available in the area of school health. We do support 
it to the extent that we can but I will tell you that, you 
know, very few of the schools in this country have school 
health projects. We know that, because of the population of 
kids--virtually all of them, 5 and up--are at schools, it's an 
excellent way to provide health services.
    One of the things that we are trying to do right now in 
addition to the direct funding for the school services is we 
are putting together a technical assistance unit, not only for 
school health services but also we are going to do this for 
Healthy Start to help those grantees that are out there be able 
to bill the Medicaid and other programs within their States to 
make sure they can collect whatever money from any providers 
that will reimburse for any of the services that they are 
currently giving.
    Again, this is not a total answer to school health programs 
but it's something that we think will help sustain those 
projects and even last some of the ones that are out there to 
grow.
    I see Dr. Gaston wanting to make a comment.
    Dr. Gaston. Thank you.
    Specifically for healthy schools, healthy communities, 
there was $6 million that was already there to support the 
initiation of it. With the $100 million that the Congress gave 
us this year, we are doublingthat amount, number one, to really 
increase the number of this model.
    Around 250 health centers also support school health and so 
we are taking additional dollars to shore up those school 
health programs and help them to become models like healthy 
schools, healthy communities in terms of enhancing services, et 
cetera--making them more of a community school health program. 
This year we plan a number of major school health activities 
with the additional dollars.

                       COORDINATION--APPLICATIONS

    Mr. Hoyer. Thank you, Doctor.
    Dr. Fox and Dr. Gaston and others, and Mr. Chairman, 
tomorrow we will have on the floor a bill sponsored by Mr. 
Portman and myself. It is a bill aimed at trying to coordinate 
the applications for financial resources from local and State 
governments and to coordinate the application of those 
resources by the Federal Government itself.
    Dr. Fox, in terms of the population you try to serve--the 
children--that you coordinate both with Dr. Shalala, with 
Secretary Riley, Secretary Cuomo, and Secretary Glickman.
    My thought is that we need to better coordinate services at 
school-level delivery points not just for children but for the 
community, as well, because people of limited resources who 
can't get health services, can't get other services as well--
and one of the services they can't get is transportation. It is 
difficult for them to get from point A to point B, particularly 
on public transportation, particularly if you live not so much 
in a city--which is a little easier but not all easy--but in a 
suburban area, as Mr. Porter and I do. It is very difficult to 
get across the county and you may get in and out of major areas 
but getting across is tough.
    So, I would urge you as you focus on these two programs to 
look at the ways we can better coordinate the delivery of those 
services and maximize the access of the population we want to 
serve as well as maximizing our ability to serve them through a 
coordinated effort.
    Dr. Fox. Two comments. One, there is a departmental 
interagency coordinating committee on school health with the 
exact intent of trying to make sure that we are working 
together and know what is going out there.
    Second, one of the reasons that we have, as I am sure you 
are aware, the school health issue in community health centers 
is the linkage with a primary care side----
    Mr. Hoyer. Yes.
    Dr. Fox [continuing]. And the ability to provide a broad 
array of services and, again, I think what schools do each as 
individuals--some have more limited services--but we think that 
linkage for follow up and treatment of primary care 
conditions--the linkage that often can bring in the whole 
family--is something that is, indeed, important and many of 
these kids are not covered or their families anywhere. So, we 
couldn't agree with you more.

                              ORAL HEALTH

    Mr. Hoyer. Mr. Chairman, I am transgressing on your time.
    Oral health, you mentioned that a little earlier. It is 
interesting. The only program that I know of specifically that 
demands oral health is for 5-year-olds or 4-year-olds in 
HeadStart and, ironically, it is only the baby teeth that we 
really have a program to focus on. As soon as they get their 
adult teeth, we don't pay much attention to them. My wife used 
to be very concerned about that and tell me about it regularly 
and that is something that we need to look at and we could do 
so if we really did have a comprehensive health care system 
throughout the school years for kids.
    Mr. Chairman, I have transgressed on the time and I want to 
thank profusely and profoundly my colleague from Arkansas. I 
forget his name but----
    [Laughter.]
    Mr. Hoyer. Thank you.
    Mr. Porter. Thank you, Mr. Hoyer.
    Mr. Dickey.

                               UNINSURED

    Mr. Dickey. Dr. Fox, we are having an outbreak of uninsured 
patients in my district in Arkansas. You may know about 
Portland, Arkansas and Clarendon is in Arkansas. You have given 
increases to us for those two centers. What is the reason for 
the outbreak, if I am using the right term?
    Dr. Fox. Well, I don't know that I can speak specifically 
to that area you alluded to, Mr. Dickey, but I will tell you in 
general I think there are a number of reasons. One, we know 
that over time we continue to see an erosion in employer-based 
health insurance, that employers are providing less and less 
coverage, many of them opting out of coverage as a fringe 
benefit. I think as you see the evolution of managed care the 
ability of a hospital or a provider to cost-shift and to be 
willing to see somebody when they know they can add that one or 
tack it on a little bit somewhere else and provide the cost, 
that is becoming more and more difficult.
    So, we know there are a variety of reasons that it is 
happening. We know that, again, many of the people who were 
covered under Medicaid prior to Welfare reform, although they 
might still be eligible for Medicaid don't know that. Our 
States have had a difficult time getting them back in. So, you 
have many people who could still be on Medicaid that are not 
on.
    In fact, one of the things we are beginning to see, and I 
think we have provided a report to Congress on the CHIP 
program--we have had the first reports from CHIP coming in at 
the end of this month and I haven't had a chance to fully 
review them--but we do know that one of the things we are 
finding with CHIP is a lot of kids that are potentially 
eligible for Medicaid that are not on--there are findings on 
the part of the CHIP outreach.
    So, there are some people out there that, for whatever 
reason, are eligible for the public system, public programs 
that aren't getting in. We think that employers are doing less 
and this decreasing ability to cost-shift. So, it's a whole 
variety of factors. But, we do know that the numbers are 
definitely on the rise.
    Mr. Dickey. All right. Now, last year we got $100 million 
increase. This year the projection is $20 million. What is 
going to happen if we just run out of money for the community 
health centers? I mean, it looks like we are increasing the 
numbers and we are getting less dollars. Now, what in the world 
is going to happen to our children and our impoverished people 
in my district?
    Dr. Fox. Well, I think we are obviously concerned about 
that. That's part of the reason we did ask for an increase, 
although we know that we are not going to be able to fully meet 
the need with that. One of the things we try to do is make sure 
within a community--again, for instance, kids come in that 
might have HIV, AIDS, or mothers or family members to make sure 
that what we are doing in the Ryan White program coordinates 
with what we are doing in the community health center program 
coordinates with what we are doing in the Maternal and Child 
Health program.
    So, I think we are making every attempt to try to make sure 
that we operate our system as effectively as we can. But, we 
know that there are still a significant number of people out 
there that are not going to be--my home State is Mississippi 
and I was born right across the river from you in the heart of 
the Mississippi Delta and we faced the same problems, huge 
problems.
    Mr. Dickey. You understand----
    Dr. Fox. Exactly.
    Mr. Dickey. Well, I want to thank you. You did come help 
the Mainline Health System in Portland and the Mid-Delta Health 
System in Clarendon. You all did do that at that time. I am 
just concerned. I have been to these community health centers--
every one in my district--and I have more in my district than 
any other district in Arkansas and I am telling you, these 
people are really doing tremendous work and getting very little 
encouragement and here we come up with less money.
    I just don't know whether we are ultimately going to turn 
people away or not. That's my concern.
    Dr. Fox. Well, again, I think you will find a lot of health 
centers cannot meet the need for those who come to the door. 
They have waiting lists. And we know there are communities who 
have approximately 3,000 health profession shortage areas right 
now and we know many of those would qualify for a community 
health center and we just don't have the dollars to put them 
out there.

              MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM

    Mr. Dickey. Thank you, sir. What is the status of the 
implementation of the Medicare Rural Hospital Flexibility 
program?
    Dr. Fox. We, as you know, were asked by Congress to 
administer the Critical Access Hospital program, which really 
interfaces with the Medicare Rural Hospital Flexibility 
program. You provided us $25 million. We are in the process of 
getting out an initial $200 thousand to each State virtually as 
we speak to help them with their planning.
    We plan to make this available initially through our State 
Offices of Rural Health. It's an entity that's already there 
generally that works for the State health department that 
answers to the governor and we think it's a good vehicle. We 
can do that as a supplemental award. So, we are going to try to 
get those out over the next couple of months.
    And then, we will provide the remainder of the money to the 
States by the end of the Fiscal Year. We are asking them to 
come in with a plan, a very short plan, about how they plan to 
go about this. Obviously, our goal is to do two things: one is 
to try to help as many of the States that have hospitals that 
want to try to get on this program and, as you know, they have 
to limit the number of in-patients and acute care beds, look at 
other kinds of services that the facility provides, make an 
application to HCFA and, if they are approved, they will 
qualify for Medicare cost-risk reimbursement. So, we want to 
facilitate that through this program.
    The second thing we are trying to do is to use this also as 
a way to help them look at what is going on in the community 
with other health care providers and, again, to use my own 
community as an example, the health department had a home-
health program. There was a private home-health program in the 
community. There was a series of other services. But, again, I 
don't think any of them ever sat around the table and looked at 
what they could do to kind of support each other.
    It's a two-pronged approach. One is to get the hospitals 
that want to be on the Medicaid cost-benefits program and the 
second is to try to help them build a network so that they can 
all survive and have a core capacity in the community that may 
not otherwise have. But, we have to put the moneyout in the two 
ways.
    Mr. Dickey. Dr. Fox, I know my time is up but I am just 
more and more concerned that we are going to lose the rural--I 
am so glad you are from Mississippi----
    [Laughter.]
    Mr. Dickey [continuing]. And, particularly, from the Delta 
because you understand. But I think we are going to lose the 
rural way of life as a choice and it's bothering me 
considerably and medical care seems to be the center of the 
reason why we should be able to keep people in those areas.
    Dr. Fox. Well, Dr. Myers is from Kentucky. I don't hold 
that against him----
    [Laughter.]
    Mr. Dickey. Arkansas beat Kentucky the other day----
    Dr. Fox. All right. All right. [Laughter.]
    No more needs to be said.
    Mr. Dickey. Right. [Laughter.]
    Dr. Fox. But, I would agree with you and I think, again, I 
alluded to it a little bit in my opening statement but there 
are not only direct health implications for the community but 
there are a lot of economic implications. When you have a 
clinic or a hospital, it creates a lot of jobs and these 
communities are struggling. Most of them have huge unemployment 
rates. So, we want to do anything we can to help support those 
communities.
    Mr. Porter. Thank you, Mr. Dickey.
    The Chair would inquire who intends to stay for round two. 
Not Mr. Dickey. All right. Let's start with 7 minutes each.
    Dr. Fox, I had intended to spare you this and I certainly 
respect the job that you are doing and I don't believe that 
your budget requests reflects the true priorities that you 
believe are necessary in the many, very important line-items 
and programs that you have under your jurisdiction. So, I will 
address these remarks to Bill Beldon, who has heard them 
before----
    [Laughter.]

