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



      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION,

              AND RELATED AGENCIES APPROPRIATIONS FOR 2001

                 DEPARTMENTS OF LABOR, HEALTH AND HUMAN

               SERVICES, EDUCATION, AND RELATED AGENCIES

                        APPROPRIATIONS FOR 2001

_______________________________________________________________________

                                HEARINGS

                                BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS

                             SECOND SESSION
                                ________

  SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
                    EDUCATION, AND RELATED AGENCIES

                 JOHN EDWARD PORTER, Illinois, Chairman
 C. W. BILL YOUNG, Florida          DAVID R. OBEY, Wisconsin
 HENRY BONILLA, Texas               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, Carol Murphy, Susan Ross Firth,
             and Francine Mack-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........  461
 Agency for Health Care Research and Quality......................  771
 Health Resources and Services Administration..................... 1091
                                ________

         Printed for the use of the Committee on Appropriations

                                ________

                     U.S. GOVERNMENT PRINTING OFFICE
 64-152                     WASHINGTON : 2000

                        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             MICHAEL P. FORBES, New York
 RODNEY P. FRELINGHUYSEN, New Jersey CHET EDWARDS, Texas
 ROGER F. WICKER, Mississippi       ROBERT E. ``BUD'' CRAMER, Jr., 
 GEORGE R. NETHERCUTT, Jr.,         Alabama
Washington                          MAURICE D. HINCHEY, New York
 RANDY ``DUKE'' CUNNINGHAM,         LUCILLE ROYBAL-ALLARD, California
California                          SAM FARR, California
 TODD TIAHRT, Kansas                JESSE L. JACKSON, Jr., Illinois
 ZACH WAMP, Tennessee               CAROLYN C. KILPATRICK, Michigan
 TOM LATHAM, Iowa                   ALLEN BOYD, Florida
 ANNE M. NORTHUP, Kentucky          
 ROBERT B. ADERHOLT, Alabama        
 JO ANN EMERSON, Missouri           
 JOHN E. SUNUNU, New Hampshire      
 KAY GRANGER, Texas                 
 JOHN E. PETERSON, Pennsylvania     
 VIRGIL H. GOODE, Jr., Virginia     

                 James W. Dyer, Clerk and Staff Director

                                  (ii)

 
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2001

                              ----------                              

                                       Thursday, February 10, 2000.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

                                WITNESS

JEFFREY P. KOPLAN, M.D., M.P.H., DIRECTOR
    Mr. Porter. The Subcommittee will come to order. We 
continue our hearing on the appropriations for the Department 
of Health and Human Services with the Centers for Disease 
Control and Prevention. We are very pleased to welcome Dr. 
Jeffrey Koplan, the Director of CDC.


                               HANTAVIRUS


    Dr. Koplan, let me begin by saying I have great confidence 
in your leadership at CDC. You are doing a wonderful job there. 
I am going to start with an issue that has come, not under your 
watch, but for which you are responsible and that is the 
question of hantavirus and the reporting to Congress for the 
funding of that disease research. I am not going to dwell on 
it. I know that you are going to address that in your remarks, 
but I think it is a subject we have to raise and discuss right 
here.
    Earlier last year the question of reporting funding on 
chronic fatigue syndrome research was before us. You took very 
definite steps to correct a problem that many of us saw and now 
of course we have a similar question regarding research on 
hantavirus.
    I want to emphasize at the very beginning that this is not 
a question of how the funds were spent. It is not up to 
Congress to make scientific decisions. It is up to you. You are 
the scientists. If a severe threat comes along and there is 
funding for hantavirus and it needs to be re-addressed to Ebola 
virus, of course you ought to put the money there and do that 
research and protect our population and the population in the 
other countries in the world. That is not the issue at all. It 
is not our trying to second guess what the money is spent on. 
It is having the information as to what in fact the money was 
spent on and having it accurately before us so that we have the 
truth on which to base public policy. And of course this 
problem has occurred a second time. It appears now, and I am 
sure you are going to address this, it appears now that for 
some period of time, it's not clear how long, money that was 
put in the budget justification as being spent on hantavirus 
was in fact spent on other research.
    Again, that is fine, but we need to know it. If this had 
not happened a second time, it probably wouldn't raise the 
question for us, but it obviously leads us to say is this going 
to happen a third time or a fourth time. Is there a culture at 
this agency of not giving us accurate information. We need to 
know. We need to be reassured that that is in fact not the case 
and that you are taking steps, as I know you are, to address 
this problem and to make certain that it is minimized and does 
not happen again in the future.
    So I am going to call on my colleague, the ranking member, 
Mr. Obey, for any statement he would like to make and then we 
will call on you, Dr. Koplan, for your response. Mr. Obey.


                          EXPENDITURE OF FUNDS


    Mr. Obey. I thank you, Mr. Chairman. And I think that your 
opening statement, Mr. Chairman, is a very responsible 
description of the situation with which we find ourselves 
facing. Let me be clear. The Congress is given by the 
Constitution the power of the purse. The Congress has the right 
to determine whether money should be appropriated to the 
Administration or not. That doesn't always mean that the 
Congress exercises the best judgment in doing so. The Congress, 
as you know, often when it appropriates money will also give 
directions about the way that money ought to be spent. Under 
the Chada decision, most of those directions that are in report 
language will in fact not be legally binding. But nonetheless, 
in my view, we have a problem. If the agency chooses to spend 
those funds in a different manner without facing that issue 
squarely with the Congress, I fully agree with the chairman 
that I do not want one dime of health money spent on the basis 
of political considerations rather than scientific 
considerations. I have a whole lot more confidence in 
scientists than in politicians, so when it comes to deciding 
where the best scientific opportunities lie to lick disease, I 
would say one thing to the agency and one thing to the 
Congress. To the agency I would simply say I hope that you will 
find your way clear to in most instances follow the direction 
that Congress lays out. If the agency feels that that is not in 
the public health interest of the citizens of the United 
States, then the agency has an obligation to simply have guts 
enough to come up here and explain to the Congress why you 
think we are wrong and why you think there is a better use of 
that money, and if you make a good case, we shouldn't squawk 
about it.
    So I think that in this instance I agree with the chair 
that the problem is not in my mind where the money was put by 
the agency. The problem is that the agency made a different 
determination, which may very well have been a sound 
determination, but then the Congress was not fully and squarely 
informed, and therefore we can't exercise our oversight 
responsibilities or our fiduciary responsibilities to the 
taxpayer, and that is one problem.
    To the Congress I would make this observation. About a 
dozen years ago in CDC's budget, there were only about 25 
legislative directions about how they wanted that money to be 
spent. Today in last year's bill there are about 130. With all 
due respect, I think that is getting a little heavy and I can't 
help but recall the time in the Foreign Operations Subcommittee 
when the Congress got so enthusiastic about deciding where the 
money ought to go that it earmarked 102 percent of available 
funds. That is a pretty good trick if you can do it.
    So I would say there is a lesson for the Congress, too, in 
that we should be restrained in directing where money ought to 
go because very often what politicians would like to do, 
unfortunately, is take credit for every dollar that is directed 
to be spent against any disease, even if in the process the 
Congress itself doesn't appropriate enough money to effectively 
attack all of those problems. So I think the Congress has some 
thinking to do in terms of the way it conducts its business. 
But as the chairman said, I am very concerned about the manner 
in which the agency approached this, and I think we have got to 
know that if the agency is going to make a different judgment 
than the one urged by the Congress, your agency has to come up 
here and level with us, and lay it out, and explain it because 
otherwise you lose the political support for scientific 
judgment that you need in order to protect the American people.
    Mr. Porter. Thank you, Mr. Obey. Dr. Koplan.


                         FY 2001 BUDGET REQUEST


    Dr. Koplan. Mr. Chairman, Congressman Obey, other 
distinguished members of the subcommittee, thank you for the 
opportunity to appear before you today on behalf of the Centers 
for Disease Control and Prevention. With your permission, I 
would like to submit for the record a comprehensive written 
statement in support of CDC's Fiscal Year 2001 budget request. 
In the next few minutes, I will briefly summarize some of our 
efforts and the highlights of our budget request, and then we 
will turn to issues that have been raised regarding CDC's 
fiscal responsibilities.


                       PUBLIC HEALTH EMERGENCIES


    During 1999, CDC responded to more than 700 public health 
emergency requests from State and local health departments and 
from around the world. These emergencies and epidemics ranged 
from Hurricane Floyd to the West Nile encephalitis outbreak in 
New York City to racial and ethnic disparities in heart disease 
deaths among women in the United States.


                 HEALTH CHALLENGES FOR THE 21ST CENTURY


    For fiscal year 2001, we are requesting $3.5 billion, an 
increase of $195 million over our fiscal year 2000 
appropriation. Our request will allow CDC to begin preparing 
the public health system for the health challenges for the 21st 
century. That preparation must take place in States and 
communities throughout the country and at the national level. 
Together we can work toward eliminating syphilis, preventing 
HIV both in the United States and internationally, preventing 
tobacco use among youth, stopping violence against women, 
expanding worker safety research, and improving the Nation's 
infectious disease control capacity.
    All of these health challenges require CDC to be able to 
conduct state of the art scientific research to support our 
public health partners. The major investment you are making in 
building modern, safe, facilities for CDC is truly an 
investment in the future of this Nation. For the fiscal year 
2001 we have requested a total of $127 million to continue the 
next phase of CDC's building and facilities plan. CDC's 
thousands of scientists and program leaders strive every day to 
protect America's health and safety by promoting health and 
preventing injuries. To do that, we rely on the trust of the 
United States Congress and the American people.


          CHRONIC FATIGUE SYNDROME AND HANTAVIRUS EXPENDITURE


    Thus, I am deeply concerned about the issues raised about 
CDC's chronic fatigue syndrome and hantavirus programs. These 
diseases and the people who suffer from them are very important 
to us. In 1993, CDC was called upon to discover quickly what 
was causing previously healthy young people in the southwestern 
United States to die from acute respiratory failure. Within a 
few weeks, CDC discovered the cause, hantavirus, how it was 
spread, and worked with State and local health agencies and 
communities to control the outbreak and prevent future cases of 
this deadly disease.
    Preliminary analyses of our fiscal year 1999 expenditures 
indicate that while we have continued to support the hantavirus 
program, some of the funds appropriated for hantavirus have 
been used to combat other life-threatening infectious diseases, 
such as Ebola and Nipah virus. Responding to these issues is my 
highest administrative priority.


                           CORRECTIVE ACTIONS


    Secretary Shalala and I have taken the following actions: 
As the Secretary announced Tuesday, the Department's Chief 
Financial Officer will review and certify, along with CDC's 
Financial Management Office, the correctness of all the 
National Center for Infectious Diseases' expenditures through 
the remainder of this fiscal year. Further, the Department's 
Chief Financial Officer will ensure that all senior decision 
makers in the National Center for Infectious Diseases will 
receive certified budget execution and financial management 
training.
    In addition, I have taken several steps. I have initiated 
an external review of CDC's fiscal management practices, 
similar to that done for NIH at the request of Chairman Porter. 
This is to be completed within 6 months. The results of this 
analysis will be communicated to you as soon as that review is 
complete. Number two, I will ask CDC program managers to 
conduct a top to bottom review of CDC's 133 programs and 
projects in order to make sure there are no other areas of 
concern. During a 90-day period, CDC managers will be able to 
fully and openly identify any area for which there may be a 
discrepancy between actual expenditures and the information 
provided to Congress. I will report back to you. Third, this 
week CDC commissioned PriceWaterhouseCoopers, a firm of 
independent auditors, to fully examine our hantavirus 
expenditures. The results will be communicated to you 
immediately upon completion. When this audit is complete, we 
will expand the effort to the entire National Center for 
Infectious Diseases.
    Finally, we are seeking new leadership for our viral 
disease programs. In the interim period, Dr. James LeDuc has 
been appointed to serve as Acting Director of the Division of 
Viral and Rickettsial Diseases.
    I believe that these are strong and complementary actions 
with both internal and external review and examination and that 
they will address the concerns that you and I both share. CDC's 
services and research are delivered by talented staff with 
considerable expertise and commitment to improving the Nation's 
health, a commitment that occasionally puts their own health in 
jeopardy as they respond to the threats of deadly and unknown 
disease. However, our fiscal management capability has not kept 
pace with the growth of our scientific responsibilities. Our 
goal is to make sure CDC always fulfills both its obligation to 
protect the public's health and its obligation to be 
accountable to Congress.
    We are looking diligently to put in place the systems that 
will help us have more precise reporting and accountability in 
the future. Believe me, I wish it could be a quick fix but 
genuine changes in the system will take some time. If any 
additional problems arise, I will act upon them immediately.
    I want to express my thanks for your understanding and 
support for CDC in particular and public health in general. 
Your leadership will yield long-term benefits to the health of 
the American people. I would be pleased to answer any questions 
you may have about these particular issues or CDC's program 
directions for fiscal year 2001.


                       REVIEW OF ALL CDC PROGRAMS


    Mr. Porter. Dr. Koplan, I feel very satisfied that you have 
taken this matter very seriously, that you have a very well 
thought out plan to address it, and that it will be debated and 
corrected and that it won't happen, I think, in the future.
    I would ask you, if I understand correctly, the 
Department's efforts go only to the National Center for 
Infectious Diseases and so do the training efforts and the 
reporting. What in your plan addresses what may be a broader 
issue? In other words, how do we know that it is only confined 
to infectious diseases or whether it is happening elsewhere 
without looking into that more thoroughly? Will that external 
review look into that? Will that help us understand that?
    Dr. Koplan. Thank you. My thought was these various steps 
would complement each other and groups of them would target 
various levels of the organization. We have one level of 
concern in the hantavirus activity. For that we are working 
with PriceWaterhouseCoopers. The next level of concern is at 
the division level, what is going on more broadly there. For 
that we have a change in leadership and then 
PriceWaterhouseCoopers will move to the division level and 
look. At the third level is the National Center for Infectious 
Diseases, and for them we are getting financial oversight from 
the Department and a concentrated look for training and this 
standdown day for that group. In addition, 
PriceWaterhouseCoopers will move on to that Center as a whole.
    For CDC as a whole, we have already instituted similar 
training on fiscal responsibility with external trainers using 
the GAO Redbook. In addition, the external consulting firm will 
look at all of our policies broadly across CDC and our top to 
bottom management review, the 90-day review, will be CDC-wide 
as well. My goal is to intensively look at it in various pieces 
of the organization but cover the whole organization as well.


           YOUTH MEDIA CAMPAIGN--PUBLIC SERVICE ANNOUNCEMENT


    Mr. Porter. I have no further questions along this line 
because, as I said, this is an aspect that needs to be 
discussed, but obviously your mission in public health is what 
we are here to discuss this afternoon. You are doing a very 
fine job there at CDC. We are very encouraged with the work 
that has gone on. I want to ask about a plan that we have put 
in the Committee report on reaching out with public messages to 
young people and their parents regarding health behaviors so 
that we can perhaps change, in the future, the kind of health 
habits that have led to so much of the disease and early death 
in our country by changing the health habits of our children. 
You and I have discussed this in the past. I wonder if you 
could tell the subcommittee what your plans are in this area.
    Dr. Koplan. We put together a proposal for a youth media 
campaign to be linked to other health promotion activities. One 
of the aspects of this is to try to create a positive message 
to kids, not just a negative don't do this and don't do that. 
It would involve quite a bit of saturation of mass media, which 
seems to be what is necessary to get people's attention and do 
so in a very contemporary, hopefully enticing manner. It would 
cover a range of health risk factors for children, targeting 
probably 9- to 11-year-olds as being at the most impressionable 
age and ability to respond to this. And we would hope to link 
with some other DHHS agencies in doing this as well and look to 
see what they are doing in the area and see where we can be 
complementary, including HRSA, SAMHSA, our colleagues at Child 
Health.
    Mr. Porter. I am glad you added that. I was just about to 
request that you meet with Dr. Fox, Dr. Alexander, and Dr. 
Chavez, each of whom I have asked if they would meet together 
with you so that we could all sit down and see if we can 
develop this concept further. So I very much appreciate that.


                        BUILDINGS AND FACILITIES


    The construction, buildings and facilities, when I was down 
to visit CDC last year, I found in some cases your situation to 
be appalling for an institution as renowned both here at home 
and throughout the world as CDC is, particularly the quonset 
huts that date back to probably World War II that your 
environmental health people are required to work in. What 
impact would this have in regard to the environmental health 
people, Dr. Jackson and others, that occupy those antiquated 
buildings?
    Dr. Koplan. We have managed to get rid of a couple of those 
buildings just in the last couple of weeks, thank you, with 
your assistance in this year's budget. We have begun 
construction on an environmental lab to take care of some of 
our facilities that is underway right now. Design is going on 
for other buildings. For Fiscal Year 2001, that would involve 
the design of a considerable environmental health lab which 
would remove all those quonset huts, unless someone desired 
them for historical purposes, but we get our staff into safe, 
modern facilities from which they can do extremely important 
work.
    Just to mention the labs, and it doesn't mean anything to 
you until you realize what is going on in them. These are the 
laboratories that are the only places in the world that can 
study various toxic chemicals in the human body. It is 
particularly important for bioterrorism activities. It is 
important for all kinds of exposures. We think it is going to 
be an extremely important area to compare genetic markers in 
people with environmental exposures, and the two together may 
give us information we never had before. So this is an 
important laboratory facility.
    Mr. Porter. Thank you, Dr. Koplan. Mr. Obey.


                              TUBERCULOSIS


    Mr. Obey. Three questions. First of all, for FY 2000 I 
tried to get $63 million above the President's budget in these 
accounts for infectious diseases, such as TB, malaria, and 
AIDS. We wound up getting about $10 million extra this year. As 
I understand, the President's FY 2001 budget is asking for $26 
million above the FY 2000 level. I welcome that increase. But I 
note that the amount for TB was not increased. Could you give 
me a very brief response as to why that was frozen so I have 
time for two other questions?
    Dr. Koplan. There is a fair amount of TB interest and 
activity going on right now. TB remains an important disease in 
the U.S. and particularly in terms of importation. About 40 
percent of the cases in the U.S. come from people who are 
originally from overseas. But it is something that has not gone 
away, remains a problem. In my professional judgment, it could 
always use more attention and resources.


                ATTITUDES AMONG CDC SCIENTISTS ABOUT CFS


    Mr. Obey. I thank you. Mine too.
    Let me ask one other question. The Washington Post article 
on the unfortunate incident that we have been talking about, 
with respect to funds, quoted one person at CDC as saying that 
his superiors did not consider chronic fatigue syndrome to be a 
serious health threat. I had a staffer who was plagued with 
that for years and it so mucked up her life she wound up 
committing suicide. That really is not the attitude of your 
agency with respect to that disease, is it?
    Dr. Koplan. It is not the attitude of myself, of our 
agency, of any responsible person in the agency. We have 
colleagues at CDC that have chronic fatigue syndrome. We have 
colleagues in other aspects of public health relevant to that. 
We all work with people and know people with it. It is an 
extremely important health area that has frustrated all of us 
in not finding an etiology, a cure, or a way to prevent it, but 
we are committed to trying to do that. So, no, we consider it a 
major important concern.


                   DESIGNATION OF FUNDS FOR DISEASES


    Mr. Obey. I thank you. So do I.
    Just to reinforce what I was saying earlier on this 
question, I think it is important for the general public, I 
think it is important for the groups that lobby for a 
congressional designation of different diseases for your 
attention. I think it is important for members of the press to 
understand that whether we see references to diversion of 
funds, while that sounds very bad and spooky and while I 
certainly don't appreciate the way it happened, that does not 
mean that what your agency did was illegal. It may have been 
right or wrong in terms of substance. It may have been stupid 
in terms of its refusal to inform the Congress, which it 
certainly was. But I think we need to put in perspective what 
words like that actually mean and what does happen when we 
designate funds.
    I would hope that at the earliest possible date your agency 
can come before us and tell us that this problem is fixed 
because you have got a lot of serious work to do. I know you 
know that and we need to have the full confidence of the 
Congress behind the processes as well as the substance of the 
work that you do.


                              USE OF FUNDS


    Dr. Koplan. Thank you.
    Mr. Porter. Thank you, Mr. Obey. Mr. Bonilla.
    Mr. Bonilla. Thank you, chairman. Dr. Koplan, all Americans 
take great pride in what the CDC does. I want to thank you for 
attempting to take decisive action on this problem. Hopefully 
it will be investigated and finished and done with as quickly 
as possible. I didn't quite understand, perhaps you can tell 
me. Maybe you don't know whether the diversion of funds, was it 
intentional? Was someone trying to hide what they were doing or 
was it just a case of honest dumb mistake? Or do you know yet?
    Dr. Koplan. The level of intelligence attached to it I 
won't venture, but I would say it is not one we want to repeat 
and it is not the way we want to do business. I feel we clearly 
had a failure to communicate. It has been well described and 
the chairman described well the fact that no one in our staff 
should question the willingness of this committee and Congress 
to work with us. We have gotten terrific support from you all. 
I think people just weren't thinking in their rush to do other 
things that there is a responsibility here and they need to 
meet it. They need to report it to us within the organization 
and we need to be able to report it to you. And we are taking a 
number of steps that I think is going to correct that.
    Mr. Bonilla. Hopefully that is all it is because if it--
let's hope it is not but someone who really did try--malicious 
may be too strong a word--but try to sneak around and do this 
behind people's back knowing it was the wrong thing and 
probably even more decisive action on your part would be 
appropriate down the road. We will let it go at that for now.
    Before I ask a question in another area, I wanted to let 
you know I am going to submit some questions for the record 
from my friend and colleague Joe Skeen of New Mexico. As you 
know, the hantavirus outbreak was in his district so he is 
concerned with some of these issues. So I will pass that along 
to you. I also want to mention the good work Bill continues to 
do. We are always glad to see him up here. He is a great 
ambassador as well as what he does daily for you at the CDC.
    Mr. Obey. What do you expect from somebody from Wisconsin.