                        PRESIDENT'S BUDGET-CAPS

    Mr. Porter [continuing]. In hopes that he will pass them on 
to Dennis, who will pass them on to Secretary Shalala who will 
pass them on to the President.
    The comments on our side from Mr. Miller and Mr. Bonilla 
and others are right on the money. The President's budget is a 
thoroughly cynical, dishonest and political document that, 
unfortunately because it is so cynical and dishonest, doesn't 
get much standing here in Congress.
    What the President has done is to cut important accounts--
like the ones that are under your jurisdiction including 
community health centers, for example, which has a small 
increase and health professions which has some zeroed out 
programs--knowing darn well that the Congress puts these at a 
higher priority. That, then, allows him along with a lot of 
phony revenues that he knows won't materialize such as a lot of 
forward funding in offsets that are ridiculous and everybody 
knows it, to plusup other accounts to say how concerned he is.
    It's just not honest at all and I know Ms. Pelosi is going 
to want her time to respond to this but it seems to me that 
what we really need is a great deal more honesty in budgeting 
so that we can look at the President's budget and he can tell 
us what he truly thinks is important for the country and not 
simply play to every interest group that exists out there.
    I believe very strongly that we have to raise the caps. I 
think that the caps are impossible to live with. Last year's 
budget, the appropriations effort, obviously was totally away 
from reality in terms of the final product and we need to be 
honest about this and raise the discretionary caps and I have 
said that publicly and I will continue to say it to anybody who 
wants to hear it. I think that Dr. Fox and the able people that 
he has here at the table would be shocked if we, in fact, 
provided a budget that looks like the President's. You should 
be.
    But, somehow, we need the message to go forward that the 
President needs to look at this in a much more honest way and 
tell us what the true priorities are. What it leads us to want 
to do is to call his bluff and fund things at the levels that 
he suggests, which obviously is not in the best interests of 
the country or the important priorities that we have before us.
    But, it's very, very frustrating to get a budget like this 
bill and I hope that something can be done to make it more 
honest because I am afraid that the President is so successful 
politically that Presidents that follow him will think that 
this is the way it ought to be done and, unfortunately, we will 
be saddled with this kind of approach for years to come.
    That is not to say he's been alone; other Presidents have 
done it, believe me. But, I think it's gotten to be an art form 
that has been carried to its ultimate extreme which is, I 
think, again, completely cynical. And, that's my unfortunate 
sermon this morning, which I had not intended to deliver but I 
think it's true.

                        COMMUNITY HEALTH CENTERS

    Dr. Fox, last year at the hearing, you stated that about 5 
percent of community health centers were either bankrupt or 
would soon be bankrupt and another 5 to 10 percent were at risk 
for bankruptcy. What's the financial status today? Has that 
changed? Improved? What has happened?
    Dr. Fox. Again, I will maybe defer some of the specificsto 
Dr. Gaston and I will tell you that of the $100 million increase that 
the Congress gave us last year, Mr. Chairman, we provided $45 million 
of that directly to help shore up centers that we knew--based on the 
information we had--were in financial difficulty and we had a 
methodology for doing that which I won't try to detail. But, the Bureau 
certainly, I think, has done a good job of that.
    We have used the additional money in part to do that but in 
part also to expand services. We do estimate that by the end of 
the phaseout of cost-risk reimbursement, health centers will 
lose some $300 million in Medicaid reimbursements beyond where 
they are now. So, we have that yet to come.
    Dr. Gaston, do you want do comment?
    Dr. Gaston. The good news is that as we mentioned last 
year, 40 [Clerk's note.--Later corrected to 50] percent of the 
centers were doing very, very well. That's up from 50 [Clerk's 
note.--Later corrected to 40] this time. However have centers 
at risk. Last year, it was about 54 percent of the centers 
which were at risk. That's down to about 45 percent now. We 
have been really working hard over the year.
    The centers that were bankrupt--that 5 to 10 percent that 
you talked about--that has not changed. That's the bad news. 
They're different. They're not necessarily the same centers as 
last year, there's movement back and forth.
    But, in the midst of all this, as we help centers to 
survive, there are a lot of site closings. There have probably 
been about 60 to 70 sites that have had to close. A lot of 
layoffs have occurred, and services have been cut back. So that 
is the total picture, but we still have that five to ten that 
right now are in severe trouble.
    There are a number of reasons for that. It is not only that 
there is increased competition and increase in the uninsured, 
and as Dr. Fox says, but in addition as provisions of the BBA 
go into effect, it is going to get worse in terms of the 
losses.
    The provider issue is also a problem. Being able to keep 
enough providers so that you have adequate market share is an 
issue so that when the country talks about a physician glut, we 
all know that there is no physician glut in our under-served 
areas. So programs like the HRSA programs really struggle to 
have adequate numbers of providers that can give them adequate 
market share.
    Mr. Porter. Do I understand correctly that you said 50 
percent are in great shape and 45 percent are at risk?
    Dr. Gaston. Yes.
    Mr. Porter. There is sort of a big dividing line down the 
middle?
    Dr. Gaston. Yes.
    Mr. Porter. When you were describing this, I was concerned. 
How do you set standards for centers so that you can determine 
that it is not the market only that is a problem. Perhaps it is 
the way that they are run and deliver their services. Are there 
standards set for community health centers that you can 
evaluate their own performance despite the market?
    Dr. Gaston. Absolutely. We have site visits and site visit 
teams that provide evaluations. We have nine specific measures 
such as how many of the uninsured go up a sliding fee scale, 
loss in patients, and turnover in terms of the management team. 
There are a number of indicators that are flags that centers 
need help. We have all kinds of rapid responses that are 
initiated as soon as we see these flags. We send people in to 
help with the management, to help with the fiscal situation, 
and to make recommendations.
    So we have learned how to better help centers in need over 
the past couple of years, and how to get into the situations, 
stop the bleeding, make some changes that are important. We 
have experts that help us do that.
    Mr. Porter. I have some further questions on that, but Ms. 
Pelosi?

                             BUDGET PROCESS

    Ms. Pelosi. Thank you very much, Mr. Chairman. Again, thank 
you, for your very interesting and informative testimony today. 
Mr. Chairman, I appreciate your frustration with the 
President's budget because as one who has fought year in and 
year out for increased spending on AIDS and HIV, I know that it 
has come to the Congress to have to increase that funding. 
Indeed, I hope we will again this year.
    But I do take issue with your laying the responsibility for 
this approach on the President's doorstep, without the 
recognition that this budget has to be sent within the reality 
of what this Congress is about. If the majority in the Congress 
says that tax cuts are the be-all, end-all, if people want 
increased funding in NIH but do not want to raise the caps, 
instead want to give tax cuts, if people won't increase the 
NIH, but instead want to increase defense spending without 
raising the caps on our side, then I think that the message of 
the President's budget, and I think he has demonstrated that he 
supports the NIH, the message in the President's budget is if 
you want to do that, you have to find the money some place. We 
have no right, not any one of us, to proclaim our support for 
huge increases at the National Institutes of Health while we 
are not interested in doing what is necessary in order to 
achieve that kind of funding.
    I do not put our distinguished chairman in the category 
that I am describing here, the Republicans in Congress, because 
as he has said, he supports increases in the capsand he has not 
supported some of the programs which would make it impossible for 
increases the NIH.
    So I say it very respectfully to you, Mr. Chairman, but 
also with the idea that you say you want integrity, honesty in 
budgeting. We like to see values in budgeting. This budget is 
supposed to be a statement of our national values. I think in 
the testimony that we heard today, the value that we all share 
is the value that a strong country, the strength of our country 
should be measured in the health and well-being of our people. 
We have heard that on both sides of the aisle. But we can't 
just talk about that. We have to put our resources there if 
indeed this is important to us. If this budget is a statement 
of our values, then we have to put the money where the ideas 
are.
    So I think that we have to recognize that the whole budget 
process is that, a process. The budget is not just that piece 
of paper. It is a starting point. Now let's see how interested 
we are if the President were indeed, as you suggest, Mr. 
Chairman, playing to interest groups in his budget, he would 
have increased the National Institutes of Health budget very 
significantly, because if you want to talk about breast cancer 
advocates or AIDS advocacy, or the list goes on and on. As you 
well know, we will see that array before us in the process of 
our hearings of all of the people who are concerned about 
increased biomedical research funding.
    So I think that we have to recognize the reality with which 
we are dealing. I would like to see the budget the President 
would send to a Democratic Congress. Then we could criticize I 
think more appropriately what his tactic is. But as long as a 
tax cut is the be-all, end-all, and we talk about increasing 
NIH without--it is not the price, it is the money. Where is the 
money coming from? I think if we all want to find common ground 
in reducing the national debt, instead of giving a tax cut and 
reducing the debt, therefore decreasing the debt service, and 
therefore freeing up some money for discretionary domestic 
spending, that that might be a place where we could find some 
common ground.
    But I think if you want to talk about cynicism in 
budgeting, there is a lot of blame to go around. A great deal 
of it, I think, rests on the spending priorities of the 
Republican majority in the House.

                      MEDICAID MANAGED CARE PLANS

    Speaking of balanced budgets, the Balanced Budget Act 
created a mechanism, Dr. Fox, whereby Medicaid managed care 
plans must reimburse health centers what they reimburse other 
network providers. The act also required States to pay health 
centers the difference between those reimbursement rates and 
some percentage of the reasonable cost. As you know, this 
payment by the State is known as the ``wraparound payment''. It 
is my understanding that California is not yet making 
wraparound payments to health centers. I appreciate that HRSA 
has been instrumental in working with HCFA and California to 
expedite resolution of the matter.
    How are the discussions proceeding? When might California 
come into compliance with the Balanced Budget Act?
    Dr. Fox. I don't know that I would hazard a guess on the 
latter, on your question. But I might defer the first part to 
Dr. Gaston.
    You are correct. I mean we have had a lot of discussions 
and ongoing discussions with HCFA. Obviously the States, I 
think both the States and the department realize that Medicaid 
programs are in large part State-run programs within a set of 
Federal guidelines. We are certainly interested in seeing the 
States comply with the BBA in this area, but there is I think 
some limitation on how far the department feels it can go in 
making that happen.
    Dr. Gaston, do you have any more updated information on 
California? We can get that for you. I just do not know right 
off hand. We will be glad to provide that information.
    [The information follows:]

    In December of 1998, the State of California requested an 
additional nine months to comply with the Federally Qualified 
Health Center (FQHC) and Rural Health Center (RHC) 
reimbursement provisions in the Balanced Budget Act (BBA). HRSA 
and HCFA are working with the State to prompt rapid 
implementation of BBA provisions, which entitles health centers 
to wraparound payments with an annual reconciliation.

                      RYAN WHITE UNMET NEED--ADAP

    Ms. Pelosi. Okay. When you do, would you also just 
following up on my earlier question on AIDS, could you please 
provide some information on documented unmet needs in the Ryan 
White care program, including the ADAP program?
    [The information follows:]

    As we stated in our Justification for FY 2000, unmet need 
refers to the service needs of those individuals not currently 
in the system of care as well as those individuals in the 
system of HIV care whose needs are only partially met. The CDC 
estimates that 650,000-900,000 Americans are living with HIV-
infection. Assuming a mid-point of 750,000, it is estimated 
that 550,000 are knowledgeable about their HIV status. The 
recent Health Cost and Services Utilization Study (HCSUS) 
estimates that approximately 335,000 individuals received 
medical care during a typical six month period in 1996. It is 
also estimated that approximately 215,000 of those who know 
their HIV status, are believed not to be receiving medical 
care. When you include the remaining 200,000 who may not know 
their serostatus, it is estimated that 415,000 HIV-infected 
persons (either with or without knowledge of their HIV antibody 
status) are not under medical care. With respect to AIDS Drug 
Assistance Programs (ADAP), it is estimated that in 1996 
Medicare and Medicaid covered about 160,000 people living with 
HIV/AIDS and that ADAP provided medications for an additional 
41,000. This combined total of 201,000 is only 36 percent of 
the estimated 550,000 people who are aware that they are HIV 
seropositive. Given the HCSUS estimate of only 32 percent with 
private insurance, it is clear that there is significant unmet 
need for ADAP.