                    DIABETES AND PERIODONTAL DISEASE


    Mr. Bonilla. Absolutely right, David. David and I agree, 
let the record show.
    I am going to start out, Dr. Koplan, you and I have talked 
about diabetes before in our meetings and hearings over the 
years, glad for the CDC's work in trying to combat the disease 
in areas of high minority populations. Specifically I want to 
ask today about periodontal disease because although CDC 
guidelines recommend that diabetics get regular foot and eye 
exams and dental exams, it seems that in reality the dental 
visits are the ones that seem to be overlooked and occur less 
often. Tell me what you are doing to increase public and 
professional awareness of the importance of this aspect of a 
person's health when they have diabetes?
    Dr. Koplan. As you indicated, our emphasis has been on 
retinal exams, the leading cause of blindness, foot care in 
particular, the leading cause of amputation diabetes and 
adherence to low glucose levels, normal glucose levels, the 
major causes of renal disease. I don't think our program has 
done much in the way of periodontal disease. It is an important 
area, certainly for quality of life, but we have not gotten--I 
believe, and we will put in the record if I am mistaken on this 
but I don't believe we have done much in that area.
    [The information follows:]



                      BIRTH DEFECTS AND FOLIC ACID

    Mr. Bonilla. If CDC hasn't, hopefully we can look at 
getting into that area as well because it can be equally as 
harmful as some of the other areas that patients are often 
reminded about.
    In fact if I could move now to birth defects. Two years ago 
Congress passed and the President signed into law the Birth 
Defects Prevention Act. As you know, the late 80's and 90's we 
saw terrible epidemics in south Texas with birth defects 
occurring both in the Brownsville area of Texas, which is south 
of me, and in Eagle Pass, which is actually in my congressional 
area. That is what spurred my colleague Solomon Ortiz, and I, 
to put this act together and we are delighted it was signed 
into law.
    I am glad to see CDC's efforts in this area, particularly 
in Texas, to educate mothers and prevent defects through the 
folic acid program, which if fully everyone knew about that we 
would probably do a great deal to eliminate this problem 
entirely. I was happy to read about the study released on the 
Texas neural tube defect project in the last month's CDC 
Morbidity and Mortality Weekly Report. Tell us, Doctor, give us 
an update on this and other folic acid education programs that 
CDC now has.
    Dr. Koplan. Thank you. We agree that the birth defects area 
and program is particularly important. I think the biggest 
breakthrough in the last few years is this folic acid--we are 
interested in prevention--to know that folic acid during 
pregnancy can prevent most of the cases of neural tube defects, 
spina bifida, is a terrific advance. The emphasis has been 
increasing the amount of folic acid that women take even if 
there is the possibility of their becoming pregnant. The 
emphasis is on 400 micrograms per day for women. That is a big 
push. This year we are about to do a resurvey of women's 
knowledge about this. We have been doing it every 2 years. I 
hope to see that knowledge level continuing to increase 
upwards. In addition, we now have eight prevention--birth 
defects research centers, prevention research centers in 
different academic sites, including one in Texas, and that 
group is looking at a wide variety of different birth defects 
and how we can prevent them. In addition to neural tube 
defects, a wide range--we are looking at potentially adding 
departmental disabilities to research centers as well. This is 
an area where there is great promise and we hope to see that 
number of neural tube defects drop markedly in the coming 
decade.
    Mr. Bonilla. Thank you. I hear the beeper going off so my 
time is up. I have some questions I will present you in 
addition for the record. I appreciate your getting back to me 
on that. Thank you.
    Mr. Porter. Thank you, Mr. Bonilla. Ms. Pelosi.

                                HIV/AIDS

    Ms. Pelosi. Thank you, Mr. Chairman. Dr. Koplan, welcome. 
Thank you for all your good work. The questions asked by my 
chairman and ranking member afford me the luxury of moving on 
to some specific questions and I have chosen on this panel to 
try to have a comprehensive view of what the administration is 
doing in terms of minority health, especially as it pertains to 
AIDS, since my district has suffered so many thousands, almost 
tens of thousands of deaths from AIDS. I want to spare everyone 
else that. I have two lines of questioning, one about AIDS and 
one on the environmental health labs. Following the model of my 
ranking member, Mr. Obey, I hope that we can keep the answers 
short so that I can get to both of them.
    As you know, every day 16,000 people are newly infected 
with HIV, the virus that causes AIDS. This is worldwide. The 
vast majority of those people infected are in developing 
countries, particularly in sub-Saharan Africa. When I am in my 
Foreign Operations Subcommittee, I ask USAID and the State 
Department and the Treasury Department what they are doing in 
their international duties to collaborate with our domestic 
agencies on some of these issues. So I am asking you what you 
are doing internationally.
    Last year we provided $35 million in additional funding 
through the Labor-HHS bill to fight the global AIDS epidemic. 
Can you tell us how this funding--it is such a little tiny bit 
of money compared to the need that we have, but can you tell us 
what we are getting for that?
    I have been told that you recently attended a National 
Immunization Day in Africa. Could you tell us generally about 
the importance of the trip and your observations?
    Dr. Koplan. Thank you very much. I will try to speak very 
quickly to get everything in, not shortly but quickly. This is 
an extraordinarily important area. Countries are being 
devastated in sub-Saharan Africa around this. It is estimated 
by the year 2010 the average life span in Zambia will be 33 
years old. That is a medieval life span. In Zimbabwe, it is 
going to be about 40. It is estimated in some countries that 25 
percent of the population are HIV positive. This is a disaster 
of epic proportions. It is not just in the making. It is there 
now.
    Ms. Pelosi. And it was predictable, I might add, for many 
years.
    Dr. Koplan. The fact we have some resources to do something 
on this is extraordinarily important to us at CDC and I think 
to the country as a whole. What we are doing is we are actually 
going to put people in the field in a number of these 
countries. We have some there already. We have an important 
field study site in Kenya for HIV and for malaria together and 
we will be adding bolstering staff across the region. We will 
be working closely on this with the U.S. State Department 
Agency for International Development and we already have 
partnerships in a number of countries with them around this 
issue.
    The areas of focus will include improved surveillance. Some 
of these countries don't know what is going on in the country, 
need it documented. Improve laboratory work so people can know 
whether they are positive or not. Treatment as much as possible 
and counseling for people in these countries. An emphasis on 
prevention and public campaigns, everything that we would want 
to do here needs to be done there and more so.
    Sub-Saharan Africa has a particularly devastating problem 
but I was in India last month and visited our AIDS program 
there. We have an assignee to the Agency for International 
Development there. They are showing the collaborative status 
and working in a burgeoning HIV epidemic in a country of nearly 
a billion people, which is going to be massive as well. So it 
is an issue of worldwide proportions and we are very grateful 
to have funding to be able to participate in controlling it.

                    ENVIRONMENTAL HEALTH LABORATORY

    Ms. Pelosi. Thank you, Dr. Koplan. More on that as we go 
on. As you know, contaminants in the environment have been 
associated with a range of birth defects and diseases, 
including breast and prostate cancer. We have been able to 
substantially increase funding at the environmental health lab 
at CDC. I want to commend the administration's request this 
year for additional funding for the lab. Can you tell us 
something about the importance of the research being done in 
the environmental health lab and the contributions the lab can 
make to children's health, cancer prevention and the 
preparation for public health emergencies. You addressed this a 
little bit in your opening remarks about the environmental work 
that you are doing at CDC.
    Dr. Koplan. The lab currently can measure about 50 toxic 
exposures and we are trying to add as many more per year as we 
can. We are trying to add 20, 25 per year to that. They include 
the areas of heavy metals, indoor air pollutants, pesticides, a 
wide variety of toxic agents. Our staff has developed the 
ability to add new tests that nobody else can do, measure these 
things in the human body at an infinitesimal level. It is one 
part per many, many parts. In many instances it is unclear what 
that means. We may all carry a certain amount of this but the 
only way to correlate it with disease is to do that 
measurement.
    We think these measurements are vitally important. They 
have several areas of importance. One is acutely. In a 
bioterrorism event the ability to measure quickly what someone 
has in their body may give us the clue as to what that chemical 
agent was. In chronic conditions such as many of those you have 
mentioned, the ability to correlate a given birth defect with 
higher levels of a given substance is an extraordinarily 
important way to document a relationship between those two. 
That is the type of work that is going on and why it is 
important.
    Ms. Pelosi. I appreciate that. Thank you, Dr. Koplan. The 
chairman has said we will have a hearing this year on 
environmental health so I look forward to pursuing this issue 
further with you between now and then and certainly at that 
time. Do you have more time, Mr. Chairman?
    Mr. Porter. Quick.
    Ms. Pelosi. I guess not. I shouldn't have asked. Thank you 
very much, Mr. Chairman.
    Mr. Porter. Thank you, Ms. Pelosi. Mr. Wicker.

                          REDIRECTION OF FUNDS

    Mr. Wicker. Thank you, Mr. Chairman. When we are on the 
House floor, we are admonished not to refer to the television 
cameras but I suppose since we are not on the floor of the 
House, I could say that it is good to have TV cameras here 
today. I suspect they might have been assigned to this hearing 
because of the controversial matter that was addressed by the 
chairman and the ranking member about the redirection of funds. 
I think that the comments of the chairman and ranking member 
were well put. They reflect, I think, the opinion of the 
majority of the members of this committee and I think we will 
get beyond that. This doesn't have to be a disaster for CDC.
    The good thing about having the cameras here is that the 
viewing public will be able to see what wonderful programs we 
have at CDC, what a great Federal agency this is. And I hope 
that at the end of the hearing those within the sound of our 
voices will see that the things you are doing at CDC around the 
Nation and across the globe are fine expenditures of the 
taxpayers' money, that we get our money's worth and also that 
the things we are doing are worthy of a great superpower. So it 
is good to have CDC back here. I just have two things I would 
like for you to talk about, one about cardiovascular disease 
and then also to get your take on privacy.

                         CARDIOVASCULAR DISEASE

    In 1998 and 1999, for the first time Federal funds were 
directed specifically to address cardiovascular disease. I 
don't know if the public is aware that cardiovascular disease, 
including heart disease and stroke, is still the leading cause 
of death among men, among women, among all ethnic groups. So 
tell us how this program is going. It is now in 18 States. Some 
grants are at the planning stage. Some are at the comprehensive 
stage. Are we ready to take the program nationwide and what can 
you tell us for the record about this program?
    Dr. Koplan. Thank you, Congressman Wicker. As you indicated 
it is an extremely important disease. The crucial one is we 
have knowledge on the shelf that we are now putting in place. 
We have invested in large research studies that show us we can 
make a difference in cardiovascular health and indeed in the 
last 15 years in this country, we have dropped the mortality 
rate from heart disease by 50 percent. That is due to both 
improved prevention activities and improved treatment and we 
can do better. There continues to be marked racial disparity in 
those rates and those need to be corrected in a variety of 
programs.
    There are some very interesting and important examples of 
things. One of my favorites is a partnership in New York State 
that is part of their cardiovascular disease program which I 
think is a model, a partnership between private industry, 
particularly the milk and dairy industry and activists in the 
community and public health groups and it involves a joint goal 
of increasing milk consumption and increasing that proportion 
of milk consumption that is low fat milk. They are working on 
doing both, but it is a natural linkage and one that increases 
calcium levels in men and women and kids, decreases the amount 
of fats in the diet. It seems to make everybody happy in this 
regard.
    There are examples of targeting obesity and chronic 
diseases in Mississippi and using school nurses in an 
innovative way to deliver cardiovascular health messages to 
kids. I think this plays into what Chairman Porter mentioned 
earlier in his interest, which is a key time to make some of 
these health habits and make them lifelong in informative years 
in childhood. I think that is a common target we might think of 
for many of our programs.
    Mr. Wicker. I appreciate that and I would appreciate your 
thoughts about are we ready to take the program nationwide. 
What do you think about that?
    Dr. Koplan. Absolutely. I think again the knowledge of what 
we could do to prevent heart disease involving both diet, 
physical activity, tobacco use, blood pressure, and cholesterol 
determinations is usable in every State, so it is somewhat like 
saying if we had measles and rubella vaccine, we would only use 
them in these six States and let's wait for the other ones to 
join in. I think we have a product that could make a 
difference.

                       PRIVACY OF MEDICAL RECORDS

    Mr. Wicker. Let me briefly ask you about privacy. As you 
know, the Health Insurance Portability and Accountability Act 
required Congress to enact a Federal privacy law by last August 
or if not the Secretary would take on that responsibility. 
Congress did not act and the Secretary is moving forward. You 
and I had a conversation about this the other day. What do we 
need to be careful about? Obviously if this were an easy 
question, it would already have been done. What does the 
government need to be mindful of in the area of a free flow of 
medical information as we are protecting the privacy rights of 
patients?
    Dr. Koplan. It largely involves a balance. Any of us as 
citizens are very concerned about the privacy of our medical 
records and we all want them maintained. By the same token we 
all benefit from the health data that gets collected in a wide 
range of important governmental and academic surveys and 
studies. We need to get a balance in those so we don't lose all 
the health benefits we have gotten from doing studies and 
surveys, at the same time pay careful attention to keeping 
people's privacy. But a lot of what we have learned about the 
relationship of cholesterol to heart disease, the relationship 
of tobacco to a variety of diseases relates to studies and 
surveys done and which we need to continue to get that kind of 
information.
    Mr. Wicker. Have you visited with the Secretary? Have you 
provided input to the Secretary of HHS about how she might 
formulate this regulation?
    Dr. Koplan. We have regular input. She has a standards 
committee that is looking specifically about this legislation 
and the issue of privacy and it is balanced with data 
collection. We have considerable input into that.
    Mr. Wicker. Thank you very much. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Wicker. The Chair is going to 
ask the permission of the Members of the subcommittee to 
interrupt the questioning for just a few minutes and allow Dr. 
Koplan to make the presentation that he would have made were we 
not required to address an issue that we all thought was of 
great importance. Would you do that, Dr. Koplan, with the 
charts that you have brought?
    Dr. Koplan. I am happy to continue with questioning.
    Mr. Porter. You would rather not do that?
    Dr. Koplan. I think--I appreciate it but I am more than 
happy to do----
    Mr. Porter. I thought we were preventing you from doing 
that. I see the charts are here.
    Dr. Koplan. You are kind, but I would prefer to ensure that 
not a member here leaves without having every question they 
would like to have answered answered.
    Mr. Porter. All right.
    Dr. Koplan. If there is time at the end and you care, I 
would be glad to give a slide show.
    Mr. Porter. I think there will be time. We just called and 
the floor informs us we won't have a vote for about 50 minutes, 
so I think we will have time. If you are still willing at that 
point, I would like to see what you have to show us.
    Mr. Jackson.
    Mr. Jackson. Thank you, Mr. Chairman and Dr. Koplan. 
Welcome to our subcommittee. Thanks for taking time out of your 
schedule to speak to our subcommittee about your budget.

          ELIMINATION OF RACIAL AND ETHNIC HEALTH DISPARITIES

    Dr. Koplan, the elimination of disparities is one of the 
administration's top priorities. In Fiscal Year 1999 this 
subcommittee appropriated $10 million for this effort. In 
Fiscal Year 2000, the subcommittee provided $30 million. In 
Fiscal Year 2001 I believe your request is $35 million. I know 
that the University of Illinois at Chicago and Sinai Family 
Health Centers receive funds for demonstration grants. I would 
like for you to explain how CDC's reach initiative will address 
this priority and how you are using these dollars.
    Dr. Koplan. Thank you, Congressman Jackson. This is a 
terrific program. We solicited a wide range of community groups 
and organizations that had previously not participated in 
health action before and got an extraordinary number of 
responses from them, many of them linked both--almost all of 
them linked with both local health departments and an academic 
center nearby, so it is a terrific partnership. We had over 200 
applicants for this, approved applicants. We are able to choose 
across a wide range across the country and a very different 
group of partners than we would normally have for many of our 
programs.
    So in 1999 we have had 35 planning projects and now we are 
able to move some of those in to actual community demonstration 
projects to do more substantive work. They include the areas of 
infant mortality, heart disease, breast and cervical cancer, 
diabetes, immunizations and HIV/AIDS. And the communities can 
pick amongst those important health issues which ones they are 
going to target. They are well into that first year now and we 
expect them to really make a difference and be models for 
growth.
    Another really nice piece of it is foundations in different 
places have seen the merit in this kind of program and have 
bought in. So some of the programs that we have been unable to 
fund but have been approved have been supported by private 
foundations so that they can get going. We have seen an 
expansion of this in the future, so again a nice opportunity 
for partnerships.

                    ABSENCE OF MINORITY RESEARCHERS

    Mr. Jackson. Let me also congratulate you for what I think 
is an outstanding program and effort that the CDC has been 
making in this particular area. As you probably well know, I 
have been querying the NIH on the absence of minority 
researchers of African Americans and Hispanics. There is a 
dearth of minority researchers as a result of NIH's inability 
or present inability to award grants in that particular area. 
At the appropriate time, I would like to query CDC as well on 
the question of minority researchers at the Centers for Disease 
Control and not only in the areas of research but also in the 
areas of administration in terms of African American, Hispanic, 
Native American participation. But let me continue the 
questioning.

                  CHILDHOOD LEAD POISONING PREVENTION

    Dr. Koplan, childhood lead poisoning continues to be a 
serious public health problem, particularly in inner city 
communities. The GAO estimates that more than 400,000 children 
eligible for Federal health programs have undetected harmful 
levels of lead poisoning in their blood. Could you update the 
committee on the CDC's Childhood Lead Poisoning Prevention 
Program, what you have been doing to combat this problem and 
also I noticed that funding for this program has been 
relatively stagnant for the past several years. Should we be 
investing more in this area?
    Dr. Koplan. Childhood lead poisoning is an important area 
and it is particularly important for its racial and ethnic 
discrepancies and rates and exposures. One of the areas that we 
have been emphasizing in the face of relatively flat funding 
has been developing technologies that may improve detection of 
lead, particularly in neighborhoods and in communities, and we 
have worked hard at developing a handheld lead detection device 
that gives an instantaneous readout of what that lead level 
was. In the past it was a laborious collection, got sent 
someplace far away and took a while to get back. This does make 
a real practical difference. It means doctors' offices, nurses, 
potentially even school nurses can apply this and increase the 
rates at which we find elevated lead and then can treat. It 
remains an important health environmental exposure area.

                             HIV PREVENTION

    Mr. Jackson. One last question if I might, Mr. Chairman.
    Dr. Koplan, I am a little concerned about your budget for 
HIV prevention. I noticed that your budget included $66 million 
new dollars for prevention plus another $10 million in 
redirected dollars. The way I understand these numbers $50 
million would be spent on domestic prevention and $26 million 
would be spent on global prevention. Do you think that $50 
million is adequate to address the prevention needs in the 
country?
    Dr. Koplan. I think it is a good beginning on where we 
would like to go. I think it is a considerable increase over 
increases we have had recently and we can put it to good use 
right away. Similar, the international, the global HIV is a 
vital increase as well. So we are grateful for both.
    Mr. Jackson. Thank you, Dr. Koplan. Thank you, Mr. 
Chairman.
    Mr. Porter. Thank you, Mr. Jackson. Mr. Dickey.
    Mr. Dickey. Hello, Dr. Koplan. How are you?
    Dr. Koplan. Mr. Dickey.

             ATTITUDES OF CDC SCIENTIST REGARDING CONGRESS

    Mr. Dickey. I want you to know that when I started, I 
became a gigantic fan of CDC, still am but it was after I had 
to fight through a circumstance involving a Dr. Kellerman. Do 
you know that circumstance, Dr. Koplan?
    Dr. Koplan. I don't actually.
    Mr. Dickey. Well, we had a situation where we wanted to get 
a copy of a report from Dr. Kellerman that was generated by 
funds that were given to CDC and then granted to him and he 
pretty much said this is my work product and I am not going to 
let you have it. Month after month after month went by and we 
don't know whether they were sanitized or what, but we finally 
got them and I think in this committee I mentioned the fact 
that arrogance was a big part of this and how in the world 
could someone hide behind science and the needs and so forth 
and say I am going to keep this report from you all. Well, I 
made it through that and, as you know, I have been very close, 
been there many times and I see the good that is being done.
    Now I come up to this situation where we have almost the 
identical thing, the identical thing, of taking money and 
saying this is my money and I will decide how it is going to be 
used and how dare those people in Washington who don't know 
about science, how dare them question us. Well, I am back to 
where I am losing confidence again, and I know that is not 
something you want. I just wonder if there is anything that you 
can tell me that you are going to do to try to eradicate CDC 
from the arrogance that I have just described.
    Dr. Koplan. Well, I believe Dr. Kellerman has never been a 
CDC employee.
    Mr. Dickey. That is correct.
    Dr. Koplan. So I can't comment on that. I don't believe we 
are arrogant. I think that we have made a serious mistake in 
communication and an error to do so and there is no excuse for 
that, but I think the organization tends to have a culture that 
emphasizes getting stuff done and worrying about some of the 
managerial budgetary niceties afterwards and we are going to 
change that culture as much as we can through the efforts that 
I have just described we are going to take. I think that none 
of us in any leadership position throughout the organization or 
people doing work want to withhold purposely any information 
from you. Indeed, in many ways it is the opposite. We are very 
proud of what we do. We think we put out a really good product. 
We want to share it with you all and when we do, you always 
give us positive feedback for it.
    So I think we can play on that desire and your positive 
feedback all the time. Even now the tone and the manner in 
which you are indicating what we need to do is a very positive 
one that we need to do better and we do want to do better.
    So I think we can work with you on that. I think our staff 
would be eager to do that.
    Mr. Dickey. It is painful to watch it because of how many 
people, how many thousands, tens of thousands, hundreds of 
thousands of people who depend on you and depend on us to 
provide the relief and the cures and the studies that we have. 
Has the Secretary, Secretary Shalala disciplined CDC in any way 
or required anything more of you than what was there before?
    Dr. Koplan. She is working with us to put in the corrective 
actions that we think are going to take care of these problems.

               CDC'S INJURY CONTROL AND PREVENTION CENTER

    Mr. Dickey. All right. Then I want to be more specific. I 
want to talk about the CDC's injury control department or 
center. It has led the field with its vision of Safe U.S.A., a 
public-private coalition of all the major organizations 
concerned with safety. I know personally what a long struggle 
that was and how hard people worked to get it there. Because 
Congress believed in that leadership the injury center had--
because it believed in the leadership--the injury center had 
the direction. We gave the injury center its biggest budgetary 
increase ever last year of $27 million. Now you are without a 
director of that center. Are you going to continue its 
direction and if so, how and what are your intentions 
concerning the future of that program?
    Dr. Koplan. Thank you for that question. The injury area is 
certainly one of the most important areas of public health. You 
just have to look at different age groups and different parts 
of the population to see what a toll it takes in terms of 
disabilities, in terms of deaths.
    Dr. Koplan. CDC has regular turnover of its senior 
management and we are going through that now. We are replacing 
a previous excellent director. We have a nationwide search that 
has just gone on and I think it is the end of this week that I 
am going to get what is called a certificate, which lists the 
finalist candidates for that and we intend to make a 
determination, interviews and make an appointment as soon as 
possible.
    In the interim, one of our most senior and respected public 
health officials, Dr. Steven Thacker, I asked him to move over 
from his position as chief of epidemiology to run the injury 
center during this interim period. We don't want to lose a step 
either in this interim period or with the new nationally well-
known director.
    Mr. Dickey. How do you describe the importance of this 
center?
    Dr. Koplan. I would say it is as important as any other 
area of public health.
    Mr. Dickey. As any other area of any other center in your 
responsibility, your jurisdiction?
    Dr. Koplan. Sure.

                                OBESITY

    Mr. Dickey. We have talked in the past about obesity being 
a national epidemic. What do you think we should do about that?
    Dr. Koplan. Well, we actually discussed at last year's 
appropriation hearing, and you saw those charts which remain, 
that epidemic continues. It is particularly strong amongst 
children. While we have had a 50 percent increase in obesity in 
the adult population in just the last few years, it has gone 
100 percent up amongst children. It is striking. I don't have 
an easy answer for you. I wish I could say if we do one, two, 
three and four we will solve it.
    But what we ought to do is take it seriously as a health 
issue and not a cosmetic or aesthetic issue and do behavioral 
and other work to determine why. We are doing that. And one 
clear issue is there has been a decline in physical activity 
among kids inside schools and outside of schools. There is an 
increasingly attempting array of foodstuffs for them as they 
sit and watch television or play video games.
    Everyone knows that it is a simple caloric issue: If you 
take more in and put out less, you will gain weight. But to 
have that happening in our youngest citizens, it sets the 
pattern for the rest of their lives. Marked increase in Type 2 
diabetes. We are seeing a marked increase in Type 2 diabetes in 
children, which we have never seen before.
    Mr. Dickey. In your testimony, you have said before there 
is a relationship between obesity and diabetes.
    Dr. Koplan. Relationship between obesity, diabetes, heart 
disease, osteoporosis, gallbladder disease and a number of 
other conditions. But when you see kids with an increasing rate 
of Type 2 diabetes, that is a particular troublesome finding, 
so we really need to address it.
    Mr. Porter. Thank you, Mr. Dickey.
    Mr. Miller.

                       HEMOPHILIA AND HEPATITIS C

    Mr. Miller. Good afternoon. Having visited CDC before, I 
look forward to doing it again some time soon. I went to school 
at Emory in the sixties, and I thought it was a nice building 
back then. But when you go back to the World War II Quonset 
huts, you really do need for such a prestigious institution--
and we are sorry about this incident. It is an institution we 
should all be proud of.
    Let me start all by talking about hemophilia and hepatitis 
C. Could you update me what is happening in the hemophilia area 
and with respect to hepatitis C? There was an article in the 
paper, not that The Washington Post should be my major source 
of medical information, but update us with what is happening in 
that area hopefully with encouraging news.
    Dr. Koplan. Hepatitis C, one of the thrusts of our program 
is to evaluate what is going on with the callback. Many of the 
blood banks in which people had received blood and may have 
been exposed to hepatitis C, we are trying to get people to 
know whether they are hepatitis C positive or not. And we are 
engaged in an evaluation of that program and see how well it is 
working at the moment, and that is a big thrust.
    In addition to communication campaigns, trying to get 
people to come in and be tested, so they will know what their 
results were.
    Mr. Miller. The article I saw was talking about the fact 
the cocktail type of treatment like is being successfully used 
for the treatment of HIV has the potential in hepatitis C. Can 
you update us on that issue?
    Dr. Koplan. I know Interferon was being used alone and was 
having some benefit. I would have to say I don't have adequate 
expertise to comment.
    Mr. Miller. The hemophilia treatment centers which are 
funded through the CDC, I am familiar with that and I think it 
is a good program and I know you are going to continue that.
    Dr. Koplan. I think they are terrific. They have made a 
real difference. The striking aspect of those is that persons 
with hemophilia who receive their treatment, particularly their 
prevention treatment at a hemophilia treatment center that we 
fund, have a much lower mortality rate than those who don't get 
their treatment in those centers. So there can be no better 
outcome than to improve lifespan through these treatments.

                   YOUTH SMOKING PREVENTION PROGRAMS

    Mr. Miller. There are so many different programs that you 
are involved in, and that is one that I know also is not a huge 
dollar item.
    Let me switch over to the smoking programs, especially 
encouraging young people to stop smoking. And you referred to 
Florida having some success.
    Summarize briefly what the CDC does. But now with all of 
those states getting millions of dollars of money and Florida 
was an early one, and hopefully most of them are putting it 
into antismoking, antiyouth smoking programs, what results are 
we seeing? I know you mentioned one in Florida, but elsewhere 
around the country. And are we learning how to get kids to stop 
starting to smoke and such?
    Dr. Koplan. Florida is to be commended. It is a role model. 
Florida early on did a rather remarkable thing. It turned over 
its youth smoking prevention programs to youth and let young 
people design the program. In addition, put adequate resources 
in it to make a difference. And one of the striking things, we 
have had a stagnation in our ability to limit youth smoking. 
But if one looks at States that have put adequate resources in 
it, namely, California, Florida, they have made a big 
difference and have been able to move those rates down.
    Your point about the tobacco settlement and funds going to 
the different states would be that your logical impression were 
true. Most States are not spending--or many States--many States 
haven't made their final determination, but it is terribly 
troublesome for a public health official to look and see that a 
number of them either have already decided or are leaning 
towards not using these funds not only not for public health, 
but not for tobacco prevention amongst kids in particular.
    And so I think this is a lost opportunity. My understanding 
in having spoken to some of the Attorneys General involved in 
that settlement was that that was the intent of the settlement, 
to get this money to use to prevent future smokers and all the 
expenses that were attached to that. We don't tell states what 
to do, but we do tell them if they spend x amount of dollars, 
what they can expect to get out of these programs and those 
amounts are not being met in those states.
    Mr. Miller. That is disappointing. So there is a 
statistical difference in teen smoking rates between states and 
the direction it is going? Like, in Florida, is it going down? 
Is that what you are saying?
    Dr. Koplan. There is a practical difference. It makes a 
difference if you invest in it. If you have a good program, you 
will drop rates of smoking.
    Mr. Miller. It is clear the statistics support the dollars 
spent on education, and I have seen some of the ads in Florida 
and you are right, they got the young kids, they can relate to 
the smoking problems better than you and I can to the teenager. 
I am glad.
    That is disappointing that the States--I hope the States 
that haven't made those decisions will allocate the proper 
amount of money for that because it does really pay off.

                              BIOTERRORISM

    Let me switch to another subject entirely: Bioterrorism. 
How prepared are we? Throughout the country, if what happened 
in the Tokyo subway, if something happened in the San Francisco 
subway--we don't have subways in Florida.
    Dr. Koplan. Congressman, we are variably prepared. We are 
not prepared well enough, but we are getting better prepared. 
What I mean is, we have an uneven public health infrastructure 
and public health system, and if an event occurs in some 
localities, a county or city or state which has invested in its 
epidemiologic capability, its laboratories, has trained staff 
able to look into things, then we will do better with one of 
these events.
    Many of our States and--many of our county health 
departments still report diseases by phone or by nonelectronic 
means, and that slows up the whole system. One of the things we 
are trying to do as part of our bioterrorism effort is put into 
place an electronic integrated surveillance system so that 
reports move straight up the line, get to us quickly and can be 
shared across county and State lines. We are improving but we 
are not there yet.
    Mr. Miller. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Miller.
    Mrs. Lowey.

                   CHRONIC FATIGUE SYNDROME RESEARCH

    Mrs. Lowey. Thank you, Mr. Chairman. And thank you Dr. 
Koplan for your forthright responses to the probing questions 
of my colleagues. And I look forward to the clarification in 
the reports that will follow.
    But as you know, I have taken particular interest in CFIDs, 
and I believe we in Congress have made our concerns very clear 
and we are looking forward to hearing more about your response 
to that. We have got an IG report, we have got a forthcoming 
GAO report. We have got rigorous accounting requirements. But 
what the patients and I really want to know is what is the 
science, where are we on the research. And if you can comment 
on that, I would appreciate it.
    Dr. Koplan. I welcome that, because I think that is an 
important redirection that we are engaged in.
    A large scale study is about to come out and be published, 
and I hope a congressional appropriations hearing doesn't 
prejudice publication by the journal. We will not mention the 
journal, but they are very antsy about having information out 
beforehand. But it will show that the numbers that were 
previously estimated for chronic fatigue syndrome were 
underestimates, and actually when a survey takes place in a 
larger population, that there seems to be much more than was 
previously expected.
    This study also gives us a cohort of individuals who suffer 
from this disease that will permit us longitudinally to look at 
a variety of different things related to it. So we are quite 
excited about having this information that is about to be 
released in the next few weeks. We put together a specific 
panel from all over the country, and also people who suffer 
from chronic fatigue syndrome, and looked at what should they 
do and what things to emphasize or not. And we also, in the 
last few weeks, and before that as well, have brought in other 
parts of CDC to look at what goes on in the biology area to see 
if there are other things and logically--genetically, 
environmentally. So trying to step back and try a fresh 
specific look and ask the questions and bring in the people.
    We expect to be getting a first rate neuroendocrinologist 
to be joining our staff. I believe the hangup is getting 
spousal employment, and we are working that out. But the point 
is we will markedly increase our capabilities to look at 
another piece of the picture and add a whole range of new tests 
to ones that are already employed. We are geared up and 
excited. We want to get some more information and we want to 
make some progress in this area. It has been frustrating for 
all of us.

              HUMAN PAPILLOMA VIRUS EDUCATION AND RESEARCH

    Mrs. Lowey. Thank you. Another concern of mine is HPV 
education and research. We know that some HPV causes cervical 
cancer and HPV is considered a sexually transmitted disease. I 
consider myself a pretty well-educated policymaker on 
reproductive health issues. I have been working on these issues 
throughout my congressional career. Frankly, neither my staff 
or I, many young and female, even heard about this and the 
problems associated with it until very recently. Women and men 
need medically accurate--not inflammatory--I want to repeat 
that--medically accurate information about this STD, and I am 
determined to see that we fund more research.
    What are the CDC's plans to address HPV infection among 
Americans? What kind of work are you doing with the NIH? 
Because you need the prevention and you need the research and 
then we really have to see where we are and what we need to do 
further. Could you respond?
    Dr. Koplan. Sure, thank you. As you know our emphasis is on 
the prevention side. At NIH, we work closely in this and many 
other areas. This is an area that just recently had some 
breakthroughs, particularly with a new improved screening test 
for HPV positivity. It is very promising in the initial couple 
of studies.
    One of the troublesome issues is that about 50 percent of 
the invasive cervical cancers are women who have never been 
screened or haven't been screened in the last 5 years.
    Nevertheless, what we are trying is NIH has a big trial in 
place now which is supposed to give some further illumination 
as to what is the preferred mode of screening and what should 
we look at in the future when it comes to our policy and what 
we advocate for screening, obviously we advocate Pap smears for 
women strongly. Any changes in that, we listen to American 
Cancer Society, which sets guidelines in this and the U.S. 
Preventive Services Task Force. And so we work with them and we 
attend their meetings on that.
    There may be changes and breakthroughs I hope in the next 
couple of years.

         RACIAL DISPARITIES IN MATERNAL MORBIDITY AND MORTALITY

    Mrs. Lowey. Let me say my colleague, Rosa DeLauro, 
certainly has been a leader in this area, and I would hope we 
would make it our business to work cooperatively to get more 
research done in this area and more preventive work done, 
because it is just so pervasive and the ignorance is 
overwhelming.
    Another area, as you may know, I have introduced a bill to 
address the terrible racial disparity in maternal morbidity and 
mortality that CDC reported on last year. Frankly, I think it 
is disgraceful that any woman should die of pregnancy or 
pregnancy-related complications in the year 2000 and absolutely 
unacceptable that black women die at four times the rate of 
white women.
    What our bill would do is give CDC more resources. I won't 
tell you any more about what the bill will do. What I am 
interested in is the epidemic services account where the Safe 
Motherhood Initiative was to be funded and was cut in your 
budget. And if you could comment on that and how can we make 
progress on this initiative. Because I think there is uniform 
bipartisan support for this.
    Dr. Koplan. We agree. We think this is an important area. 
In the last part of this last century, maternal mortality was a 
risk that every woman faced. It is a risk that we couldn't even 
consider today, and it makes it particularly, I think, tragic 
to have this discrepancy for what should be a normal happy 
healthy event.
    One of the things we are doing in that regard is we have 
tried to put more people into states, particularly, to 
determine what are the risk factors, what is going on that 
causes this increased risk. And there has been an intensive 
look at it. We don't have a good answer. We have looked at a 
wide range of things and are adding more with each project.
    This is an area well worthy of support.
    Mrs. Lowey. But the account has been cut. Our Safe 
Motherhood Initiative, which had strong bipartisan support, 
would come out of that budget and it has been cut. So given the 
limited time I wish you would think about it and perhaps we 
could work together to increase those dollars to be sure we are 
addressing the needs.
    Dr. Koplan. Look forward to working with you.
    Mr. Porter. I would tell the Gentlewoman that we don't have 
to follow the President's recommendation and we can do our own.
    Mrs. Lowey. Let me say, Mr. Chairman, I look forward to 
working with you.
    Mr. Porter. I look forward to seeing your amendment. Thank 
you.
    Mrs. Northup.

                                 NIOSH

    Mrs. Northup. Doctor, I have some questions that follow 
questions I have had in the past, and I think my concern goes 
to the question of integrity too. Specifically, it is about 
NIOSH. NIOSH is, according to your web site, there to provide 
help to employers on safety practices in the workplace. In this 
case I am talking about coal mining. The implication on the web 
site is that they get requests from employers to evaluate, to 
give suggestions, to provide support for recommendations.
    And I just wondered how requests for information and 
research come to you. Do they come from employers or do they 
come from the Department of Labor?
    Dr. Koplan. My understanding is we have had a marked 
increase, and that has been one of the thrusts, I think, of Dr. 
Rosenstock, who is the director in the last few years, has 
tried to markedly increase the number of requests we get for 
working with employers. And my understanding, and we would be 
glad to provide you details of that information for the record, 
is that that has shown a marked increase in recent years.

                   COAL MINING AND BLACK LUNG DISEASE

    Mrs. Northup. Well, I am concerned because, obviously, coal 
mining is very important to Kentucky and to a number of other 
states. I asked the Secretary of Energy last year what role he 
thought coal would play in the long term, what is our plan for 
coal; 50 percent of the next 50 years of the energy it 
provides.
    Now we know we need safe mines. We need to be able to burn 
it cleanly. And we need to have the healthiest environment for 
our miners.
    But I am concerned that there is another dynamic going on 
in the new definitions that the Department of Labor since, for 
3 years, have been proposing to change the definition of 
``black lung.'' As a matter of fact, in Kentucky, we have 
actually gone to all screenings being done by the schools of 
medicine because we felt that that was so important. And the 
new proposals being proposed by the Department of Labor go in 
exactly the opposite direction.
    So when CDC and NIOSH, in particular, when I first arrived 
here, I asked the Director of NIOSH if she had any new medical 
science that supported the change in definition and she said, 
``no''. And as a matter of fact, I think that if you look in 
the printed record you will find where on two occasions, both 
spoken to me in a hearing, and in return to written questions, 
CDC has said that.
    Then the Department of Labor requested that NIOSH go back 
and answer public comments made to DOL. As a matter of fact, I 
believe what they did is take the coal mining association's, I 
don't know which one, but they took their submissions about why 
medical science did not support these changes and asked NIOSH 
to respond to them. Clearly, with a wish that NIOSH support the 
Department of Labor's need to change these. And so NIOSH did.
    I have copies from a Freedom of Information request of 
where some e-mails went back and forth from NIOSH and 
Department of Labor employees stating that we have got to make 
sure that Mrs. Northup isn't under the impression that NIOSH 
doesn't support the DOL's changes.
    My question to you is--has NIOSH done any scientific 
analysis of their own or have they only reviewed the past 
studies that were done regarding this?
    Dr. Koplan. I don't have that information at hand but we 
will get it for you.
    Mrs. Northup. Well, originally, the Department of Labor 
referred to NIOSH information as if they had conducted some 
medical tests of their own. I believe that a DOL lawyer or one 
of the legal people in charge of that has corrected that and 
said no, NIOSH just reviewed the past studies. Is there anybody 
at the table that can verify that?
    Dr. Koplan. I don't think so. We will get that information 
for you.
    Mrs. Northup. Well, I think my question is, if there are no 
new medical studies, why would you change your position on 
that? Why would NIOSH now be telling the Department of Labor or 
me something different than what they told 3 years ago?
    I would also like to know whether you have any medical 
doctors review the material. The person that signed the letter 
changing the information, signed the letter, he was a Ph.D. Are 
there any medical staff people that have known research 
capabilities that have reviewed this? That is another question.
    I would like a list of all the panelists. It is very 
strange that I could get the answers I got and then so quickly 
get a change. Did they put a panel together in that short time? 
Who were the panelists and how did they come to a directly 
different result than what they had before the Department of 
Labor proposed these changes?
    And if there is no new medical science and if this was done 
by people not in medical science, and if we are going to now 
change the rule, doesn't it make sense to take this sort of 
research away from CDC and put it at NIH or some place where 
the integrity of the research is so well grounded?
    Dr. Koplan. I think if I could just say that I think the 
integrity of our research is as well grounded as any 
institution in the country and we will get answers to your 
question.
    [The information follows:]




    Mr. Porter. Thank you, Mrs. Northup.
    Ms. DeLauro.

                   CARDIOVASCULAR DISEASE AMONG WOMEN

    Ms. DeLauro. Thank you, Mr. Chairman. Welcome, I just want 
to say thank you for addressing, aggressively addressing the 
issue on Hanta virus and I have three questions. It looks like 
we all have three questions. The first is I know your concern 
and I have a concern about the burden of heart attack, stroke, 
other cardiovascular diseases among women. There are about 
950,000 deaths from cardiovascular disease each year occurring 
among women. Heart disease is the number 1 killer of women and 
stroke is the number 3 killer of women.

                           WISEWOMAN PROGRAM

    In addition to what CDC is doing in the cardiovascular 
health program, CDC has undertaken the WISEWOMAN Program. The 
program deals with trying to improve the health of low income 
uninsured women by building on your breast and cervical cancer 
programs.
    The screening is the same in terms of taking a look at 
trying to reach hard-to-reach women for heart disease and for 
stroke. Last year, we provided CDC with additional funding to 
expand this program. Tell us about your progress with the 
program and your plans for expansion of the WISEWOMAN Program, 
which we need to do.
    Dr. Koplan. Thank you. We are approaching the issue of 
cardiovascular disease in women from a number of different 
fronts. The [Wisewoman] Program is terrific. It is one-stop 
shopping. It is an incredibly cost-effective way to build on to 
an already useful program. Important program. Breast and 
cervical cancer screening--I would remind you that the 
[Wisewoman] Program adds, while a woman is in the clinic 
doctor's office hospital setting for breast or cervical cancer 
screening, the staff takes the time and the advantage of having 
the person there to check cholesterol and blood pressure. Just 
that. It is quite simple.
    In a study in Massachusetts of several thousand people who 
came in, 50 to 75 percent of the people who came in either had 
high blood pressure or had high cholesterol. And this is 
largely poorer women coming in for this. So it is a 
terrifically important finding, something that is treatable and 
makes a long-term life difference. Needless to say, I am 
enthusiastic about this program. It is currently going on in 
Alaska, Massachusetts, and North Carolina. With--increased 
funding, we are going to add three new states.
    Ms. DeLauro. How much money do we need to expand it around 
the country?
    Dr. Koplan. It is about a million dollars a state. So can I 
take advantage of the Chairman's recent offer to jump up and 
show a chart for a second?
    Ms. DeLauro. Only if it doesn't come out of my time, Mr. 
Chairman. I want to see this chart, but you have to put my time 
on hold to do that. Thank you, Mr. Chairman.
    Dr. Koplan. We take this area very seriously and it is 
important. What we have done is an atlas of nationwide, county 
by county for rates of heart disease death in women all over 
the country, and that permits states to target where is the 
problem greater than others and adds focus and interest in the 
particular area.
    It is hard to see the U.S. on a map like this, but 
Illinois, which may be of interest to some of you----
    Mr. Hoyer. A random choice, I am sure.
    Dr. Koplan. You can see that there are markedly different 
areas of rates of heart disease by county and some counties may 
choose to do more in an area, particularly when they have the 
incentive to see that they have a particular problem to do some 
more. So we are approaching it from a number of different ways.