    Ms. Pelosi. Now on the matter of health insurance for 
people with HIV. In its report last year, the House 
Appropriations Committee encouraged States to utilize Federal 
ADAP funding in the most cost-effective manner, and to allow 
States the ability to use ADAP funds to purchase and maintain 
health insurance policies for eligible clients. Could you give 
us an update on HRSA's administration of this directive?
    Dr. Fox. Certainly. We have issued a policy memorandum that 
States can, and I think that was done in January. I can get you 
the exact date, January 6, but we did notify States this can be 
done as long as the insurance coverage is comprehensive 
coverage. We obviously do not want to buy coverage that is 
inadequate, but we certainly have made that clear to States, 
that they have that option.
    We also have been working with the States within the 
context of their ADAP program, other ways to make sure the 
dollars are well spent, and buy as many medications as 
possible.
    One of the things you may be aware we did, I believe it was 
back this summer, is we actually--many States were going after 
a rebate for the ADAP drugs which were in our opinion not 
getting the best price that they could get. So one of things we 
did is basically set up the provision for a national rebate so 
that all States that wanted to go the rebate option could get a 
rebate price that approximated the discounts that they were 
getting on the direct purchase option part of the program. In 
fact, we have a number of the States now that are moving toward 
a rebate. We estimate that probably 22 States will have a 
rebate and 22 States will have the direct purchase. They can go 
either way, we don't care. But what we are trying to do is to 
again, help them get the best price if they go the rebate 
route.
    We also have a monthly reporting system on the ADAP program 
now that we didn't have when I was here before. We think it is 
providing again, a lot of information on the kind of 
limitations and restrictions that States are both having to put 
on their ADAP programs, the kind of things where they are 
having to, as I mentioned earlier, the fact that we can say 
that 12 States have capped enrollment. A number of States have 
capped expenditures. Ten States have waiting lists. We know 
what States are doing around protease inhibitors. All that we 
are getting out of that monthly report.
    We also, we have been working and I think we are about to 
see developed the ability for us to have a prime vendor 
program, much like the VA has, that will allow those direct-
purchase States to get an even better price for their 
medications. We have been working with both the States and 
within the department on that. We are on the verge of having 
that done.
    Finally, one other thing that we are working on that I did 
want to mention is we have explored, and I know there wassome 
concern expressed by this committee, Mr. Chairman, but the proposed 
rule by the agency that would ask that States either do one or the 
other as far as a rebate if they are involved in the discount program, 
that they either do one or the other, the rebate or the direct 
purchase, or if they can show us they can get a better price otherwise, 
then they can get a waiver basically.
    But we are doing everything we can both one, not to make 
States do any particular thing except to help them get the best 
price.
    I would be glad to answer any other questions you might 
have. There is a lot of spade work that is going on to make 
that happen, but we feel real good about it.
    Ms. Pelosi. I appreciate that. Thank you. I do have other 
questions, but my time has expired.
    Mr. Porter. Well, you will have four more minutes.
    Ms. Pelosi. If I just may say in closing that I want to 
associate myself with the comments made by our colleagues about 
the importance of oral health. One place where it is very, very 
important of course is with the Ryan White Act. I hope we can 
do the best possible funding for the Ryan White dental 
reimbursement program.
    With that, Mr. Chairman, I thank the witnesses again, and 
thank you.
    Mr. Porter. You are not going to stay for the remainder of 
our debate?
    Ms. Pelosi. I would be happy to. Let me say this. I am 
happy to stay to listen to the chairman, but I will have no 
further questions.
    Mr. Porter. You might have a further comment. [Laughter.]
    Well, first of all, we don't have a Republican budget yet. 
There will be time enough to criticize it when we see one. I 
might join you in that criticism, presumably, because I agree 
that there are things that it might contain that I might not 
agree with either.
    I think we have to remember the difference between the 
President's budget, which is really to suggest the priorities 
for spending in each line item for our country for the next 
Fiscal Year, and what the Budget Committee does, which is 
always misinterpreted by the press. But all they have 
jurisdiction of doing is giving us one figure that we then 
allocate among the 13 subcommittees, and allow us to then 
choose the priorities within that cap.
    I would say to the gentlelady from California, the thing 
that the President ought to be doing now when he is hearing 
people like myself saying we ought to raise the discretionary 
cap, the President ought to be saying we ought to raise the 
discretionary cap. But he is not. There is dead silence from 
the White House. That makes it so much harder for us to deal 
with what we have to do in order to make this budget work.
    So I would urge the gentlelady to talk to the President, 
and say, ``Look, we need some honesty here, and let's all talk 
about getting it back into the budget process.''
    Ms. Pelosi. Will the gentleman yield?
    Mr. Porter. I will yield, yes.

                           DISCRETIONARY CAPS

    Ms. Pelosi. Does the gentleman honestly believe that the 
President asking the Congress to raise the discretionary cap 
will increase the discretionary caps? If so, I am pleased to 
hear you say that.
    Mr. Porter. Well, I think it would certainly lead us in the 
right direction. Right now, there are a few Republicans saying 
we have got to do this, and Democrats are certainly saying it 
as well, but there is nothing coalescing because the White 
House has the leadership on matters like this, and nothing is 
happening.
    I am worried that our Budget Committee and the people who 
are going to put the budget out are going to say, ``Well, I 
don't hear enough out there to lead us in that direction, so we 
are going to stick with the budget caps.'' That is going to 
make it really difficult. We will have to draw a spending 
blueprint that will look like the President's budget, which is 
no way to do the Nation's business, in my judgement.
    Ms. Pelosi. Will the gentleman further yield?
    Mr. Porter. Yes.
    Ms. Pelosi. I would say this. That if the President wanted 
to go out there and make a public campaign about raising the 
discretionary domestic budget caps, some in this body might 
consider that political. But I am happy for him to make that 
fight because that is what we do here. We spend most of our 
time directly or indirectly on budget, whether it is policy, an 
authorizing committee establishing a budget blueprint, or where 
the rubber meets the road here. But I think that that is the 
most appropriate national debate that we can have. How do we 
define the strength of our country? What are our priorities? Is 
this budget a statement of our values?
    I would welcome the gentleman joining the President in 
calling for an increase in those budget caps, because that is 
the only way we are in fact going to meet the needs; as many of 
us are fond of saying in this committee, we have lamb-eat-lamp 
appropriations bill. Because everything here is good. Where 
would you take the money from? There has to be a bigger pie if 
indeed we are going to double the NIH budget in five years or 
meet any of the other goals that we have.
    In all fairness to the President, and I join you in 
supporting increased funding for the NIH, we did have at the 
initiative of Congress, in this case largely on the Senate 
side, the increase in the NIH budget. The baseline 
wasdrastically increased last year. I think that is the response we 
would get from the administration, we increased it over a giant 
increase last year. You have to look at the thing, the budget over 
several years.
    So in any case, that is music to my ears that you would be 
willing to join the President in calling for those increases in 
the discretionary spending caps.
    Mr. Porter. I thank the gentlelady. Almost everything here 
is good, not quite everything. [Laughter.]