                                 Asthma

    Ms. DeLauro. Mr. Chairman, I would love to have the 
opportunity to talk about how, in fact, we can promote the 
expansion of this program at a greater rate.
    Let me move on to the issue of asthma. Kids, elderly dying 
from asthma at increasing rates. African-American children 
three times as likely to die from asthma as white children. I 
use my district as an example. The increasing rates are 
alarming. The direct medical costs related to asthma exceed $2 
billion a year. Indirect economic costs of asthma add another 
$3.6 billion. If we had additional resources given to CDC for 
asthma-related efforts, how would these efforts be expanded?
    We now have, I will just tell you, on Sunday, Yale, the 
Children's Hospital, the mayor of the City of New Haven, and I 
am kicking off a week devoted to this issue because of the real 
problem that we have in our community on the increasing asthma 
rates.
    Dr. Koplan. It is really a striking issue for its increase 
in rates and severity right around the country. Those of us who 
have taken care of patients with asthma or have had relatives 
or friends with it know how frightening a disease it is, 
because one is well one minute and deathly ill the next. It is 
particularly of interest in areas of racial disparity, 
disproportionately affecting poor and some ethnic and racial 
groups.
    We currently have programs in four state health departments 
to help them from a public health perspective, and the issue 
here for us is there are environmental things one can do and 
behavioral things one can do to take a population base 
perspective on asthma, in addition to the very important work 
that individual clinicians do. And it sounds like what you have 
going on in New Haven addresses that. You have clinicians who 
need to know the right way to treat people; people need to get 
to those doctors really soon, or before an attack occurs for 
appropriate therapy; people need to know the right therapy, but 
at the same time, their home environment has to be made as free 
of likely inciting agents as a problem.
    So there are a range of things we can do. We hope to expand 
into 16 states this coming year. That will be a big increase in 
state activities for that. But it is a well, worthwhile 
program.

             Prevention of tobacco use and Bidis Cigarettes

    Ms. DeLauro. And I would like to talk to you more about 
that in terms of the infestations in housing, et cetera, which 
we could really do something about.
    Last question has to do with the prevention of tobacco use. 
I will just--Mr. Miller is not here, but in my State of 
Connecticut, less than 1 percent, less than 1 percent of the 
settlement money is going into anything that is related to 
health or to the prevention of tobacco use. I frankly believe 
it is a disgrace that states are not taking advantage of those 
settlements to do something about this.
    Can you talk about what you are doing on the efforts to 
deal with the prevention of tobacco use on the increase use of 
Bidis, the flavored cigarettes now coming from India. What is 
your sense of what is going on there? And I found kids in 
middle schools when I went in to talk about cutting back on 
tobacco, they knew the flavors, they knew all kinds of things 
about Bidis.
    Dr. Koplan. We talked about it. I know Chairman Porter and 
others are interested in the international aspects of health. 
Here is an example where infectious agents go back and forth 
and we communicate health risks in other ways. And while we are 
a big exporter of some health risks, we also import others, and 
these Bidis, I don't know whether any of you have adolescents 
at home, but they have become the rage among middle school and 
high school kids.
    They are largely Indian made tobacco cigarettes in a 
wrapper and they are flavored and that is what makes them 
insidious. Cherry chocolate, raspberry, mango, they sound like 
shakes or shampoos, and the kids get hooked on them. They have 
two or three or four times the amount of nicotine as regular 
cigarettes, so the kids are smoking them as like candy, and 
they are getting hooked.
    So in our surveys, I believe and we will make sure the 
number is correct for your record, but I believe it is about 40 
percent of kids--we will get right number for you--but a large 
number of kids have tried these at some time. Much higher than 
I would have ever imagined.
    We are working with every state health department in trying 
to institute a balanced, comprehensive tobacco control program 
particularly focused at kids. We are doing it in the face of 
what we thought would be markedly increased resources for state 
health departments, and the tragedy of not seeing that take 
place makes our efforts all the more important.
    Nevertheless, some states have put in marked amounts from 
their settlements for tobacco control, the State of Washington, 
New Jersey, Maryland, Wisconsin, Massachusetts, Minnesota have 
all put in significant sums. But many have not.
    Ms. DeLauro. Thank you very much. Thank you, Mr. Chairman.
    Mr. Porter. Thank you.
    Mr. Hoyer.

                              Hanta virus

    Mr. Hoyer. Thank you very much, Mr. Chairman. And Doctor, I 
apologize for not being here for the bulk of your testimony and 
answers to questions. I was on the Floor with the tax bill that 
is currently on the Floor.
    But first of all, I want to say that I understand that you 
addressed the Hanta virus issue very well. I am pleased with 
that. I know you have talked with me personally, and I 
appreciate the forthright and energetic way that you are 
addressing that issue to make sure that we have full and open 
and accurate communication between the Congress and CDC. Thank 
you for that, Doctor.
    Let me go at, first of all, let me say proudly that 
Governor Glendening, you mentioned Maryland, has made it a top 
priority that the overwhelming majority of the dollars emanate 
from this tobacco tax settlement go into health-related issues 
and efforts to dissuade and prevent children from starting to 
smoke. So I agree with the lady's observation. It is a tragedy 
that the Connecticut governor has not seen to do the same.

          Childhood Development Disabilities and Bad Behavior

    Doctor, on disruptive behavior, you talked about violence, 
other behavior of young people brought about by substance abuse 
or whatever. Do you have any interagency or your agency areas 
of research on prevention and treatment of child health and 
behavioral habits that are either new initiatives or exist now 
that are working with others?
    Dr. Koplan. In the area of developmental disability, we 
are----
    Mr. Hoyer. I might say that I also was not here because I 
had something else that the Chairman mentioned his interest in 
perhaps putting some substantial sums into this issue. I don't 
know whether it was CDC or where it is, but so the Chairman 
obviously has a very significant interest in this as well.
    Dr. Koplan. You have just shifted my answer because there 
your interest is kind of risk factors for various bad health 
habits in life or----
    Mr. Hoyer. Yes, but I don't want to shift your focus. I 
want to go back to my original question, I think the Chairman's 
is related. But on the child behavior and research related to 
that and why, obviously, bad behavior occurs and what we can do 
to change that.
    Dr. Koplan. In an area that I wouldn't characterize it as 
bad behavior but on the issue of some childhood disabilities, 
such as attention deficit disorder, we are beginning to wish to 
expand some of our sites where we have study centers and try to 
gain some more information, particularly in terms of rates and 
amounts of this. It is very important information in 
populations at large on a population basis, how much of this is 
there and how does one characterize it? So that is an area we 
are working with.
    [The information follows:]




                 NATIONAL CENTER FOR HEALTH STATISTICS

    Mr. Hoyer. Thank you. I will pursue that further. Let me 
also ask you about the National Center for Health Statistics. I 
had the opportunity to address that issue. I thank the Chairman 
for his help on that as well. What has been accomplished with 
the additional funding that that has been extended?
    Dr. Koplan. A lot, and we greatly appreciate the support of 
yourself and the Chairman and this committee for the National 
Center for Health Statistics, a national treasure in terms of 
the information which is provided for all of us every day on 
different health areas.
    A variety of different surveys have been both rejuvenated 
and permitted to go forward and expanded in different ways. The 
National Health and Nutrition Exam Study, which a couple of 
Members of this committee have visited its truck and had some 
examinations themselves.
    But we have been able to proceed with that and think about 
the next version of that as it comes up. We have done national 
health care surveys of interest to all of us around this 
quality area. Our national health interview surveys are being 
redesigned, so all of the different major surveys that give us 
information on vital statistics, the huge emphasis on improving 
the quality of birth and death records and linking them to 
other health issues. So every big survey area is either being 
redesigned or put in a place to get new information for us.

                               PFISTERIA

    Mr. Hoyer. Doctor, it is my presumption that the products 
that we receive in terms of statistics are critically important 
to making good policy. I know you agree with that. I hope we 
continue to support that. Pfisteria--Doctor, could you comment 
on that briefly? As you know, Maryland has been interested in 
that. We have included money. I appreciate your updating us on 
what the surveillance systems you put in place have found 
regarding the health risk and impact of pfisteria.
    Dr. Koplan. As you know, I am sure, better than I do, it is 
both seasonal and seems to have ups and downs at different time 
periods. At the moment, what we have got in place is 
standardized surveillance going on in the key States affected 
in recent past by pfisteria, including Delaware, Florida, 
Maryland, North Carolina, South Carolina, and Virginia. And we 
are getting regular reports from them. They report themselves. 
This permits them to take a close look themselves and see what 
the problem does over time, and we do not have enough timelines 
yet to know what the trend is for it.

                                 Asthma

    Mr. Hoyer. Thank you. Let me, while I have time remaining, 
associate myself with the questions I am sure that maybe others 
asked; but I heard Congresswoman DeLauro on asthma, obviously a 
critically growing problem for our populations. I think we 
need, Mr. Chairman, to look at that very carefully both from 
NIH's standpoint, CDC's standpoint, and perhaps even the 
Department of Education's standpoint because it is, I guess, 
one of the principal reasons for absenteeism in schools now, 
asthma.
    Dr. Koplan. Major reason for emergency room visits, 
hospitalizations, and terrible deaths.

                                Epilepsy

    Mr. Hoyer. I have a little time left. Last question on 
epilepsy. What actions has CDC taken and what progress has CDC 
made on the problem of epilepsy?
    Dr. Koplan. Again, what our focus has been on is largely 
surveillance for epilepsy. It is something that has really 
never been reported before, and we made a particular focus on 
epilepsy and related pregnancy and try to look and see what 
that relationship is. We have a pregnancy surveillance system, 
so we have attached those two together and hope we get some 
more information about the end of the year. Also combatting 
stigma and public awareness are other big parts of what we are 
doing.
    Mr. Hoyer. Thank you very much, Doctor. Thank you, Mr. 
Chairman.

                Auditors Meeting with Subcommittee Staff

    Mr. Porter. Thank you very much, Mr. Hoyer. Dr. Koplan, let 
me make a request of you in regard to the outside consultants 
that you intend to provide for the entire agency and also the 
PricewaterhouseCoopers audit and that is, would you be willing 
to have those auditors and consultants meet with the majority 
and minority staff of the subcommittee so that any concerns 
that we might have might also be factored into the approach 
that they take in providing their services?
    Dr. Koplan. Absolutely. We would be pleased to do so.
    Mr. Porter. I think that would help a great deal. I guess 
we did not coax you into giving this because we really wanted 
to see you pronounce these words.
    Dr. Koplan. I believe we have got aedes aegypti and aedes 
albopictus on that chart.
    Mr. Porter. Mr. Wicker.
    Mr. Wicker. I was just about to volunteer that, Mr. 
Chairman.
    Mr. Porter. Go ahead. I want to hear you say it.

                         Human Papilloma Virus

    Mr. Wicker. I appreciate the chairman allowing me to get in 
this final question before we go on to a vote. Mrs. Lowey 
brought up a very important bit of information that I think you 
need to expand on. And that is HPV, human papilloma virus. Mrs. 
Lowey said that she had not until very recently been familiar 
with this. I know it is pretty much the same with me. But the 
fact is that there is a virus out there that is prevalent, and 
it is called human papilloma virus. It is transmitted sexually. 
It causes cervical cancer. And it cannot be prevented by the 
use of a condom. Now, am I correct there?
    Dr. Koplan. I believe that is true----
    Mr. Wicker. I wonder what you can tell us about how 
prevalent this virus is. Is it a fact that some 40,000,000 
Americans may have this virus? That is what Mrs. Lowey just 
told me before she left the room. How correct are we on that?
    Dr. Koplan. We do not have absolute data on that. The 
estimates I have seen are 20 to 24,000,000; 20 to 24,000,000 or 
40,000,000 is a lot of people.
    Mr. Wicker. Either figure is an astounding number.
    Dr. Koplan. Exactly.
    Mr. Wicker. Mrs. Lowey said we need more education and we 
need it done in a noninflammatory way. I agree with her on 
that. But the fact of the matter is this is a very serious 
matter. We need further research. Mr. Istook went into great 
detail the other day about the need for abstinence education. 
Mrs. Lowey just mentioned to me her interest in abstinence 
plus, but the fact of the matter is we need more research in 
how this can be prevented, and I would certainly encourage the 
CDC to tell us what we need to do as a Congress and as a 
committee to combat this very, very serious virus.
    Dr. Koplan. Thank you.
    Mr. Jackson. Mr. Chairman, may I make an observation.
    Mr. Porter. Yes. The majority had an extra question. You 
may certainly have an extra question.

            Accounting Firms Headed By Minorities and Women

    Mr. Jackson. Thank you, Mr. Chairman. I would just at the 
appropriate time--I know the majority and minority are going to 
meet with the CDC regarding the accounting firm and the 
processes and procedures with respect to the appropriate use of 
these appropriations. I would hope that both the majority and 
the minority would be sensitive to the fact that there are 
other accounting firms that could also participate in this 
audit that include--including but not limited to those headed 
by women and those headed by minorities because the amount of 
accounting and the size of this agency could certainly suggest 
that the business could be spread out beyond just one 
accounting firm. So I would like that consideration. Thank you, 
Mr. Chairman.
    Mr. Porter. Well, if I could say to the gentleman from 
Illinois, I do not think the outside consultant has yet been 
selected and so that lies ahead. I assume that Pricewaterhouse 
has been retained.
    Dr. Koplan. Pricewaterhouse has been retained, and they had 
been before.
    Mr. Porter. Thank you, Mr. Jackson. Dr. Koplan, thank you 
for your excellent testimony, as always. I particularly 
appreciate the very forthright way you have addressed a problem 
that we certainly cannot ignore, and thank you for the 
excellent job you are doing as head of CDC. Thank you very 
much.
    Dr. Koplan. Thank you for all your support.
    Mr. Porter. The subcommittee stands in recess until 10:00 
Tuesday next.
    [The following questions were submitted to be answered for 
the record:]




                                       Wednesday, February 9, 2000.

       SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

                               WITNESSES

NELBA CHAVEZ, PH.D., ADMINISTRATOR; ACCOMPANIED BY BERNARD S. ARONS, 
    M.D., DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES;
RUTH SANCHEZ-WAY, PH.D., ACTING DEPUTY 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; AND DENNIS P. WILLIAMS, 
    DEPUTY ASSISTANT SECRETARY, BUDGET, HHS
    Mr. Porter. The subcommittee will come to order. We 
continue our hearings on the appropriations for the Department 
of Health and Human Services with the Substance Abuse and 
Mental Health Services Administration. We are very pleased to 
welcome Dr. Nelba Chavez, the Administrator. Dr. Chavez, it is 
good to see you again. You are doing a fine job there, and it 
is a huge and important job. We very much appreciate your 
coming to testify today. As I said a minute ago, I don't know 
how many members will be here, but I think we should proceed. 
Why don't you go ahead with your statement, and then we will do 
questions after that.
    Ms. Chavez. Good afternoon, Mr. Chairman. Before I proceed, 
I would like to introduce members of my staff who are with me 
today. To my far left is Dr. Donald Goldstone, Director for the 
Office of Applied Studies; Dr. Ruth Sanchez-Way, the Acting 
Deputy Director of the Center for Substance Abuse Prevention; 
Dr. Bernie Arons, Director of the Center for Mental Health; 
Richard Kopanda, SAMHSA Executive Officer and Chief Financial 
Officer; Dr. Westley Clark, Director of the Center for 
Substance Abuse Treatment; and Mr. Dennis Williams representing 
the Department. I got all the names right this year.
    Mr. Chairman and members of the Subcommittee, I am pleased 
to present to you the President's FY 2001 budget request for 
the Substance Abuse and Mental Health Services Administration.
    Before I begin, I would like to express our appreciation 
for Chairman Porter's leadership over the last 5 years. 
Together we have worked to establish a new agency, SAMHSA, as a 
critical component of our Federal health and human services 
system. With your leadership, we have created strong Federal 
substance abuse prevention and treatment, and mental health 
programs.
    In the past 5 years we have proven that substance abuse 
prevention programs can and do work. We have seen communities 
come together to develop plans to reach children early. We have 
seen English and Spanish speaking parents improve communication 
with their children and even more importantly, listen to their 
children about substance abuse. Our efforts appear to be paying 
off. A series of encouraging reports indicate a leveling off 
and even a possible decline in teen drug use.
    We have also shown that substance abuse treatment not only 
reduces drug use and criminal activity, but improves job 
prospects, income, and physical and mental health.
    We have established strategies to improve mental health and 
well-being, reduce homelessness and increase employment for 
adults with serious mental illness. We have seen children's 
mental health become something to cultivate and celebrate 
rather than closet away. This fall the National Household 
Survey on Drug Abuse will provide for the first time state-
level estimates of substance abuse among youth. These data will 
provide us an invaluable tool for directing future investments, 
especially for the Substance Block Grant and for measuring 
outcomes of the National Drug Control Strategy. Our investments 
have helped millions of people live productive and fulfilling 
lives in their community.
    To continue the progress in 2001, the President has 
proposed $2.8 billion for SAMHSA, a $171.1 million increase 
above the FY 2000 appropriation. To achieve our priorities and 
SAMHSA's overall mission, we continue to employ the balanced, 
four-part strategy which forms the foundation for GPRA goals. 
SAMHSA's four-part strategy is first, support and maintain 
State service systems through block and formula grants; second, 
to cultivate a system responsive to the current and emerging 
needs through Targeted Capacity Expansion (TCE) grants; third, 
to improve system performance and service quality in 
communities where people live through Knowledge/Development and 
Application (KDA) grants; and fourth, to provide accountability 
through data collection.
    In his State of the Union address, the President said, 
``never before has our Nation enjoyed at once so much 
prosperity and social progress. * * * '' Yet too many Americans 
are denied the opportunity to share in the prosperity and 
progress because of substance abuse or mental illness.
    The unprecedented Surgeon General's Report on Mental Health 
makes it clear that we must step up our efforts to treat mental 
illness and promote mental health. To open more doors to needed 
mental health care for people with serious mental illness, the 
President has requested an increase in funding for the Mental 
Health Block Grant of $60 million, for a total of $416 million.
    To continue to improve access to substance abuse treatment 
and prevention services through State systems, the President is 
proposing a $31 million increase for the Substance Abuse Block 
Grant, for a total of $1.631 billion.
    While block and formula grant investments are vital, they 
are only part of a balanced approach to address emerging drug 
use trends, mental health needs and related problems, including 
HIV/AIDS.
    Mayors, town and county officials, the Congressional Black 
and Hispanic Caucuses and Indian Tribal Governments all 
emphasize to us the need for Federal leadership in providing 
rapid and strategic responses to the demand for services that 
are more regional or local in nature. In response, we developed 
the Targeted Capacity Expansion program. In 2001 we are 
requesting a new investment in the targeted capacity approach 
to increase access to mental health services.
    Our studies have clearly identified a ``window of 
opportunity'' for early intervention before troubling behaviors 
compound, potentially leading to mental health problems, 
substance abuse, school violence, family discord or even 
suicide. We are therefore proposing to invest in the 
development of prevention and early intervention services. We 
also plan to expand access to mental health care in primary 
care and other service settings. For these two new initiatives 
the President has requested $30 million in FY 2001.
    We are also moving forward with additional Targeted 
Capacity Expansion grants for substance abuse prevention and 
treatment. Our budget supports about 100 new substance abuse 
treatment grants for cities, towns and counties to address 
urgent needs for women and their children; youth; the homeless; 
people with both a substance abuse and mental disorder; and 
people living in rural areas. And, because our studies suggest 
that many people seek care outside of treatment programs, we 
propose a new effort to make it easier to enter treatment 
through primary care organizations, social service agencies, 
mental health, welfare, and child welfare agencies, jails and 
detention centers.
    As you are aware, our progress during the past few years 
applying the knowledge derived from Federal research is having 
an impact on the delivery of services. However, much work is 
still needed.
    SAMHSA's Knowledge, Development and Application program is 
producing results. Already our new grants to reduce school 
violence are using findings to improve services for children in 
54 school districts throughout the United States.
    We are also working to improve the quality and oversight of 
methadone treatment programs. And because we know that family 
based programs are nine times more powerful in reducing the 
risk for substance abuse than those that focus on education 
only, we have created a new Family Strengthening Prevention 
program.
    Through these investments we will continue to study the 
impact of managed care and the changing demographics in this 
country on the delivery of services. We will pursue the answers 
to questions such as why prevention or treatment is effective 
for some but not for others, how to improve access to quality 
care for people with both a mental and an addictive disorder; 
and we will assure that services are more relevant to 
individual needs, cultures and situations.
    To continue this and other KDA efforts in FY 2001 the 
President has proposed $282 million. Mr. Chairman, our strategy 
at SAMHSA is to make every ``door,'' including entry into 
primary care, welfare and criminal justice systems, an open 
portal to access quality mental health and substance abuse 
services as well. So when a homeless child needs treatment for 
a cold, there is no wrong door; when a young man has AIDS, is 
addicted and depressed, there is no wrong door; when an elderly 
woman who is depressed about the loss of her husband and begins 
to drink, there is no wrong door.
    Over the coming year, I look forward to working with you 
and the other members of the Subcommittee to ensure that the 
strength and longevity of SAMHSA's programs represents an 
enduring legacy of your chairmanship.
    A few years ago, I remember the first time I appeared 
before you and how helpful you were in introducing me to this 
process. It was under your leadership that the Committee 
directed SAMHSA to do several things. One was to look at our 
whole organization and see how we could begin to reduce and 
reorganize, which we did. The other area that you advised 
SAMHSA to change was its program direction. What you said is 
that you really wanted us to focus on developing and applying 
new knowledge, rather than simply supporting service 
demonstrations. We discussed how that could be achieved.
    I am very pleased to report to you that for the first time 
SAMHSA is able to report some concrete findings in our budget 
justification which will be widely adopted throughout the 
country. While some of these accomplishments are still 
preliminary, they will be of exceptional value to the field as 
they plan their prevention and treatment programs.
    Mr. Porter, we thank you for leaving with us this program 
legacy which will bear even more fruit in future years to come. 
Thank you, and we will be pleased to answer any questions you 
may have.
    [The statement of Dr. Chavez follows:]




                         COORDINATION WITH CDC

    Mr. Porter. Well, Dr. Chavez, thank you for your very kind 
and generous comments. It is not my leadership, it is your 
leadership that is making a difference. We are just here to 
support you and provide the resources that you need to do your 
very important work. I want to start by asking, what kind of 
coordination do you have with CDC? I know it is kind of a 
general question, but do you interface with them on health 
issues, realizing you cover different bases, but nevertheless, 
I thought you would have some work together.
    Ms. Chavez. Yes, Mr. Porter; we do. We coordinate with them 
in various areas. One area is HIV/AIDS; another is in mental 
health. Through some of the violence programs that we are 
conducting; another is hepatitis C, an area that the Center for 
Substance Abuse Treatment has been very much involved in. Is 
there any other area, Dr. Clark or Dr. Arons?
    Dr. Arons. I would like to comment on the question just for 
a moment. One of the things that we do in coordination with the 
CDC is use the opportunities they have for surveillance. For 
example, in the area of suicide, a number of the facts and 
figures about our Nation and the extent of illness in this case 
of suicide is something we make use of in our work.
    Mr. Porter. You make use of their resources, but how much 
interface is there between the leadership in the two 
organizations in terms of coordinating efforts to work on 
problems that may cross jurisdictions?
    Dr. Clark. With regard to HIV, I have personally met with 
Dr. Helene Gayle, who directs the Center for HIV at CDC. I have 
gone down there and met with her. Our staffs have come back and 
forth. They have had multiple meetings together. We share some 
of the same planning efforts together, and we discuss how best 
to address the HIV and the hepatitis issues. We are co-funding 
a major meeting on hepatitis and HIV that is coming up in May. 
So we have got planning meetings together. We have got 
strategic sessions together. We talk on the phone together. It 
is a fairly frequent exchange of at least brain power.

                           CHILDREN'S HEALTH

    Mr. Porter. Okay. Now, that was probably unfair to ask that 
in that way. Let me tell you something that I have been 
thinking a great deal about and working on, and that is, it 
seems to me, that we need to focus on children's health in this 
country. There is a lot of knowledge that we have developed 
about what are good health habits and bad health habits, but we 
don't necessarily see them being applied in terms of conduct of 
our citizens. You have a piece of this and CDC has a piece of 
this. CDC may have, for example, exercise, diet and tobacco 
use. You have drug use, mental health, including suicide, 
alcohol, and both of you may have a piece of violence, let us 
say. So, looking at it together, CDC and SAMHSA probably cover 
a great deal, of what I would like to see accomplished.
    I am talking with CDC and Dr. Koplan about how you change 
behaviors and how you reach young people and their parents with 
messages that often we leave to schools or others to do, which 
really doesn't penetrate consciousness or change behavior and 
how we can reach out using the knowledge that we have to reach 
young people where they mentally are, and that may be running 
television ads on MTV. It may be using a lot of different ways 
that we don't use today to actually reach them, and I am about 
to provide about $125 million for CDC to do a major effort in 
this area. It seems to me, under their responsibility, that CDC 
needs to coordinate with an agency like yours that does the 
other part of this and see if we can't work the whole picture 
instead of just part of the picture.
    As I've said, I don't know whether this is the kind of 
thing that could be successful, but I do know that we are 
seeing a lot of things that ought to be going in the right 
direction, but you have described some improvements we have 
seen recently, for example, in drug use, that are going in the 
wrong direction. Another example, obesity is a problem that 
everyone has the knowledge to understand that it is a health 
risk factor, and yet the whole population or large segments of 
it are going in the wrong direction on this particular issue. 
How do we change this--we probably can't change adults very 
easily, but if we can start kids in the right direction, we can 
probably change their behavior if we put enough resources into 
it and reach them with the right messages in the right places. 
So that is why I asked you about CDC. Can you give me some 
thoughts in this whole area?
    Ms. Chavez. Yes. Another area which I forgot to mention to 
you where we have quite a bit of cooperation with CDC is the 
area of tobacco, because SAMHSA has responsibility for managing 
the SYNAR program. We also coordinate with FDA in this area.
    I really appreciate what you have said about a very 
holistic approach when it comes to looking at some of the 
behaviors that we must deal with. One of the things that we 
have done, that I may have mentioned in the past is that about 
3 or 4 years ago, SAMHSA developed a program called Starting 
Early/Starting Smart, which focuses on children age 0 to 7. The 
program looks at healthy behavior, a holistic approach, not 
just in terms of the developmental phases that children go 
through, but what factors impact children and what differences 
those impacts have later on in life.
    I have learned in the past 5 years that many changes have 
occurred in the prevention area. What we have seen is that a 
lot of the approaches we thought were very effective for 
example an educational session or an ad, were found not to work 
as well. What is needed is a very comprehensive approach, yet 
it doesn't have to be a very expensive approach. It can be an 
approach where you really start looking at parental training, 
including the skills that we need as parents. With two parents 
working, families need skills to deal with some of the issues 
they face today. We also know that for many, overeating and 
obesity may be due to some psychological problems. Many 
illnesses we address have a behavioral aspect that is very much 
part of the syndrome.
    SAMHA has also learned that in order for preventive 
approaches to work, we have to take into account the other 
target problem behaviors. We are not just dealing with 
substance abuse, we are dealing with many adverse behaviors 
that must be addressed within a comprehensive approach.
    Another important issue we see for helping young people at 
a very young age to create and/or enhance positive 
relationships. We are getting away from this in terms of young 
children because everyone is so busy, and that leads to 
disruptive behaviors which may hurt other people. Individuals 
may hurt themselves in such ways as inappropriate eating 
habits.
    So what I would like to do is maybe have Dr. Arons, Dr. 
Clark, and Dr. Sanchaz-Way to comment on this. I think that 
what we are looking at, and I agree with you, we can't just 
have one program here and one program over there. We must bring 
it together so that we look at it from a very comprehensive, 
integrated, and holistic approach that deals with the entire 
the community and the family, and not in isolation. I am a firm 
believer that you must start at a very young age.
    Bernie?
    Dr. Arons. I do have a couple of brief thoughts on your 
comments. The budget we are proposing tries to echo the major 
message of the Surgeon General's report on mental health, which 
is mental health is fundamental to health. I think this ties 
into your thoughts about changeing behaviors. We are proposing 
budget increases to revitalize the mental health system and 
make sure that the Nation as a whole is served by the mental 
health system.
    The budget also maintains the legacy of some of our 
programs that we have been building on. One of those programs 
is of course the Youth Violence Prevention Program. In addition 
to the grants that we are issuing out through that program, we 
have a major public education, public information campaign that 
we launched to try and work with the public around the kinds of 
behaviors. We are trying to build on the positive aspects of 
young people, the resilience that we think are intricate to 
young people.
    We had a number of principles used to develope the Youth 
Violence Prevention Program. One of the principles that has 
stuck with me is the notion that young people can walk away 
from trouble if they have somewhere to walk to and someone to 
walk with. We are trying to envision this program as creating 
places to walk to and people to walk with as part of that 
program.
    Mr. Porter. Dr. Arons, the discussion I had with Dr. Koplan 
yesterday was about the positive aspects of messages. You can't 
just tell young people don't do this or don't do that. That 
doesn't get through. That doesn't work. That doesn't change 
anything. You have got to think how you build on the positive 
aspects of their life experiences and how you move them in 
positive directions, and God knows, we have the best marketers 
on earth in this country. We ought to be able to figure out a 
way of getting the right message to them at the right time in 
their lives, or to their parents, through the right mediums. 
Unfortunately, we can't count on the cooperation of the owners 
of our air waves who ought to give us these public services 
free but won't. If we can't do that, we ought to buy it because 
it would be money well spent if you can send a child down the 
right direction at an early stage in life.
    You can certainly justify it on an economic basis, but 
obviously the human aspects of surviving--and in many cases, 
our kids don't live long enough to survive--but having a 
healthy life and a long one, is something that seems to me we 
really ought to make a major effort on. It doesn't mean we 
should shirk our other responsibilities to take care of people 
who have problems with their health, but it certainly means we 
can maybe change the direction a bit for the future.

                    Positive Direction for Children

    Dr. Arons. We think we have some excellent people at work 
on just such a campaign.
    Mr. Porter. Good. I am trying to get this whole thing 
going, and I might say to my colleague from California these 
are not the only aspects. She and I want to work together on 
the environment and its effect on children's health, which is 
an entirely separate, but also an important component of a 
child's health in this country. Unfortunately, we didn't get 
our hearing last year, but we are going to this year, Nancy, 
guaranteed. Ruth, would you want to comment or Wes?
    Ms. Sanchez-Way. What you are saying, Mr. Chairman, is very 
true. We need to reach children at an early age. Our programs 
have showed us that between the ages of 11 and 15 the risk 
factors for the use of substances goes up and their protective 
factors go down. So we need to reach them at an early stage.
    Mr. Porter. Prior to age 11.
    Ms. Sanchez-Way. Prior to age 11.
    Mr. Porter. CDC was talking about 9 to 12, not for drugs 
but in general but you are saying prior to age 11.
    Ms. Sanchez-Way. Yes, prior to age 11. We have a number of 
programs that focus on the younger child, such as our Starting 
Early, Starting Smart initiative which starts for young 
children ages 0 to 5 in primary health care settings. We also 
have shown through our research that the best route, the best 
paths of nonuse is through the family bonding, supervision, 
parents and caretakers, messages of nonuse. We have found that 
the environment and childrens feelings of self-worth and 
accomplishment, success in school are also important for young 
people not to use substances.
    Dr. Clark. Mr. Chairman, the Center for Substance Abuse 
Treatment which is working with the other centers agrees with 
you. We are working on a number of projects for adolescents, 
but we are also working with a number of agencies 
collaboratively. I mentioned HIV and hepatitis. We are also 
working with NIDA and CDC to develop an adolescent prescreening 
instrument to assist school and other personnel in the early 
identification of potential drug and mental health issues. We 
are working with the NIAAA on an adolescent treatment research 
program. Our objective is to focus on the service delivery 
system and service providers, but these collaborations assist 
us in that objective. We are working with the Department of 
Justice on family courts and on juvenile issues along those 
same lines, and because our focus is on services, we tend to 
focus on those connections that will facilitate the provision 
of services to people.
    But in terms of early intervention, I would also cite our 
pregnant and post partum women's program, the data from which 
are quite impressive. The data show that by addressing the 
needs of pregnant women who have substance abuse problems 
early, the number of low birth rate infants goes down, and as 
you know, recent data point out that prematurity can produce 
longer lasting effects in children than we imagined. So by 
developing the pregnant post partum programs and residential 
programs for women, we can demonstrate to the local 
jurisdictions, cities and counties and States and tribes, that 
these programs will help in reducing some of the subsequent 
problems that we will observe subsequently, and I think that is 
a key issue.
    And by having residential programs for women, we can engage 
in parenting efforts for people who are at a much higher risk 
for parenting dysfunction, and again, we are working with HRSA 
and primary care settings, et cetera.
    Mr. Porter. Thank you, Dr. Clark. I guess we will operate 
under the 8-minute rule, although if you want equity you get 25 
minutes. Let us try 8, Ms. Pelosi.
    Ms. Pelosi. Well, I would argue for the equity except that 
our governor, and forgive me for having to go in and out, but I 
just got buzzed that he is back again, and we are meeting with 
the Republican appropriators so I have to be in the room for 
that subject, but I told him that this was of primary 
importance so I would have to step outside because the work of 
SAMHSA is so important in so many respects that you have 
reviewed, and thank you for your beautiful statement, Mr. 
Chairman, about reaching our children early enough and making 
every effort to do so.
    I have a couple of comments I want to make. First, I serve 
with the chairman on Foreign Ops, and we will soon be asked to 
approve a $1.3 billion package for Colombia for fighting the 
drug war, and my initial response to the $1.3 billion request 
was I will consider it if you put $1.3 billion in reduction of 
demand in the U.S. to fight the drug war and for prevention and 
early intervention because I think if in fact the rationale for 
the $1.3 billion is to address the plague of drugs on our 
society and substance abuse, then that money would be much 
better spent in our own country with treatment on demand and 
prevention and the kind of outreach the chairman described. 
That doesn't mean that we shouldn't do something to interdict, 
and so far I haven't seen the benefits of that, but I am 
willing to listen, but I think we ought to make it a 
precondition to the administration that if they really want to 
fight this war on drugs they have to start at reducing demand 
instead of trying to snuff out a source, no pun intended, 
because there are plenty of other sources in the world, no 
matter how many billions of dollars we spend on that.
    Having said that, I wanted to ask a couple of questions. 
Dr. Chavez, congratulations to you for your great leadership on 
so many issues that SAMHSA covers and especially those that 
deal with our children and protecting them from some of these 
influences.
    In that vein, the Children's Mental Health Services Program 
has been in existence for 7 years. It provides localities with 
grants to develop intensive community based interagency 
approaches to serve children and adolescents with serious 
emotional disturbances. I know you know that basic premise. Can 
you share an example of an original grant program awarded funds 
in 1992 that continues to provide an array of mental health 
services, though no longer receiving Federal funds? How do they 
succeed to graduate from Federal funds to successful program 
without Federal funds? You can give me the answer for the 
record.
    [The information follows:]




    Ms. Chavez. Congresswoman Pelosi, it is wonderful to see 
you, and thank you so much for your support. We visited with 
you in San Francisco at the Starting Early Starting Smart 
Program, which I had mentioned earlier to Chairman Porter. I 
believe it is a critical program. In response to your question, 
to date all the graduated sites continue to deliver services, 
and we do have excellent examples, Dr. Arons will mention a 
program in Milwaukee, which has been very successful in terms 
of continuing to provide an array of services that is so 
critical for children's mental health.
    Dr. Arons. Yes. Thank you. Certainly we are very proud of 
the achievements of the Children's Comprehensive Mental Health 
Services Program. We think part of the success of this program 
was the built-in requirement for matching funds from the 
community. By the end of the 5 year grant program, the 
community has really bought into both the concept as well as 
financially. Milwaukee and Santa Barbara, California, are good 
examples, of communities that have been very successful at 
making certain that the services they provide are coordinated 
with the juvenile justice system, the child welfare system, and 
the education system. They have really demonstrated to those 
other systems, those other service assistant programs that 
mental health services can provide an assistance and, when 
coordinated with them, can succeed in moving children from 
living in institutions or residential care settings to living 
at home with the services they need.
    I think if there is anything about this program it 
demonstrates the success of integrating those services, and 
establishing those connections. We estimate over 90 percent of 
the programs that we funded are showing continuation after the 
Federal funding ends.
    Ms. Pelosi. And are we teaching others how to do that?
    Dr. Arons. Very much so.
    Ms. Pelosi. Serving as a model.
    Dr. Arons. Along with the program, in addition to the over 
60 grants that have been funded, we have a thorough evaluation 
which is trying to make sure we can document the successes, in 
improved school attendance, school performance, reduced 
difficulty with the law. We are also making certain we provide 
technical assistance, to make this information available, not 
only to those new grantees that we are able to fund, but also 
to communities across the Nation.
    Ms. Pelosi. Thank you for that. Dr. Chavez, since 1993 
Community Mental Health Service has funded a total of 65 grants 
in 42 States and served approximately 41,000 children. In your 
opinion what are the most notable improvements that program 
services have achieved for children's ability to function? Does 
this program significantly reduce the number of youngsters who 
are placed in out of home placements?

                    COMMUNITY MENTAL HEALTH SERVICE

    Ms. Chavez. Congresswoman Pelosi, there have been quite a 
few significant findings from these programs. One is that the 
out of home placements, especially the residential placement, 
and more of those expensive placements like out of State 
placements, which as you know in California this has been a big 
issue, that has been reduced dramatically. We also have seen 
tremendous improvement in school performance, the ability to 
work with other children, and the involvement of family members 
in treatment. Overall, there has been tremendous progress in 
program coordination and, as Dr. Arons said, inclusion of those 
critical elements that impact on the life of a child.
    Ms. Pelosi. Thank you, Doctor. Both the media and the GAO 
have documented serious problems with the inappropriate use of 
restraints and seclusion techniques in facilities for people 
with cognitive disabilities. I do not find proposals in the 
President's budget to address this issue. Is there anything the 
administration is doing in this area? And again you can get 
back to me on that.

                       RESTRAINTS AND SECLUSIONS

    Dr. Arons. Just a couple words because this is such a 
serious issue. Restraint and seclusion is viewed, as a major 
medical intervention that unfortunately has a potential 
consequence of injury to the individual and possible death. As 
you know there has been some documentation of possibly up to 
150 deaths a year from restraint and seclusion. We do propose 
in the budget a modest increase in the protection and advocacy 
program in hopes they can increase their surveillance, increase 
their ability to respond to individuals who feel they have been 
subject to abuse or neglect in institutions. The overall 
increase in mental health services we hope will help 
communities respond with community services as well.
    Ms. Pelosi. Two of my children are teachers of children 
with special needs and some even with those severely disabled. 
So I was very interested in your response to that. Thank you 
very much for your leadership.

                          COLOMBIA DRUG FUNDS

    Mr. Porter. Would the gentlelady yield if I give her 
additional time? I think what you said about, if I understood 
you correctly, about the money for Colombian interdiction is 
exactly right. I wonder if Dr. Chavez would be willing to tell 
us whether she had some input as to how this money might be 
spent, because it seems to me that--and this is going to be 
declared an emergency and put in a supplemental--that if we 
declared it an emergency and put it in your budget we would 
probably get a lot more out of it than we would putting it into 
Colombia very frankly. I think we need interdiction, I think we 
need prosecution, I think we need all of those things, but I am 
a firm believer that you can do all that you want and as long 
as there is demand here, it is going to get through anyway. You 
have got to cut the demand and treat the people who are 
addicted, and if you put your money in this area, you are going 
to do far better than you would trying to do something in one 
country out of, as the gentlelady points out, many that produce 
drugs or are available to produce drugs. Did you have any input 
to this program that the President proposed, and did you have a 
chance to argue that it ought to be better spent where you are 
spending it?
    Ms. Chavez. I personally did not have any input or 
discussion. Dennis, did the Department have any discussion?
    Mr. Williams. I am not absolutely certain. I don't believe 
we had direct discussions with the President on this but I can 
find out.
    [Clerk's note.--The Department did not provide any 
proposals or recommendations for ``Plan Colombia and the Andean 
Region''.]
    Mr. Porter. Presumably this is General McCaffrey's area and 
his background of course is military. So you can understand 
where he might be coming from, but it seems to me we ought to 
make an independent judgment, if we are going to spend this 
kind of money, whether it is going to do what it is designed to 
do, and if it isn't, why don't we put it where it can do some 
real good. That is how I feel about it.
    Ms. Pelosi. Reclaiming my time, if I may just take a few 
seconds, substance abuse treatment is the most effective use of 
drug control investments. The RAND Corporation study on 
reducing cocaine consumption found funds spent on drug 
treatment were 23 times more effective than source country 
control, 11 times more effective than interdiction and seven 
times more effective than law enforcement.
    Now I agree with you, we have to have interdiction, we have 
to have law enforcement and prevention of course, but you know, 
treatment and prevention are the answer. A National Institute 
of Justice report found that providing treatment to all addicts 
in the United States would cost $21 billion and save more than 
$150 billion in social costs over the next 15 years, not to 
mention, as you said so eloquently earlier, Mr. Chairman, what 
it means to the life of that person. So, in any event, I would 
have hoped that General McCaffrey would have been in 
communication with you all on the comprehensive approach to 
this. So we will have to continue this discussion in the course 
of the debate on the supplemental.
    Thank you very much, Mr. Chairman.
    Mr. Porter. Thank you, Ms. Pelosi. Mr. Miller.
    Mr. Miller. Let me make a brief comment about the situation 
in Colombia, and I am not on that subcommittee that is going to 
be involved in doing that, but I did visit Colombia earlier 
last year and that is a basket case. We have had some real 
success in Peru and Bolivia that we should be very pleased with 
and continue to support it, but there is a country that is 
getting ready to go into anarchy. It is not just a drug issue. 
It is a question of a neighbor in our hemisphere not that far 
away, it really is close to anarchy down there. So it is a very 
dangerous situation.
    And I am sorry I missed the presentation. And this may come 
up again when we talk about NIMH. There was an article recently 
in the paper about the potential of a medical solution to some 
of our drug problems. Could someone update me somewhat on what 
we are moving towards as far as, you know, developing a system 
that you could prescribe or solve some of the drug problems to 
keep people from getting the addictions or such? Update me.