                        COMMUNITY HEALTH CENTERS

    Let me go back to Dr. Gaston and ask this. The increase for 
community health centers, this is a good example I think, is 
$20 million on a base of $925 million. Forty five percent of 
the community health centers are at risk. A two percent 
increase is not going to go very far for 45 percent of the 
centers that are at risk. What is the Administration's plan to 
address this serious problem? Is there a plan? I assume $20 
million is not the plan, What is the plan?
    Dr. Fox. Mr. Chairman, if I can intervene there. I think 
again, it is a total package. Part of the idea around the 
safety net or the program for the uninsured is to look at 
because of the limitations with financing, I mean we have a 
whole variety of programs that you could add money to. I think 
we could use it well. But the program for the uninsured I think 
is an attempt to try to make sure that whatever dollars we have 
in the system, that we do the best job with it. Again, it is 
not going to solve all the problems. I think we are well aware 
of that. It is also not going to eliminate the need for some 
funding for direct services, whether it be through CHC or Ryan 
White or whatever. But we think it is certainly--the approach 
within the constrained dollars that we have today that we can 
help address the needs.
    Mr. Porter. The $70 million is also, Dr. Fox, part of the 
$945 million. Correct?
    Dr. Fox. Yes, sir.
    Mr. Porter. So where is that coming out of?
    Dr. Fox. It is actually a designation of the existing 
dollars again, that we plan to use. For instance, trying to 
target in the southeast. There are a variety of areas in urban 
areas to target the dollars for communities. We are trying to 
within the community health center area, look at those 
communities that have large percentages of racially and 
ethnically diverse populations, and make sure that any new 
centers and the sites where we are providing expansions, that 
those are absolutely on our radar screen. Again, it is a way of 
tweaking the dollars we already have.
    Mr. Porter. Yes, sir. But it sounds like it is new dollars 
for a new initiative. What it really is, is taking dollars away 
from the needs of the centers originally and redirecting some 
of them. Again, with a $20 million increase, you have got to 
lose $50 million somewhere else in order to provide the $70 
million. Right?
    Dr. Fox. Well, Mr. Chairman, it is not actually taking any 
dollars from----
    Mr. Porter. I understand, but it certainly again, in my 
estimation, not quite an honest way to address a serious need 
and a serious problem.
    I am sorry we got into all this because you are doing such 
a fine job there. I commend you and your staff. We want to 
obviously provide you the resources you need to do it even 
better. We do need an allocation for our subcommittee that 
allows us to do that. I hope that all of us can find a way to 
honestly and without cynicism address these things and say 
these are national priorities that need attention. We can't do 
it, especially when we are running large surpluses and our 
economy is humming like it has not hummed in a long time. It 
seems to me that it is time to sit down and address it 
honestly, and say we need these resources, we have serious 
problems that have to be addressed and serious priorities that 
need funding.
    Thank you for your testimony today. Thank you for the fine 
job you are doing.
    Dr. Fox. Thank you, Mr. Chairman. I appreciate the support 
of this committee.
    Mr. Porter. The subcommittee stands in recess until 2:00 
p.m.
    [The following questions were submitted to be answered for 
the record:]

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                           W I T N E S S E S

                              ----------                              
                                                                   Page
Arons, B.S.......................................................   523
Beldon, W.R......................................................  1323
Chavez, Nelba....................................................   523
Clark, H.W.......................................................   523
Eisenberg, J.M...................................................  1051
Fox, C.E.........................................................  1323
Gaston, M.H......................................................  1323
Gimson, W.H......................................................     1
Goldstone, Donald................................................   523
Koch, Rita.......................................................  1051
Kopanda, Richard.................................................   523
Koplan, J.P......................................................     1
Kumpfer, Karol...................................................   523
Morford, T.G.....................................................  1323
Myers, W.W.......................................................  1323
O'Neill, J.F.....................................................  1323
Puskin, Dena.....................................................  1323
Rogers, V.C......................................................  1323
Simpson, Lisa....................................................  1051
van Dyck, Peter..................................................  1323
Williams, D.P..............................................1, 523, 1051