                   MEDICAL SOLUTIONS TO DRUG PROBLEMS

    Dr. Clark. The National Institute of Drug Abuse is taking 
the lead on developing the new medications. We are working with 
them to bring Buprenorphine to market in order to address the 
increase in heroin consumption across the country. We are also 
working with the NIAAA on other medications to address the 
complications associated with alcohol consumption, specifically 
Naltrexone, and there is another drug in development, 
Kampesate.
    There is a lot of planning but the basic research goes on 
at the NIH on some of these drugs, and you may have seen the 
article in the Washington Post yesterday about catalytic 
enzymes--catalytic antibodies for cocaine. Those are the kind 
of things that are in the pipeline but they are not ready to be 
brought to market at this point in time.
    Mr. Miller. Where do you see the future of that leading 5 
years from today or 10 years from today? I know you don't want 
to speculate too much, but I am going to ask you anyway.

                 THE FUTURE OF SUBSTANCE ABUSE PROBLEMS

    Dr. Clark. We believe that the substance abuse problem, 
excessive alcohol consumption, use of illicit drugs is a 
complex problem with biological and psychosocial antecedents. 
So we believe the medications can be helpful in addressing 
components like craving, to prevent relapse or in the case of 
the catabolic antibodies to keep people from experiencing the 
effects of the substances, but there are also psychological 
problems. A large number of people who have substance abuse 
problems have what is called co-occurring psychiatric problems, 
depression, bipolar affected disorder, schizophrenia, post 
traumatic stress disorder, and those things, too, need to be 
addressed. Otherwise you get people shifting from one substance 
to another. So you can develop a grand medication for one 
substance of abuse only to have the person's psychological 
problems drive them to another substance of abuse. So we 
believe working with the NIH, SAMHSA, both CSAT and CMHS, is 
addressing this holistically looking at the biological, the 
psychosocial issues also, and then prevention and mental health 
issues need to be addressed. So what we will have is a more 
sophisticated system that can take each individual on a case-
by-case basis and make a decision about what that treatment 
plan should look like, should it include medication; should it 
include medication and group therapy; should it include 
medication, group therapy and other medications for other 
problems, et cetera.
    So there are a lot of exciting things going on in the 
service delivery system. We will need to be prepared to 
incorporate those new things. We are discovering that now, 
working with the National Institute of Drug Abuse in bringing 
Buprenorphine once the drug is available into the offices of a 
host of practitioners.
    Mr. Miller. This is the decade of the brain. I visited the 
Brain Institute at the University of Florida here recently. I 
mean we didn't talk about necessarily all these issues, but the 
research pouring into there and the focus of the whole 
institute, and it is not just the University of Florida, it is 
elsewhere around the country, that it seems like there is some 
potential, not just in medications, but other areas, to help 
address some of the problems we are facing.

                        WHAT WORKS IN TREATMENT

    Dr. Clark. You are correct, Mr. Miller, and that is why we 
want to be able to--we are using our knowledge development and 
application line to help facilitate the transfer of new 
knowledge into the community of practitioners. I am fond of 
saying we can have all this new knowledge but what we don't 
want is the community practitioner to be using 1970s techniques 
in the Year 2000. So we use our Addiction Technology Transfer 
Centers to help educate providers, particularly counsellors who 
are very low paid and have very little means to access new 
information. So we are using our ATTCs for that as we are 
working collaboratively with the NIH to that effect, and we are 
doing projects like our cannabis youth project, our marijuana 
project, methamphetamine project to shift these technologies 
into communities because what works in New York City may not 
work in Orlando. What works in Orlando may not work in Atlanta.
    Mr. Miller. Is there good communication and cooperation 
between all the different agencies from NIH to SAMHSA and all, 
you know?

                       COOPERATION AMONG AGENCIES

    Dr. Clark. I can speak for CSAT. I think so. We work very 
closely with Alan Leshner, Enoch Gordis, and Steve Hyman in 
their institutions, and I guess my colleagues can speak to 
their collaboration.
    Ms. Chavez. Thank you, Mr. Miller. We do have very good 
cooperation with all the Institutes at the NIH as well as other 
components within HHS, including ACF and FDA. We also work very 
closely with HUD and the Department of Labor. So there are many 
collaborative relationships and cooperative agreements.
    To follow up on your question, I would like Dr. Goldstone 
to respond.
    Dr. Goldstone. I want to make two observations. I know 
there is a lot of enthusiasm about medications, but medications 
are used only after a problem occurs. We have to deal with the 
fact that there are problems that appear, and you have to get 
people to treatment and understand how you can keep them from 
having the problem in the first place, and the enthusiasm over 
medications often obscures this fact.
    The second observation that I think is important is that we 
have long had very effective treatment for hypertension. Many 
in our society have hypertension and have never been diagnosed 
or treated for their problem. Having a medication to treat a 
disease is not sufficient.
    Mr. Miller. But the research has gone beyond medication as 
an option, too, maybe, I don't know. There is more than just 
medication as an option, is there? I don't know. Let me switch 
to one more question if I may, Mr. Chairman. I see in one of 
the handouts you gave me that the Community Mental Health 
Services Block Grant for Florida is going to increase by a 
third.
    I used to serve on the Mental Health Board in Mantee County 
back in the '80s, and I know in recent years they have been 
struggling financially because--I am not exactly sure of the 
details, but that is a pretty big increase. I am delighted for 
my State of Florida, but is it just Florida getting a one-third 
increase or is this the right number? I mean, you go from 15 
million to 20 million. Or is all of Community Mental Health 
Service Block Grant going up that much?

                       MENTAL HEALTH BLOCK GRANT

    Ms. Chavez. The increase to the Mental Health Block Grant 
has to do with the formula change that impacts FY 2001. I 
believe Dr. Arons could provide you more detail on the Florida 
block grant dollars.
    Mr. Parks. If you want to, I am sure other States would 
like it transferred to them.
    Mr. Miller. You took some away from Illinois I hope.
    Dr. Arons. Hopefully we have done this equitably. There is 
an increase for Florida this year of about $4.6 million and for 
2001 of an additional increase of about $4 million. This is 
part of our effort, as I mentioned before, to really put into 
action some of the findings of the Surgeon General's report on 
mental health and the White House Conference on Mental Health 
to really try to revitalize the mental health system in this 
country.
    The Mental Health Services Block Grant actually provides 
relatively little of all of the expenses a State must spend for 
its services. It does provide leverage and incentive for states 
to provide those services in a community setting and to do so 
in a way that is effective for adults with serious mental 
illnesses and children with serious emotional disturbances.
    We think we have the knowledge. States are ready to move 
forward. They need additional Federal funds to be sure they can 
improve and revitalize their system. States need to and bring 
the services to the people, such as those who are homeless and 
aren't getting the services they need, and people in the 
criminal justice system hopefully that we can identify before 
they get involved in the criminal justice system. If not, we 
need to afterwards or when they are being transitioned into the 
community. Young people and children who get in trouble with 
the juvenile justice system as you well know in Florida, those 
are all significant groups that need services.
    Mr. Miller. Is Florida getting a proportionally larger 
increase than other States?
    Dr. Arons. No, not proportionally.
    Mr. Miller. One of the debates we had earlier today was the 
formula for aging, and it is based on the 1987 census, which is 
a sore subject for us in Florida, but that is not the case--I 
have not heard that being a problem here. It is a fair 
distribution based on fairly current population.
    Mr. Kopanda. There is a technical change in the way the 
formula is run which affects the State distributions between 
the year 2000 and 2001 in our budget. For fiscal year 1999 and 
fiscal year 2000, State distributions have been held harmless 
by appropriations Bill language, but that language doesn't 
permanently amend the statutory formula for our block grant. So 
for fiscal year 2001, since the budget is not proposing that 
hold harmless language continue, we have run the State 
allocations based on the statutory formula. Unless the 
authorizing committees change our permanent statute for year 
2001, the budget reflects the distribution at the level we have 
requested.
    Mr. Miller. Without the hold harmless?
    Mr. Kopanda. Yes, without the hold harmless. The 
distributions would change if the hold harmless applied in 
2001.
    Mr. Miller. Let me make one concluding comment, but my area 
has got lots of seniors, Sarasota and Bradenton area, lots of 
old people, and we had a drug sting operation in my area, it 
was in the paper last, a week ago. I think it was on Monday 
after the weekend, and the police and the FBI ran a sting 
operation for cocaine, and they arrested an 88-year-old man 
buying--I mean, you have heard everything. To me that is 
shocker to have an 88-year-old man buying cocaine, and his 
concern was in the paper was being quoted that he used to go to 
the Senior Friendship Center, which is a center that is a day 
care program for seniors. He said, I had a good reputation 
there. Now I have ruined my reputation. You don't have 88-year-
old cocaine users very often, do you, to deal with?
    Dr. Clark. We are concerned about substance use in the 
elderly. I am a psychiatrist, addiction medicine specialist and 
ran an in-patient unit, and I wound up with a 72-year-old 
methamphetamine user who had just started using methamphetamine 
that year, and people start using substances of abuse for a 
wide range of reasons, a lot of psychological issues, and we 
believe----
    Mr. Miller. He was bored, he said.
    Dr. Clark. Boredom is a good example. Depression, boredom 
are events that occur across the age range and especially for 
people who are experiencing life changes. So we do need to 
address the substance abuse treatment needs of the elderly.
    Mr. Miller. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Miller. Dr. Chavez, I have a 
number--in fact, I have all my questions that were prepared by 
staff that I would ask that you answer for the record, please.
    Ms. Chavez. Yes, sir.
    Mr. Porter. And I would like to get Dr. Koplan and you and 
perhaps Dr. Alexander at NICHD and maybe others together and 
meet on the subject that I raised earlier about children's 
health and health habits. Would you be willing to do that?
    Ms. Chavez. I am so excited about the prospect I will call 
them tomorrow.
    Mr. Porter. Wonderful.
    All right. Thank you so much. Thank you all so very much.
    Ms. Chavez. Could I make two quick comments?
    Mr. Porter. Absolutely.
    Ms. Chavez. There is something that I really would like to 
mention to you because it is so exciting, and it happened under 
the leadership of this Committee. The information that will be 
available to us in August of this year, from the Household 
Survey, information that will be available are things related 
to some of the issues that you raised Mr. Miller.
    For example, we will have information on drug use among 
those that are 55 years of age. We will also have information 
on patterns of drug use among minority groups. Some that we 
have never had before, for example, Japanese.
    We will also have information on a variety of GPRA issues, 
such as comparing one State's results with another.
    Donald, do you want to comment on that?
    Dr. Goldstone. Well, I go back to the observation about the 
elderly. We really have had--we know a fair amount about 
alcohol abuse among the elderly, but with respect to other 
substances, both licit and illicit, we know virtually nothing. 
The Household Survey, which is a random sample of the 
population, will have in it for the first time about 6,000 
people over the age of 55. The survey will give us a broad 
picture of the nature of the problem and how extensive the 
problem is in the United States.
    With the expansion of this survey we also, for the first 
time, will really be able to look at the differences between 
rural areas and a variety of more settled areas. We now call 
anything that isn't metropolitan rural, and we can't make the 
kinds of distinctions that I think will turn out to be very 
important with respect to understanding the variation in 
substance use in the country as a whole and in particular 
States.
    Mr. Porter. Will that data be published in August, is that 
what you say, or collected in August?
    Dr. Goldstone. The 1999 survey, which includes about 70,000 
respondents, will be surveyed in a report which traditionally 
is released in August. This report will have about eight 
variables describing substance use in the States. Towards the 
end of the year we will have a more expanded report that will 
present the findings in more depth.
    Mr. Porter. Thank you.
    Ms. Chavez. We will follow up on that. It will cover 
calendar year 1999. This survey has been conducted for a long 
time.
    Dr. Goldstone. Well, the first of the surveys was in 1971, 
but up until 1999, it included about 18,000 respondents. We 
have now increased the survey to 70,000. This change makes an 
extraordinary difference in terms of the kinds of information 
you can gather and the way you can divide up the population to 
look at problems. You can't make estimates of subpopulations 
when you have small samples.
    Mr. Porter. My colleague from Florida is a former professor 
of statistics. He knows this.
    Dr. Goldstone. Then I won't go any further because I will 
get in trouble.
    Mr. Porter. Dr. Chavez, thank you very much. Thank you all 
very much. The subcommittee will stand briefly in recess.
    [The following questions were submitted to be answered for 
the record:]




                                       Wednesday, February 9, 2000.

               AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

                               WITNESSES

JOHN M. EISENBERG, M.D., DIRECTOR, AHRQ
LISA SIMPSON, M.B., B.Ch., DEPUTY DIRECTOR, AHRQ
RITA KOCH, CHIEF, OFFICE OF MANAGEMENT, DIVISION OF FINANCIAL 
    MANAGEMENT, AHRQ
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 hearings on the funding for the Department of 
Health and Human Services with the Agency for Healthcare 
Research and Quality. We are pleased to welcome Dr. John 
Eisenberg, the Director.
    Dr. Eisenberg, why don't you simply proceed with your 
statement.
    Dr. Eisenberg. I will, thank you very much.
    Mr. Chairman, members of the committee, I am pleased to 
join you to present the President's fiscal year 2001 budget for 
the Agency for Healthcare Research and Quality, and let me 
introduce Dr. Lisa Simpson, to my left, your right, who is 
AHRQ's Deputy Director; Rita Koch, who is the Chief of our 
Division of Financial Management; and you know Dennis Williams, 
the Deputy Assistant Secretary for Budget for the Department.
    Mr. Chairman, I understand that you are going to be 
retiring, and I just want to say personally how much of a 
pleasure it has been to work with you in your role. I have only 
been on this job for 3 years, but in just those 3 years I have 
come to appreciate your concern about the quality of health 
care in this country, your commitment to the kind of a job that 
we all can do in government, but in particular this Agency can 
do to improve the quality of health care and people's access to 
health care; and in particular, your commitment and your 
insistence that we not just support research and do research, 
but that we be sure that that research gets translated into 
improved health care, and that then gets translated into 
improved health for the Nation. We are appreciative of that. 
Our strategic plan was shaped in many ways as a result of your 
urging, and I think it has made a big difference in the way our 
Agency operates.

                   AHRQ'S REAUTHORIZATION AND MISSION

    We are here as staff now of this newly named agency, the 
Agency for Healthcare Research and Quality, formerly the Agency 
for Health Care Policy and Research. This reauthorization is 
more than just a change in name. It is more than just symbolic. 
It really does change the core mission of the Agency, focusing 
on quality, focusing on the way in which government can help 
through research to improve the care that Americans get so that 
we can translate that new knowledge into improved health care.
    The mission which this committee has been so important in 
guiding has been to be sure that we are driven by the needs of 
our users, the people who are the users of this information. 
And when we think about our users, who are the customers of the 
information we generate through our research or our grantees 
generate, we think about patients. We think about clinicians, 
clinicians of all stripes. We think about people who lead 
health care systems, hospitals, nursing homes, managed care 
organizations; people who purchase health care; people who are 
policy-makers at all levels--because we believe that all of 
them want evidence to make better decisions, and we think it is 
the government's responsibility, in particular our 
responsibility as an agency, to be sure that that information 
is there.
    This mission is achieved by what we think of as a pipeline 
of research. The pipeline has three major parts. The first part 
is to invest in new research that generates new knowledge about 
what works in health care so that when we ask whether or not we 
ought to institute a program, we know that it is evidence-based 
and that it makes a difference when it is introduced. But just 
knowing that isn't enough, of course, because you have to be 
able to implement it. The second part of the pipeline is to 
fund people who can generate, develop and test tools that will 
translate that knowledge into things that people can do to 
improve health care. And the final part is to be sure those 
tools don't sit on the shelf, but that the tools are used and, 
in fact, that they become parts of a tool kit of knowledge that 
generates tools that people can use to improve health care and 
that get translated into improved health care for people in 
this country.
    So our agenda, and we keep saying it because we can't say 
it enough ourselves, is to translate research into practice. We 
think of it as our TRIP agenda, translating research into 
practice, and that is really the touchstone for this Agency, 
for AHRQ. In many ways we think of AHRQ as ``arc,'' as the word 
for closing that gap between what we know and what we need to 
know, between what we know and what we actually do in health 
care. It is one of the reasons we like that acronym for our new 
name because it really does symbolize what the Agency is all 
about, and it is also easier to pronounce.

                            FY 2001 REQUEST

    What we are asking for this year, as demonstrated in our 
fiscal year 2001 request, is a budget of $250 million. That is 
an increase of $47 million from fiscal year 2000, and it 
focuses on three main priority areas. The first one is to focus 
on patient safety and medical errors. The second one is to 
focus on ways in which we can use information technology, 
computers, in order to improve the care that Americans receive. 
And the third part is to focus on the health of America's 
workers and the opportunity to make the business case for 
health care.
    In addition to all this, the request will continue some of 
our other priorities. Quality improvement continues to be a 
major priority for this Agency. Clinical prevention is, as 
well. Research on health care costs continues, and building the 
Nation's capacity for better research to improve health care 
continues to be a major priority, as well. So let me talk about 
each one of those major priorities in brief.

             PATIENT SAFETY AND REDUCING ERRORS IN MEDICINE

    For fiscal year 2001 we are requesting $20 million to 
address the issue of patient safety and errors. This was 
highlighted, as you probably know, in the Institute of 
Medicine's recent report called ``To Err Is Human.'' According 
to this report, there are as many as 98,000 Americans who die 
each year because of medical errors. That would make it, if it 
were 98,000, the fifth leading cause of death in the United 
States. Even a more conservative estimate of 44,000 deaths 
would make it the eighth leading cause of death in this 
country. If errors were a disease, you would call it an 
epidemic. If errors were a disease, this country would demand 
that there be a major research initiative to deal with that 
epidemic, to understand its causes, to develop tools to deal 
with it, and to translate the knowledge and tools into improved 
practice to get rid of that epidemic. We feel the same way 
about errors.
    The IOM report was distressing, distressing for all 
Americans, but it also offered some hopeful news because it 
pointed out that errors can be prevented in health care. Some 
of the landmark research in this area was funded by the Agency 
for Health Care Policy and Research, our predecessor, and 
demonstrated that errors occur from problems in systems, and 
that we shouldn't be blaming individuals or blaming hospitals, 
nursing homes or others for these problems. We should be 
looking for system solutions. For example, we found that 
failures in ordering drugs and prescribing drugs in three-
quarters of the instances were the cause of adverse drug 
reactions.
    So we are proposing a very broad research initiative on 
medical errors and patient safety for the fiscal year 2001 
budget. It will take full advantage of this pipeline of 
research that I mentioned earlier--new knowledge about what the 
causes of these errors are, new tools that will help us to 
prevent the errors before they become problems for patients, 
and third, collaboration with our public-sector partners and 
also our private-sector partners to be sure that those new 
tools and that new knowledge get translated into improved 
patient safety.
    We have already made a $4 million down payment in fiscal 
year 2000 in this area. We have four centers around the country 
called Centers for Education and Research on Therapeutics, 
which were part of our mandate before but now are built into 
our own authorizing language to help us to understand how drugs 
can be used as safely as possible, as well as devices. And 
secondly, we have a $2 million request for applications in the 
field now, asking the best and brightest to give us their ideas 
about what to study regarding errors--and we will review those 
applications to see what we can do to decrease errors in the 
health care system.
    This is going to require teamwork, we know that. We know 
that there are other leaders who want to partner with us, like 
the National Patient Safety Foundation, like the Joint 
Commission for Accreditation of Health Care Organizations and 
many others, and we look forward to that partnership.