                               I N D E X

                              ----------                              

               Centers for Disease Control and Prevention

                                                                   Page
Abstinence Education.............................................    34
Agency for Toxic Substances and Disease Registry (ATSDR):
    Funding......................................................    85
    Public Health Activity.......................................    83
Antimicrobial Resistance.........................................    36
Arthritis.......................................................68, 151
ASSIST Program............................................124, 128, 129
Asthma..................................................25, 32, 48, 149
    Asthma Module for Behavioral Risk Factor Surveillance Survey.    57
Biotechnology....................................................    31
Bioterrorism.....................................................23, 82
Birth Defects.............................................139, 143, 146
Blood Safety.....................................................   133
Buildings and Facilities....................................40, 78, 115
Cancer Cluster Investigations....................................    69
Cancer Registries................................................    70
Cardiovascular Disease Programs.................................56, 140
Chief Financial Officer Audit....................................    66
Colorectal Cancer................................................    47
Comprehensive School Health......................................    92
Chronic Fatigue Syndrome.........................................    95
Congressional Justification......................................   152
Diabetes: National Diabetes Education Program....................    67
Dioxin Contamination.............................................   132
Disseminating CDC's Priorities...................................   148
Effects of Mass Media and Public Service Announcements...........    50
Emerging Infectious Diseases:....................................    71
Threats from Emerging Infectious Diseases (EID) and Antimicrobial 
  Resistance.....................................................   101
Funding for EID..................................................   102
Current Budget To Implement EID Plan.............................   105
Environmental Exposure In Humans.................................    71
Environmental Health Laboratory.................................39, 129
Epilepsy.........................................................    57
Food Safety..............................................27, 30, 49, 62
    Annual Incidence of Foodborne Illness and Death..............    92
    Foodborne Disease Surveillance...............................   123
Folic Acid.......................................................    58
    CDC's Folic Acid Education Program...........................   121
    National Council on Folic Acid...............................   137
Global Polio Eradication.........................................    94
Government Performance and Results Act (GPRA)....................   431
Health Statistics................................................    24
Hepatitis........................................................    32
HIV:
    Incidences...................................................    80
    HIV-Infected People..........................................    67
    Prevention...................................................    39
Immunization:
    Adolescent Immunization for Hepatitis B......................    82
    Polio Vaccination............................................    88
    Vaccines for Children........................................67, 87
    Vaccine Purchase.............................................    81
Infectious Diseases: Outbreaks of Foodborne Illnesses............   122
Injury Control:
    Centers of Excellence........................................    74
    Fire Injury Prevention.......................................   141
Ionizing Radiation on Meat Products..............................    50
Laboratory Standards.............................................    47
Listeria.........................................................    44
Measuring Toxic Substances in Blood and Urine....................    94
Medical Monitoring Program.......................................    84
Medical Research.................................................    33
National Child and Environmental Cancer Registries...............    83
National Electronic Disease Surveillance System..................    60
NIOSH:
    Economic Burden of Occupational Injuries.....................   100
    National Occupational Research Agenda (NORA).................    98
    NIOSH/NIH Collaboration......................................    99
    NIOSH/Private Sector Partnerships............................   100
    Work-Based Programs..........................................    65
Non-employee Reception Center....................................    88
Obesity......................................................22, 37, 53
Occupational Health Education and Research Centers...............    64
Oral Health......................................................41, 93
Ovarian Cancer...................................................    42
Opening Statement................................................     1
Pediatric Referral Units.........................................    85
Peer Review of Research..........................................    45
Physical Activity................................................    52
Polio Eradication................................................    51
Prevention Effectiveness.........................................    53
Preventive Health Block Grants...................................41, 66
Pulsed-field Gel Electrophoresis.................................    73
Race Initiative..................................................    30
Racial and Ethnic Health Disparities.............................    79
SAFE USA.........................................................    65
Site Acquisition.................................................    88
Suicide: National Suicide Prevention Plan........................    76
Syphilis.........................................................    40
Tobacco Control..............................................28, 44, 50
Toxicology Control in Arkansas...................................    52
Tuberculosis.....................................................    32
Universal Data Collection Program................................    89
Unobligated Balance..............................................    89
Urban Research Centers...........................................    58
U.S./Saudi Arabian Joint Commission..............................    86
Violence Against Women...........................................    26
    Violence in Schools..........................................    46
    Youth Violence...............................................    26

       Substance Abuse and Mental Health Services Administration

Access to Community Care Program.................................   563
Addiction Technology Transfer Centers............................   591
Advanced Funding.................................................   547
Best State Providers of Mental Health and Substance Abuse 
  Services.......................................................   556
Bioterrorism...................................................571, 645
Breakout of the FY 2000 Budget Requests..........................   611
Budget Caps......................................................   553
Budget Request, Justification of Estimates for Appropriations 
  Committees.....................................................   774
CSAP's Knowledge Development Portfolio...........................   578
CSAP's Knowledge Application Program.............................   581
Center's for the Application of Prevention Technologies..........   607
Children and Adolescent Drug Use.................................   650
Children's Mental Health Services Program............573, 614, 625, 668
Client Outcomes and Program Effectiveness........................   590
Closing the Drug Treatment Gap............................548, 589, 630
Community Action Grants..........................................   571
Consumer and Family Technical Assistance Centers.................   566
Continuum of Care Program........................................   571
Core Client Outcome Measures.....................................   562
Cross-site Studies...............................................   583
Cultivating a System Responsive to Current and Emerging Needs....   535
Effectiveness of the Substance Abuse Treatment System............   633
Effects of Alcohol Advertising on Underage Drinking..............   624
Employment Intervention Demonstration Program....................   566
Empowerment Zone/Enterprise Community Program....................   596
Family Members and Consumer Supporters/Organizations.............   643
Funding for State Owned and Operated Psychiatric Hospitals.......   613
Government Performance Results Act (GPRA)........................   626
HIV/AIDS Minority Initiative.....................................   624
HIV/AIDS Outcome Cost Study......................................   562
High Risk Youth Program..........................................   588
Homeless Families with Children Program..........................   604
Homelessness Prevention Program..................................   604
Impact of Substance Abuse Advertising Campaign...................   632
Improving System Performance and Service Quality.................   532
Interagency Coordination (with other departments)................   652
Inventory of State Prevention Activities.........................   611
KDA and Targeted Capacity Expansion Programs.....................   567
Legislative Proposals............................................   562
Managed Care.....................................................   661
Measuring Performance and Increasing Accountability..............   537
Mental Health and Substance Abuse Block Grants...................   574
Mental Health Block Grant Program................................   771
Mental Health Block Grant/Data Infrastructure....................   550
Mental Health Services...........................................   554
Mental Health Services for the Homeless..........................   549
Mental Illness...................................................   558
Methadone Accreditation Program..................................   614
Minority Fellowship Program......................................   605
Models for Improving Mental Health and Primary Health Care.......   603
National Clearinghouse for Alcohol and Drug Information (NCADI)..   587
National Household Study on Drug Abuse....................602, 617, 640
National Prevention System.......................................   577
National Technical Assistance Centers for Consumer and ``Consumer 
  Supporter'' Networks...........................................   642
National Treatment Improvement Study (NTIES) Highlights..........   744
Opening Statement................................................   528
Opioid Treatment Program.........................................   593
Outlook for Mental Health and Anti-drug Efforts..................   658
Overview.........................................................   529
Parity...........................................................   559
PATH Program..............................................576, 666, 773
Partnership for Planning and Performance Project.................   576
Program Measures for Targeted Capacity Expansion.................   594
Preventing Youth Violence........................................   662
Producing Results, a Report to the Nation (CSAT).................   703
Program Management...............................................   770
Program for Women................................................   663
Protection and Advocacy Program (P&A)............................   574
Reduction in CSAP KDA Program....................................   587
Report on Societal Outcome and Cost Savings of Drug and Alcohol 
  Treatment in the State of Oregon...............................   671
SAMHSA's Knowledge Development and Application Programs..........   618
Safe and Drug Free Schools.......................................   656
Safe Schools/Healthy Students....................................   647
School Violence Program/Initiative........................564, 628, 638
Spending for Alcohol and Drug Activities.........................   596
Spending for Mental Health and Substance Abuse...................   575
Starting Early/Starting Smart Initiative.........................   605
State Incentive Grant Program..................................616, 651
Substance Abuse and the HIV Epidemic.............................   665
Substance Abuse Block Grant Program..............................   630
Substance Abuse Block Grant Set-aside Funds......................   601
Substance Abuse Block Grant Table................................   598
Supporting and Maintaining State Systems.........................   531
Synar Amendment..................................................   649
Synar Provisions.................................................   551
Targeted Capacity Expansion Program:
    Legislation for the Targeted Capacity Expansion Programs.....   595
    Prevention Capacity Expansion Programs.......................   587
    Treatment Capacity Expansion Programs......................632, 669
Training Protocols for Mental Health Professions.................   603
Treatment on Demand..............................................   666
U.S.-Mexico Border Substance Abuse Initiative....................   610
Witnesses......................................................523, 539
Women and Violence Program Initiative............................   591
Working with the Alcohol Beverage Industry.......................   636
Y2K Compliance...................................................   646
Young People in Drug Treatment...................................   555