                         INFORMATION TECHNOLOGY

    The second major theme is information technology. The 
President is requesting $5 million to harness the power of 
information technology in order to improve patient care. In its 
very early days, this Agency funded some of the very first work 
that used computers in hospitals and in outpatient practices to 
improve health care, but we haven't been able to fund much of 
it lately. And in addition to that, I think all would agree 
that the health care system lags behind just about every other 
industry in its ability to apply computers to improved care, 
behind banking, behind the automotive industry, behind many 
others. And ironically, this kind of technology, which can 
offer decision support, new ways of collecting data and other 
ways of improving care, could be a major force in improving 
health care, and making it less expensive as well, in this 
country.
    For example, one study that we supported--and, in fact, we 
had this in our testimony before (the New York Times covered it 
last week in an article in the business page)--talked about the 
LDS Hospital in Salt Lake City which, with funding from this 
Agency, tested out and developed a new system in the hospital 
for decreasing errors through a computer-assisted management 
program. That decreased drug-related errors, and now the LDS 
reports to us that eight other hospitals have come to them 
asking if they can learn from LDS to take those systems into 
their own hospitals, as well.
    In fiscal year 2001, we would like to continue this 
interest, but to be sure that we make a difference in the 
application of computers in health care by developing and 
testing Web-based systems for providing evidence-based 
information to health care providers and to patients, and 
building on the National Guideline Clearinghouse that we 
produce in collaboration with the AMA and the American 
Association of Health Plans to give one-stop shopping on the 
Internet for the best evidence that is available.
    We don't produce guidelines any more, you know that, but we 
do the front end and the back end of the guidelines. We produce 
the evidence that health care leaders can use to generate best 
practices, and then once those guidelines have been developed 
through the National Guideline Clearinghouse, we make them 
instantaneously available to anybody who has access to the 
Internet. Now, there are 650 guidelines that are on the 
Internet. You could get on it this afternoon, as would 4,000 
other people every day doing a search on this Web site.
    The third theme, that of workers' health care, is an 
initiative in fiscal year 2001 for which the President has 
requested $10 million for AHRQ to support research that 
addresses the impact of health care on the well-being and the 
productivity of American workers. For example, when I was 
taking care of patients before I took this job, if a diabetic 
came into my office, I needed to know what the diabetic's work 
habits were, because if that person was a shift worker, that 
would make all the difference in the world in the person's 
insulin dosing in the person's dietary habits, and it becomes a 
very important part for caring for that individual.
    There are other examples. For example, the Social Security 
Administration asked us last year if we would help them to 
understand the impact of dialysis for people with chronic renal 
disease on their ability to get back to work. The Washington 
Business Group on Health has been urging us for some time to 
help to make the business case for quality--that better health 
care for employees is good business. That is an assertion that 
we can all make. We believe it, but the research that underpins 
it needs to be bolstered, and that is what this agenda is all 
about. We believe that there is a business case for quality. We 
believe that the case is that a healthier work force is going 
to be a better work force for this country.
    The quality of care in the health care workplace is also 
something that we are interested in pursuing because we believe 
that issues having to do with the quality of work for health 
care workers will enable them to provide higher quality care to 
their patients.

                         CONTINUING PRIORITIES

    Now, let me conclude by mentioning a few other areas, the 
ones that I said are continuing agenda items for this Agency. 
We have a request for $6 million to continue these existing 
priorities. Two million of that is for the response to the 
President's Quality Commission, which said there is a lack of 
comprehensive information in this country about what is 
happening in health care quality. We are designing a national 
quality report, which Congress mandated us to do in our 
reauthorization, and we are collaborating with other Federal 
agencies as well as those in the private sector to produce this 
report, so that we know what is happening to health care 
quality in this country, whether it is getting better or worse, 
but most importantly where there are opportunities for 
improvement.
    We are also requesting $2 million in this budget for 
another high priority for the Agency, and that is clinical 
preventive services. This effort focuses on populations who are 
getting either too few or too many, or not getting the right or 
not getting the highest quality, clinical preventive services. 
Special emphasis will be placed on clinical prevention for 
particularly vulnerable populations. We know that women, we 
know that children and we know that minorities don't get the 
clinical preventive services that they need, and we are looking 
forward to continuing to do everything we can, partnering with 
our colleagues at the CDC, who take a more public health 
approach to this, for us to take the health care perspective 
and work together to improve preventive services in this 
country.
    Last month we released ``Staying Healthy at 50+,'' and this 
is the brochure. We will make it available to you. The 
transcriptionist had one sitting at her desk, and I said, ``You 
don't look like you are 50.'' She said she grabbed one for her 
mother, and we are happy that she did that because we think 
that this is a great document. It is written in a font that 
even I can read, and it gives advice that is evidence-based 
about what makes a difference.
    This is a partnership, also. It is partnership with HRSA, 
the Health Resources and Services Administration, and the AARP 
to get information out to people about what the evidence is so 
that they can improve their health through better preventive 
services.
    And then, finally, we are requesting $2 million so that we 
can build the training opportunities for more Americans to do 
research in this area. We are particularly concerned that there 
needs to be better geographic distribution and better ethnic 
distribution of health care researchers so that we can focus 
more on issues of vulnerable populations and on rural 
populations, and we are going to bolster the number of 
individuals in those groups who are trained so that they can 
focus on those issues more than we have been able to in the 
past.
    So, Mr. Chairman and members of the committee, let me thank 
you again for giving us the opportunity to present this budget. 
Let me thank you for your service to the Nation and your 
stimulation and help to our Agency in everything that you have 
done for us in the past few years. Thank you so much.
    Mr. Porter. Thank you, Dr. Eisenberg.
    [The statement of Dr. Eisenberg follows:]




    Mr. Porter. Because he has another commitment, I am going 
to call on Mr. Miller first. Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman.
    You do mostly extramural research; is that right? Your 
number of FTEs is relatively small.
    Dr. Eisenberg. It is very small.
    Mr. Miller. What is your percentage?
    Dr. Eisenberg. The percentage of our total money that goes 
outside the Agency is about 80 percent.
    Mr. Miller. You know, do you go for the consumer-type 
educational materials? Do you do very much of that?
    Dr. Eisenberg. We don't do as much consumer education in 
print as we do on the Web, but the basic principle for us in 
spending the money on focusing on the public has been to find 
partners, because our budget is just too small for us to spend 
more. We have $1 million, for example, in our prevention budget 
for what we call Put Prevention Into Practice, of which this is 
a part. One million dollars wouldn't make much of a dent if we 
didn't have partners. But with HRSA, with AARP, with the Web, 
with a number of professional societies, we think we can get an 
amplifying effect.
    Mr. Miller. You do the Web in-house, putting all that 
together in-house?
    Dr. Eisenberg. We have a contract, a group we contract with 
for the Web.
    Mr. Miller. The controversy a few years back, I guess 
before your time, on the guidelines issue, where does that 
stand? I mean, it is not the controversy it was back 6, 7 years 
ago.
    Dr. Eisenberg. No, I think the controversy helped the 
Agency focus on what its niche ought to be and what the Federal 
Government's niche ought to be, and we decided that it was time 
for us to move out of the business of writing the guidelines, 
but rather to focus on what the evidence is for guidelines to 
be written. So we now have, as a result of that controversy and 
the focus that it gave us, 12 centers around North America, 11 
in this country, 1 just outside of Toronto, that are called 
Evidence-Based Practice Centers. And the way it works is to me 
the ideal situation because it is user-driven. We ask 
professional societies and advocacy groups--patient groups, 
consumer groups, health care providers--what kind of 
information they think they need in order to improve care: 
Where are there gaps between what they need to know and what 
they know? We then ask one of these 12 groups to address those 
questions. We are able to afford about 15 to 20 of these a 
year, and they produce a report, which we then make public and 
also give to the group who asked for it, and we expect them to 
take the evidence and do something with it. Maybe it is a 
guideline. It might be an educational program. It might be a 
system change.
    This has worked so well, in fact, that we now are finding 
that others are coming to us asking us as an Agency to help 
them to generate these kinds of evidence reports. The VA has 
asked us for a couple. The Center for Complementary and 
Alternative Medicine at the NIH has asked us for help. So we 
are able to get a magnifying effect from the centers that we 
have.
    Once those guidelines are written, our belief is that they 
ought to be made readily available to the decision-maker. So 
the back end of the process is one where we have a philosophy 
that there is no single way to practice medicine or nursing or 
any other part of health care. There is--just like there is not 
one path to heaven, I suppose. Our view is that people who are 
practicing need to know what the evidence-based guidelines are, 
be able to compare them side by side, and then consider their 
circumstances, their patients, and choose the one that is best 
for them, rather than having us say, this is the way you ought 
to go.
    Mr. Miller. You do this on an ongoing basis?
    Dr. Eisenberg. We do.
    Mr. Miller. So it is constantly being updated as far as the 
latest approved guidelines or methods or such? It is not a one-
shot deal and you move on to another disease?
    Dr. Eisenberg. That is exactly right. We figure within 2 or 
3 years we ought to have a couple thousand guidelines up there. 
In fact, for this presentation we checked to see what number we 
were at, because it is increasing every single month as these 
guidelines are submitted. They are submitted by these 
organizations who say, ``We want to be on that guideline 
clearinghouse'', and we have them reviewed by experts to 
determine whether they are evidence-based--and if they are, 
they go in.
    Mr. Miller. And physicians have access to this over the 
Internet?
    Dr. Eisenberg. They sure do. The site is www.guideline.gov. 
Actually physicians and nurses and other health care 
professionals have access to it, but we also found that, like 
the Physician's Desk Reference, the lay public wanted access to 
it, as well. So we have asked each of these groups who have 
developed these guidelines to tell us if there is a patient 
version, and if there is a patient version, then we put a 
button on the Web site so that, if you are patient and you want 
to read the patient version, you can click there, and it takes 
you to the Web site of the organization that developed the 
guideline, and you can read the patient version. So it is not a 
Federal guideline, but we give people easy access to it.
    Mr. Miller. Do you analyze the hits or source of such?
    Dr. Eisenberg. We have analyzed it to some extent. We 
stopped counting hits because we realized that hits were an 
overstatement of the number of people who are really using it. 
What we do now is we count what the experts call visits, and we 
are getting about 4,000 visits per day now. The average length 
of time that someone is spending on one of these visits is 
about 7 or 8 minutes. So they are really spending some time 
there. If we counted just hits where people fly by, it would be 
in the millions.
    Mr. Miller. Mostly it is the professionals rather than 
laypersons?
    Dr. Eisenberg. We don't know, because we don't think it is 
appropriate for us to ask people who they are. We made a 
decision early on that we weren't going to make people sign up 
for this. So all we know is what their suffix is, if they are 
.gov or .edu or a .org or a .com, and it is a relative 
limitation, but we felt that the advantages of both privacy and 
making people feel that they had easy access made it better to 
do this.
    Now, we do have an evaluation going on of the guideline 
clearinghouse, and we will know within a few months better than 
we know now through this evaluator how people are using it and 
what they think the strengths and weaknesses are of it.
    Mr. Miller. How much is available for the layperson? It is 
primarily designed the professional?
    Dr. Eisenberg. Primarily.
    Mr. Miller. And how much are you moving towards 
availability so Chairman Porter and I can understand what it 
says?
    Dr. Eisenberg. Well, I think if you went to the site and 
you looked for whether or not there was a patient version and 
clicked to that, you would certainly understand the patient 
version. My guess is, knowing that you are in the health care 
field, that you would understand some of the clinical versions 
as well. But we decided--at this point at least--not to develop 
a separate site that is patient-oriented, in part because many 
of the organizations haven't written guidelines for the 
patients, and we are just going to accommodate people's access 
to the guidelines that are available.
    Mr. Miller. That is certainly the high priority right now. 
It is focused toward the professional.
    Dr. Eisenberg. That is right.
    Mr. Miller. Let me ask, if I may, one more question, Mr. 
Chairman.
    You mentioned information technology. I used to be chairman 
of the board of our local hospital, Manatee Hospital in 
Bradenton, back in the 1980s for a number of years. So I follow 
it with a little interest. I was amazed, as you said, they are 
very slow in applying information technology. I mean, they had 
the most advanced technology in imaging technology--I mean, 
there are areas, but yet you know the bookkeeping offices were 
fine, and they have some tests--I have seen where they have the 
bedside and all that, but it has never really caught on. Well, 
it is just too expensive. Maybe the crisis, like all this drug 
interaction problem, so much of it, just get the technology in 
there.
    That doesn't solve the whole problem, I recognize. Maybe 
that is what it is going to take, a crisis, especially with the 
labor markets. I mean, you know, is this moving faster--I 
haven't been in the hospital in the past couple of years to 
watch this, but I mean, am I correct? You made the comment 
actually that they were very lax in the past.
    Dr. Eisenberg. Well, having been there for my whole career 
until 3 years ago, I can share a few problems with you. One is 
there haven't been enterprise-wide systems built except in some 
circumstances that would allow you to hook up the business 
office and the lab people. And so one of the things we need to 
do is to develop the kind of terminology that allows these 
systems to talk to one another. We also need to test out the 
systems that are used to convince the hospital decision-makers 
that it will enhance quality, and for the public then to ask 
whether or not those systems are in place when they go to the 
hospital or when they are choosing hospitals.
    But even if you just look at the bottom line, one of the 
most striking conclusions that comes out of the Institute of 
Medicine report is that the savings would be between $17 
billion and $29 billion per year in just reducing errors, not 
to mention the fact that you can get the patient through the 
system faster if you have a computerized system and attract 
more people to your hospital by making it more attractive. So 
we are optimistic that by pushing this field along, it will be 
responsive, either on a quality basis or on a cost basis. But 
we have to convince people that the evidence is there, that it 
will pay off for them right now. They are skeptical.
    Mr. Miller. It is amazing it hasn't moved faster. Every 
sector of our economy has moved fast. It is fascinating all the 
things they can do. So maybe this is good, it can help push 
them along. It is a huge dollar investment, but it is a lot 
less today than it was 15 years ago. You would think the 
software makers and all that would have--the size of this 
industry is gigantic.
    Dr. Eisenberg. It is emerging. A number of people have 
called us since this issue of medical errors came out and said, 
``We think we have a great product, how do we get it tested so 
we can do research and prove that it works,'' and we explained 
to them how the grant application process works. There are a 
lot of people who have products that are emerging and that they 
think will make a difference, but the proof isn't there, and if 
you are a skeptic, you would ask for the proof that it is 
either going to save you money or it is going to improve 
quality of care. And even as enthusiastic as I am about it, I 
would have to admit, the evidence isn't there because the 
research hasn't been done.
    Mr. Miller. Thank you very much. I am sorry I have to 
leave, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Miller.
    Dr. Eisenberg, thank you for your very kind and generous 
comments regarding my service. You, too, apparently at the end 
of this year will be returning to a different life; is that 
true?
    Dr. Eisenberg. I was appointed by the Clinton 
administration, it is true.
    Mr. Porter. Does that mean--I ought to know this, I have 
been around long enough. Does that mean you automatically 
submit your resignation to the next administration, whoever it 
is?
    Dr. Eisenberg. I have never been through this, but that is 
what they tell me happens.
    Mr. Porter. Would you rather stay?
    Dr. Eisenberg. I would love to stay in this job. It is a 
terrific position.
    Mr. Porter. I just want to say you have done an absolutely 
terrific job there and have accomplished a great deal and 
raised the focus of the Agency in ways that we had hoped you 
would and even better. And now you have a reauthorization, a 
new name, a new mission, a new title, and I think the 
opportunities for really changing some of the results in our 
society through the work that your Agency does are even 
increased more. So we hope you do stay. You are doing a great 
job there.

                           Diagnostic Errors

    Let me ask about diagnostic errors. You raised the question 
of medical errors. In the report language in the Balanced 
Budget Act of 1997, there was language that urged your Agency 
to support research that looks at misdiagnoses, such as 
cancers, in order to attempt to identify ways to improve 
diagnostic accuracy. Have you done anything in that area, and 
if so, what it is, and what progress has been made?
    Dr. Eisenberg. We have actually. I think what we have done 
actually is to go beyond what we were asked to do. We have a 
project that was submitted to us recently that reviewed five 
different diagnostic problems in direct response to the request 
in 1997, and so that will be available very soon.
    But we have gone beyond that because of at least two 
initiatives. One of them is the U.S. Preventive Services Task 
Force, which we support. It is looking at the accuracy of 
diagnostic testing for screening and is looking at a number of 
tests as they proceed to look at what works and what doesn't 
work in prevention. And secondly, the Evidence-based Practice 
Centers that I mentioned to have given us an opportunity to 
respond to questions from the outside when people want to know 
more about the accuracy of diagnostic tests.
    We took one on that was really quite difficult that has to 
do with the new testing for cervical cancer. Because there are 
several new tests, people weren't sure which ones were best in 
which circumstances, and so we asked a group to do an analysis 
of that, a group at Duke, who did an analysis. It has been 
released, and it has been well received. So we are very 
enthusiastic about that program, because the question of what 
works and what doesn't work isn't just for treatments, of 
course, it is for diagnostic tests as well.

                         In-home Renal Dialysis

    Mr. Porter. I may be inaccurate in this, but it seems to me 
that fairly recently we have developed the means of doing home 
renal dialysis, and renal dialysis is a major component of 
health care costs in our country, as I understand it, 
particularly for victims of diabetes. Have you done any work in 
this area as to the effectiveness and safety of these kinds of 
devices? My understanding is they aren't appropriate for every 
patient, obviously, but there is a fairly substantial 
population that could benefit from this, and if so, what kind 
of cost savings might be associated with doing renal dialysis 
at home?
    Dr. Eisenberg. There was a patient outcome research team at 
Johns Hopkins led by Neil Powe which has looked at the question 
of dialysis and has studied a number of aspects of dialysis, 
including the home versus center question for dialysis, looking 
at particular drugs that are used for patients on dialysis to 
get their red blood cell count up to help them with their 
anemia and when that should be used for them. As I mentioned 
earlier, we just recently had a project funded that looks at 
ways in which people on dialysis get back to work, and I don't 
recall--I just read that two weekends ago--that it addressed 
the home versus center question, but it may well have.
    So we haven't, to my recollection, in the past 3 or 4 years 
done a head-to-head analysis of home versus center dialysis, 
but have looked at the various components that would allow you 
to compare home versus center dialysis.
    One of the important issues in home dialysis is also the 
connection that the person who has home dialysis has with the 
ongoing primary care setting, and one of the things that we 
have been very interested in is the relationship between 
referral care, between specialty care and primary care 
services. That is another issue that we have continued to be 
interested in, and not just for this disease, but for others, 
as well.

                              Informatics

    Mr. Porter. Thank you.
    One of the common budget themes is increased funding for 
informatics and information technology. You are requesting $10 
million for these activities, half of which is to be used to 
support the use of information technology to improve patient 
care. I had a visit to my Deerfield office recently by a 
constituent with a palm-held electronic prescription device. 
This device was like a Palm Pilot. It was small enough to be 
carried by a physician, and instead of writing the prescription 
on a piece of paper, the physician would write the prescription 
on the electronic device, which would input it immediately and 
automatically to the dispenser. The device would also, as I 
understand it, look at the patient's other pharmaceuticals and 
protect against an inappropriate prescription or one that might 
otherwise be dangerous. Have you done any study of this, and 
what do you think would be the impact on reducing medical 
errors through a device like this?
    Dr. Eisenberg. Well, first, we have done research on the 
use of computers for improving accuracy in prescribing. One 
study that was done at the Wishard Hospital, which is part of 
the University of Indiana system, demonstrated that the 
prescribing errors are reduced when you use a computerized 
system. To go from that stand-alone computer to a hand-held 
device is an easy leap conceptually. Although we haven't 
supported research in that area yet, somehow those guys who 
visited you got our name, too. Maybe you gave it to them, but 
they were among those who have been calling us up saying they 
have an answer to the errors issue. In fact, Dr. Simpson met 
with them a couple of days ago and told them how to go about 
applying for grants to demonstrate the effectiveness of their 
program.
    We do have, as part of our SBIR grants, which you know go 
to for-profit organizations, focused on this kind of technology 
because we thought that was a place where it made sense for our 
Agency to sponsor not just the sort of purer research that we 
would fund through a traditional research study section, but 
also to have special reviews for the SBIR. And we intend to 
continue to do that.
    Lisa, you may want to say more about your visit from the 
fellows from the Chicago area.
    Dr. Simpson. I would just comment again on any evidence of 
holding this Palm Pilot and actually going through some sort of 
pediatric prescriptions I am familiar with. It seemed very 
user-friendly. And one of the things we do know from research 
is that often one of the barriers to the implementation and 
diffusion of these technologies into clinical practice is their 
usability: Can they be integrated into the flow of clinical 
practice as opposed to taking a physician away from what they 
are doing? And so I think they have really taken that barrier 
head on, and I think it could be very exciting to see how this 
technology could potentially help care in many different 
situations.
    Mr. Porter. This is the Allscripts group?
    Dr. Simpson. Yes.
    Mr. Porter. I assumed we were talking about the same. I did 
not send them to you. They got there on their own.
    Dr. Eisenberg. It is nice to know people know about us now.
    Mr. Porter. They are very resourceful, I think.
    Dr. Eisenberg. May I just add one thing to that, because it 
does raise another issue, which I think is a very important 
one. I serve as the operating chair of a group called the 
Quality Interagency Coordination Task Force, which is a task 
force of Federal agencies who are interested in health care 
quality. We meet about every 6 weeks and talk about ways in 
which different agencies can work together. One of the work 
groups of that task force is on information technology, because 
the fact is that the VA and the Defense Department are ahead of 
the private sector in the use of the kind of information 
technology that we help to evaluate and move into the private 
sector, as well. And the VA is already using in some sites a 
hand-held device to do what you are describing. I don't know if 
it is the Allscripts program or not, but they are testing it, 
and we are working with the VA so that we can be sure that gets 
translated into the private sector as quickly as is appropriate 
for that to happen.
    Mr. Porter. This may follow on to that. The other half of 
your informatics request is to improve the quality of privacy 
and confidentiality of patient data collected from providers 
and health care systems. As you know, medical privacy is an 
extremely important issue, and as you pointed out in your 
testimony, the role of computers in reducing medical errors is 
one that can't be overlooked. There is no question that we need 
systems that can provide research and policy-makers with 
health-related information, but at the same time protects the 
privacy of individuals. Is your Agency developing systems that 
will provide health data while protecting patient 
confidentiality, or are you more involved in testing the 
effectiveness of systems that were developed by someone else?
    Dr. Eisenberg. We are much more involved in the latter, 
testing systems that were developed by others. However, we 
believe that we need to provide national leadership in a role 
that could be described as convening to stimulate the private 
sector to move in the directions that you are describing. And 
so we, for example, have asked the Institute of Medicine to 
convene a group of experts to look at ways in which information 
that is used in health care systems can be made available for 
research so that it can be reviewed by institutional review 
boards and kept confidential while still being accessible for 
the research purposes. That is where we see our role at this 
point.
    We do hope that we get some applications from individuals 
who have ideas about ways of doing this better so that they can 
be tested, and some of this money that we have requested could 
be used to test and evaluate those plans.
    Mr. Porter. The Agency was also urged to support research 
that would examine a national cross-section of risk management 
models and analyze the effect of these models on patient safety 
and clinical outcomes. What has been done in this area?
    Dr. Eisenberg. We have met with the insurance people to 
discuss what can be learned about risk management in order to 
decrease errors and to improve patient safety, and we have come 
to the conclusion which is that, while risk management may be 
used in some hospitals to reduce errors, unfortunately in most 
hospitals we are afraid that it might be used for purposes of 
just being sure that the lawyers in the hospital know where the 
incident reports are. In fact, I have a personal incident, not 
one of my personal stories, but I was asked to go on the Diane 
Rehm show to talk about errors right when the report from the 
Institute of Medicine came out, and a nurse called. She 
described an event that occurred, and I asked her in this talk 
show, ``What did you do about it?'' She said, ``Well, I was 
asked to fill out an incident report.'' I said, ``Well, do you 
know where the incident report went?'' And she said, ``Well, I 
think it went to the legal office.'' And I said, ``Did it go to 
the quality assurance office, too?'' And she said, ``No, I 
don't think so.''
    The point really is that traditional risk management in 
most hospitals has not been used for quality improvement. It 
has not been part of the feedback loop. And one of the things 
we feel most strongly about, having been encouraged to begin to 
look at this, is that we have to turn risk management into a 
tool, not just to help the hospital with its liability profile, 
but also to help it to decrease the errors in the first place, 
to make it a part of the feedback system so that risk 
management truly is managing risk to the patient, not just risk 
to the hospital.