               Agency for Health Care Policy and Research

Agency for Health Care Policy and Research.......................  1051
Adoption of New Knowledge, Time..................................  1069
Advisory Commission on Consumer Protection and Quality...........  1076
AIDS Costs.......................................................  1101
Asthma Disease Management, User Liaison Program on...............  1084
Asthma Morbidity among Children, Reducing........................  1083
Authorization, AHCPR's...........................................  1069
Average Length of Research Project Grant.........................  1086
Biography, Dr. John M. Eisenberg, M.D............................  1068
Budget Request.........................................1054, 1062, 1094
Centers for Education and Research Therapeutics (CERTS)1053, 1095, 1111
Children's Mental Health Research................................  1085
Chronic Illnesses, Quality Measures for..........................  1081
Consumer Assessment of Health Plans (CAHPS)......................  1076
Data on Diabetes and Cardiovascular Diseases.....................  1083
Ethics...........................................................  1074
EPSCoR Program...................................................  1105
Fiscal Year 1999 Research....................................1053, 1059
Foundation Training Support......................................  1090
Health Care:
    Costs, Increasing............................................  1087
    Outcomes and Quality Table...................................  1092
    Policy.......................................................  1104
    Quality, Improving...........................................  1053
    Systems, Impact of AHCPR's Research......................1053, 1059
Health Insurance Coverage........................................  1073
HIV and Pharmaceuticals Cost.....................................  1089
HIV Cost, Services, and Utilization Study (HCSUS)......1073, 1088, 1091
HIV Resource Utilization Data Coordinating Center................  1089
Impact of AHCPR's Research.......................................  1052
Laboratories for Change..........................................  1081
Lawsuits.........................................................  1072
Long-term Care...................................................  1107
Managed Care:
    Evaluating Impact of.........................................  1089
    Growth and Research..........................................  1090
    Networks.....................................................  1083
MEPS Contract....................................................  1090
Minority Populations, Research on................................  1078
New Research on Priority Health Issues.......................1054, 1063
New Tools and Talent for a New Century.......................1054, 1064
National Guideline Clearinghouse.............................1054, 1099
National Nursing Home Expenditure Survey.........................  1091
National Quality Tracking System.................................  1077
Nursing Homes and MEPS Data......................................  1087
One Percent Evaluation Funds.................................1069, 1093
Overload of Information..........................................  1106
Patients and Clinicians, Impact of AHCPR Research............1052, 1058
Pipeline of Research.............................................  1052
Planning Process.................................................  1051
Policymakers, Impact of AHCPR Research.......................1053, 1059
Pressure Ulcer Rates.............................................  1086
Preventive Care, Cost Savings through............................  1110
Program Management Increases.....................................  1091
Put Prevention into Practice.....................................  1076
Racial and Ethnic Health Disparities.........................1070, 1080
Research Management Increases....................................  1091
Research Training and Other Grant Programs.......................  1084
Role of AHCPR....................................................  1098
Rural Health.....................................................  1102
Rural Managed Care Demonstration Centers.........................  1098
Schizophrenia PORT...............................................  1096
Success Rate.....................................................  1097
Tobacco..........................................................  1109
Translating Research into Practice...............1055, 1066, 1099, 1105
Violence Against Women Fellowship Program........................  1081
Witnesses....................................................1051, 1056

              Health Resources and Services Administration

Abstinence Education.............................................  1354
Allied Health....................................................  1338
Border Health....................................................  1345
Budget Process...................................................  1363
Children's Hospitals GME.........................................  1338
CHIP Program.....................................................  1346
Community Integrated Services System.............................  1355
Community Health Centers.....................................1362, 1368
Coordination--Applications.......................................  1357
Discretionary Caps...............................................  1367
Diversity--COEs..................................................  1339
Family Planning..............................................1338, 1352
Health Professions Zero Funding..................................  1345
Health Professions Budget Request................................  1349
Health Care Access for Uninsured.................................  1340
Health Centers Budget Request....................................  1348
Health Centers Need..............................................  1349
Healthy Schools, Healthy Communities.............................  1356
Increasing Coordination Efforts..................................  1350
Introduction of Witnesses........................................  1323
Medicaid Managed Care Plans......................................  1365
Medicare Rural Hospital Flexibility Program......................  1360
Models-at-Work...................................................  1351
National Health Service Corps....................................  1344
Opening Statement................................................  1323
Oral Health......................................................  1358
Organ Transplant Regulations.....................................  1353
Poison Control...................................................  1347
President's Budget--Caps.........................................  1361
Primary Care Training............................................  1343
Racial Disparities in Health.....................................  1337
Ryan White.......................................................  1341
Ryan White Unmet Need--ADAP......................................  1365
SPRANS/Hemophilia................................................  1342
Uninsured........................................................  1358
Universal Newborn Hearing........................................  1339
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