                        Improving worker health

    Mr. Porter. Your proposal on improving worker health is 
made up of three parts. I can see where two of the three parts 
are certainly things your Agency does and should do. These are 
research-related to improving the quality of health care 
delivery systems and research on the outcomes and effectiveness 
of clinical intervention. The third part, research on the 
quality of the health care workplace, is not really your 
jurisdiction, is it? To me it sounds more like research that 
should be done by NIOSH rather than AHRQ. Can you describe this 
request in further detail and tell us why it is something you 
would do rather than NIOSH, and did this request originate 
within your Agency, or did it come to you as part of your pass-
back?
    Dr. Eisenberg. Well, the idea of focusing on the quality of 
the health care workplace as it affects the quality of care 
that is provided is the focus that we are taking. The way in 
which the quality of the workplace affects the health care 
workers' own health and the care they provide is something that 
has not been a focus for NIOSH. This actually came out of a 
conference that was sponsored by the QuIC, this Quality 
Interagency Coordination Task Force, that I mentioned. We had a 
conference in which we brought together people from all kinds 
of perspectives about the hospital or the nursing home as a 
place to work, to try to understand what its impact is on the 
quality of care, and we heard people testify about many 
factors, such as about residents who are working 80-hour weeks 
and how that interfered with their own quality of life, and how 
that has an effect on the quality of care they provide.
    Staffing ratios for nurses is something we have actually 
studied over the past couple of years and demonstrated that 
there are risks if staffing ratios become more stringent, that 
there are implications for the quality of care. In fact, a 
nurse who is now at New York University worked with us a couple 
of years ago on that. It was published and, in fact, has the 
hospital industry asking us to do more because all it did was 
show a relationship, but didn't go so far as to say there was a 
threshold at which more errors would occur.
    There were people who were at the meeting who were also 
talking about issues having to do with what they call the built 
environment, which was a new term for me, but architects 
apparently for some time have been focusing on the way in which 
the hospital is built as a place to work and how that enables 
health care workers to provide higher quality care.
    There were a number of other examples, but for us the focus 
is definitely on the health care for the patient and how the 
environment for the health care worker has an effect on that.
    Were it not for the issue of how it affects health care 
quality, I would agree that it is not part of our domain, but 
we are going to focus on the outcomes as it relates to the care 
that is provided.
    Mr. Porter. Well, now that you say it, it makes sense to 
me. A few months ago I was out to the new Northwestern Memorial 
Hospital in Chicago, and Gary Mecklenburg, the CEO, said that 
they brought their architects in, worked extensively with the 
people that worked in the hospital, that is, the nurses and 
physicians and others, to design their patient rooms and their 
visiting rooms and the like; built several of them, used them 
and then went back through it again and redesigned them when 
they saw how they worked before they built their final model 
for the entire hospital. So they were actually using the 
experience of using the new designs and seeing how they worked 
out and what changes ought to be made before they actually put 
it into place, which I thought was tremendously innovative, and 
how much better can you do it than that to get it right before 
you get it locked into place.
    Dr. Eisenberg. Well, that is exactly the point, and it 
makes me think back to the call rooms I used to sleep in when I 
was a resident and how miserable they were, and I am sure that 
I could have provided better quality care if I had gotten some 
sleep. But sleeping with six other people in the room made it a 
little difficult when everybody was getting their calls.
    Some of it is as logical as that, but it is in some ways 
like the information technology question that Mr. Miller asked. 
Some of this is logical, but if it is so logical, why haven't 
hospitals done this? We think that if we can demonstrate the 
impact on quality, it will increase not only an understanding 
of which of these interventions works best, just like the 
clinical intervention, but it also might encourage hospitals to 
adopt them, the translating research into practice part.
    Mr. Porter. It is kind of fascinating to me. This is kind 
of an aside, but if you think about how we do things today and 
how we did them 20 years ago or even 10 years ago, it is so 
exciting to see how much better we think about things, imagine 
things, plan things, work them out and make certain that we are 
doing them right, and get into the details of them that we 
never used to get into. It seems to me that that, in and of 
itself, has a great deal to do with how our economy is 
expanding, along with information technology and changes in our 
basic structure of business. But we are doing things so much 
better and doing them with such great detail, and all of that 
is helping not only the final product, but helping our economy 
grow, and it seems to me that at some reasonably close time, we 
will be able to export a lot of this to other societies and 
help them do the same thing.

                      INTERNATIONAL COLLABORATIONS

    How much interface do you have with a counterpart, if there 
is one, in the European Community or any of the countries in 
Europe and in other countries around the world that are fairly 
advanced in their health care systems?
    Dr. Eisenberg. Well, we consider ourselves principally to 
be a domestic agency, so our focus is here, but we have learned 
that these issues don't honor boundaries, as you imply, and so 
when there have been opportunities for us to mutually learn 
with other countries, we have taken advantage of it.
    With the United Kingdom we have a program that was actually 
stimulated by the Commonwealth Fund, who got us together with 
the National Health Service, and we now have a program that we 
are about to initiate with the National Health Service to look 
at just these kinds of issues with them. The same is the case 
with France, with Australia. The World Health Organization has 
asked us if we would help them to address these issues for all 
countries, and one of the things I am proud of is that we are 
now starting to get recognized worldwide as a worldwide 
resource in this way. In the same way that the CDC is for 
infections and the NIH is for basic science, people are 
starting to turn to us when it comes to issues of health care 
quality and access and cost.
    Mr. Porter. Well, you keep doing the job you are doing, Dr. 
Eisenberg, and we will be there much sooner rather than later. 
And if you want to stay, and you have said you are really 
interested in the job that you are doing, I hope that you will 
stay and keep doing it because we think you are doing wonderful 
things, and obviously we want to do our best to provide the 
resources to you to accomplish them. So keep up the good work. 
Thank you.
    Subcommittee will stand in recess until 10:30 tomorrow.
    [The following questions were submitted to be answered for 
the record:]




                                       Thursday, February 10, 2000.

              HEALTH RESOURCES AND SERVICES ADMINISTRATION

                               WITNESSES

DR. CLAUDE E. FOX, ADMINISTRATOR, HRSA
          ACCOMPANIED BY:
THOMAS G. MORFORD, DEPUTY ADMINISTRATOR, HEALTH RESOURCES AND SERVICES 
    ADMINISTRATION; DR. MARILYN H. GASTON, ASSOCIATE ADMINISTRATOR, 
    BUREAU OF PRIMARY HEALTH CARE; DR. PETER VAN DYCK, ASSOCIATE 
    ADMINISTRATOR, MATERNAL AND CHILD HEALTH BUREAU, DR. JOSEPH F. 
    O'NEILL, ASSOCIATE ADMINISTRATOR, HIV/AIDS BUREAU; DR. DENA PUSKIN, 
    DIRECTOR, OFFICE FOR THE ADVANCEMENT OF TELEHEALTH; DR. WAYNE W. 
    MYERS, DIRECTOR, OFFICE OF RURAL HEALTH POLICY; DR. VINCENT C. 
    ROGERS, ASSOCIATE ADMINISTRATOR, BUREAU OF HEALTH PROFESSIONS; JON 
    NELSON, DIRECTOR, OFFICE OF SPECIAL PROGRAMS; DENNIS P. WILLIAMS, 
    DEPUTY ASSISTANT SECRETARY, BUDGET, DEPARTMENT OF HEALTH AND HUMAN 
    SERVICES

                       Introduction of Witnesses

    Mr. Porter. The subcommittee will come to order. We 
continue our hearings on the appropriations for the Department 
of Health and Human Services with the Health Resources and 
Services Administration. We are pleased to welcome Dr. Claude 
Fox, the Administrator who presides over a budget that probably 
is greater than most foreign countries.
    Dr. Fox, you are doing a fine job there. We welcome you. 
Why don't you proceed with your statement. In fact, why don't 
you introduce the people that are with you and then proceed 
with your statement and then we will have questions.
    Dr. Fox. Thank you, Mr. Chairman, and members of the 
distinguished committee. On my right is Dr. Joseph O'Neill, 
head of the HIV/AIDS Bureau. Next to him is Jon Nelson, who is 
head of our Office of Special Programs, which includes the 
noncontroversial organ transplant programs and our health 
facilities. Next to him is Dr. Peter van Dyck, who is over our 
Maternal and Child Health Bureau. Next to him is Mr. Dennis 
Williams, Deputy Assistant Secretary for Management and Budget 
from the Secretary's office. On my left, Mr. Tom Morford, 
Deputy Administrator for the agency; Dr. Marilyn Gaston, who is 
head of the Bureau of Primary Health Care; Dr. Vince Rogers, 
who is head of the Bureau of Health Professions; Dr. Wayne 
Myers, who is head of the Office of Rural Health; and Dr. Dena 
Puskin, who is head of our Office for the Advancement of 
Telehealth.

                           Opening Statement

    Again, thank you for letting us come and talk about the 
HRSA 2001 budget. I am not going to read my prepared statement. 
You have it. I would like to make just a few opening comments.
    I would like to begin by saying, as NIH is about research 
and FDA is about food and drug safety, HRSA is about access to 
health care. That is really the thread that runs throughout our 
entire agency. We are now having an increase of about 100,000 
people per month added to the list of uninsured in this 
country. As long as we continue to have that problem, we will 
have a need for HRSA programs.
    We have basically four strategies within the agency and all 
of our budget falls under those one way or the other. The first 
is to decrease barriers to health care, the second is to 
decrease racial disparities, the third is to improve quality of 
care, and the fourth is to improve public health and health 
systems of care. All of our performance measures are arrayed 
under those and tied to the budget in one way or the other to 
those four strategies.
    I am just going to mention the increases. I know the 
committee may want to talk about other parts of the budget, but 
the increases we are asking for in the 2001 budget include--the 
first is an increase of $125 million that is spread across the 
titles for Ryan White, which will provide increased care in one 
way or the other to some 23,500 patients. We are asking for an 
additional $50 million for community health centers to provide 
an increase in some 100,000 patients there. We are asking for 
$35 million for the family planning program, which will provide 
an increase of about 500,000 patients who will receive care in 
that program.
    Our rural health outreach line item has an increase of $3 
million, which includes mainly increases in grants to the Delta 
project. That is the Sixth State Delta Project, not just the 
Mississippi Delta Project.
    We have an additional $100 million for the health care for 
the uninsured and this is a project to look at helping states 
not with necessarily funding direct care but funding components 
of a system that will help them provide more care to people 
that are between that line of where they can provide--buy 
insurance and between Medicaid and try to get at that group.
    We have a $5 million increase for organ donation, and we 
have an additional $25 million for the Ricky Ray Hemophilia 
HIV-AIDS program. So all those are really arrayed in one way or 
another around increasing the capacity of the system.
    In looking at the workforce, we have $40 million increase 
requested for pediatric GME to support training of 
pediatricians, both general pediatricians and specialists. We 
have $5 million both in the Centers of Excellence and the 
Health Careers Opportunity Program under health professions to 
improve the funding for groups like historically black colleges 
and universities and to improve funding for minority 
representation within the health professions.
    We have a lot of other programs that we are not requesting 
an increase in, and I would be interested in taking questions 
on any of them.
    Let me just say finally before I stop, Mr. Chairman, and 
take questions, I want to thank you in particular for your 
leadership and for your support of HRSA and HRSA programs over 
the years. The 3 years I have been in HRSA, I certainly have 
really been impressed by the commitment of this committee to 
try to do the right thing and to help us address the access 
issues and we are going to miss you.
    Mr. Porter. Dr. Fox, you are very kind to say that.
    [The statement of Dr. Fox follows:]




                               UNINSURED

    Mr. Porter. I think we, all of us on this subcommittee and 
within the administration, have the same goals in mind. How we 
get there we may differ a little bit, but I think we really do 
try to work together and find ways of getting the job done for 
the American people.
    Let me ask about the uninsured, 100,000 a month increase. 
Do we know where the increase is coming from? Is it illegal 
aliens? Is it small businesses who can no longer cover their 
workers? Where is the genesis of this?
    Dr. Fox. It is all of the above. We know part of it is the 
immigration. Part of it is businesses have dropped insurance, 
and part of it is we have not done the best job I think we 
could have done in the welfare reform issue when the people 
came off TANF but yet could keep their Medicaid. I think there 
is going to be a lot more attention given to try to make sure 
those groups still qualify for Medicaid and may think they do 
not because of the fact they do not get welfare anymore. That 
is another area where we have lost ground. It is really a 
combination of all of the above.
    Mr. Porter. What do you say to people who say to you, look, 
if you provide access to the U.S. health care system for 
illegal aliens straight out so that everyone who is here gets 
served the same way, you are going to attract even more illegal 
aliens. What do you say when they say that?
    Dr. Fox. Let me comment on that, Mr. Chairman, by saying I 
have made three, maybe four visits to the border in the last 3 
years, and we are a country that is very porous and the 
infectious disease issue, the problems around drug resistant 
tuberculosis, the other types of things that affect us as a 
society, we all share the cost for. My own personal belief is 
one of the reasons we ought to try to make sure everybody is in 
a health care system somewhere is that the burden of that 
disease, the cost of the burden is shared by all the American 
people when we do not. I tend to believe that burden is greater 
when people have to seek an emergency room and a child ends up 
dead or with a mastoid infection rather than having a simple 
ear infection treated on the front end. We all pay more when an 
individual has a stroke because their high blood pressure did 
not get treated; and we end up having to take care of them for 
the rest of their life because they cannot even stand to go to 
the bathroom by themselves or we have a hundred schoolchildren 
infected with drug resistant tuberculosis because we did not do 
a good job on the front treating the TB case.
    I think we need to provide health care to make sure people 
are healthy and do it on the front end, good primary care that 
is comprehensive including the prevention type of aspects 
rather than provided on the rear end where we are providing 
tertiary care and the most expensive care we could possibly 
give.

                        CHILDREN'S HOSPITALS GME

    Mr. Porter. I agree with you, but I don't think that is a 
complete answer to the contention that it is just going to 
drive our own health care costs through the roof and attract 
more illegal aliens. People say we cannot provide for the 
entire world, and obviously that is correct.
    On the issue of pediatricians, we put in $40 million for 
residents training at children's hospitals last year. How much 
of the need is met by that? Are we at one-fifth or one-fourth 
or what?
    Dr. Fox. Let me say the overall discrepancy between what is 
called freestanding children hospitals--and there are 60 of 
those that don't--are not able to bill for Medicare through 
another facility and gain access to the Medicare GME. That 
amount on a per resident basis, the pediatric hospitals have 
received about $374 compared to a hospital that does bill for 
Medicare it is $23,000. That is the direct GME. So if $40 
million were allocated to direct GME, it would bring us halfway 
to that point of $10,000 per resident where the hospitals are 
getting $23,000.
    Mr. Porter. An additional $40 million?
    Dr. Fox. The $40 million we have now.
    Mr. Porter. If we put $40 million more in, have we got it 
done?
    Dr. Fox. With $80 million, it would put us almost where the 
direct GME is for the Medicare hospitals. What we do not have 
is equity for the indirect GME, and that is another probably 
$200 million plus. With the additional $40 million the 
administration is asking for this year would put us at direct 
and indirect GME together at about 25 percent equity.

                      ORGAN TRANSPLANT REGULATIONS

    Mr. Porter. As you know, I am going to talk about organ 
allocations. I want you to explain this from your standpoint. I 
have not even asked the staff to explain it to me, but last 
year, it seemed to me, the bill had two different provisions in 
it on a delay in implementing the organ allocation regulation. 
Obviously, you are following one or the other of those, if I am 
correct. How did we get where we are, and where are we?
    Dr. Fox. In regard to the regulation or in regard to the 
Bilirakis bill?
    Mr. Porter. With regard to the regulation.
    Dr. Fox. I think the bottom line is the regulation was out 
there. The dilemma is that everybody thinks--and this is in my 
opinion, a statistical improbability--everybody thinks that 
somehow they are going to be adversely affected by this 
regulation. It is not true. I think it was more of a fear of 
the unknown. There actually was no policy per se around organ 
allocation. What we laid out were a series of principles by 
which we asked the transplant community to come forward with a 
policy. We received a lot of comments, as you know.
    The regulation had been delayed several times. We went back 
and made a number--and I think even the transplant groups will 
admit we made a number of significant changes in the 
regulation. We provided, I think, a lot more flexibility. We 
clarified for the transplant community areas that they were 
concerned about. For instance, sickest first. We said from the 
start it was not intended to be people who would not benefit by 
transplant. We clarified that with language.
    There was concern that we were trying to ship organs from 
coast to coast, and we wanted to ship organs to the outside 
limits of their viability. It is not the case. We went back and 
we clarified that. We made a number of I think very, very 
positive changes in the regulation; and I think from the 
scientific standpoint, the regulation is pretty consistent with 
what we received as far as comments from the transplant 
committee.
    I looked at the comments from the transplant surgeons. We 
did 85 percent of what they suggested, and I think for the 
physicians it was somewhere in that same neighborhood. I think 
that part of it is really resolved. I think the issue now that 
is still of concern is the Secretary's authority and that is 
the main thing. We actually only received six comments from the 
last time the regulation was put out for comment.
    Mr. Porter. Did you do the 21 days and 21 days that was 
suggested in one part of the bill?
    Dr. Fox. Mr. Chairman, we have done it as the congressional 
language instructed.
    Mr. Porter. I had a problem with how congressional language 
got there because we had an agreement with the Secretary that 
was 21 and 21 and then we had another provision stuck in----
    Dr. Fox. We followed the congressional language.
    [The information follows:]

    The Department was required to delay the effective date of 
the OPTN regulations until March 16, 2000, by a rider that was 
inserted into the Ticket to Work and Work Incentives 
Improvement Act, signed by the President on December 17, 1999. 
This rider overrode a provision that had been agreed upon by 
the Department and the Appropriations Committees and included 
in the Department's FY 2000 Appropriations Act, signed by the 
President on November 29, 1999, that called for a delay in the 
effective date of the regulations for 42 days to allow the 
Department time for further discussions with the transplant 
community. The Department had agreed to this delay in spite of 
the fact that there had been two prior delays of the rule 
directed by the Congress, the first for 90 days in the summer 
of 1998 and then for a year beginning in October of 1998. As 
part of the one year moratorium the Congress directed that the 
Institute of Medicine, ``in consultation with the Secretary,'' 
conduct a review of the current policies of the OPTN and final 
rule, and, further, directed the Secretary to ``conduct a 
series of discussions with the OPTN regarding the final rule, 
during the one year moratorium. The Department made a number of 
changes to the April 2, 1998 regulation based on comments 
received on the regulation, input from the transplant 
community, and the IOM report recommendations (published in 
July 1999). These changes were published in the Federal 
Register in the form of an Amended Final Regulation on October 
20, 1999.

                       INCREASING ORGAN DONATION

    Mr. Porter. If you had a good supply of organs, you would 
not have an allocation problem. What are you doing to increase 
procurement and encourage more donation?
    Dr. Fox. Well, we have 66,000 people on the waiting list 
now. As you probably know, 5,000 people a year die waiting for 
a transplant. Congress gave us additional money in the budget 
last year for donation. We put out $5 million in competitive 
grants to look at new models. We have made some direct grants 
to groups like the organ procurement organizations, to the 
American Bar Association, to try to make sure people in their 
living wills and instructions to their families think about 
transplantation to community health centers. So we have 
actually put out about $6.5 million of competitive grants.
    The administration also had an organ initiative even before 
this. This is on top of what we would do in the faith community 
and with other professional groups like the American Academy of 
Physicians and others. We have a broad administrative 
initiative on donation. We have the conditions of participation 
that have gone into effect, requiring that all deaths be 
referred for counseling. We know that probably 50 percent of 
families that do not consent would if counselled appropriately. 
And then we have the donation grant program made available by 
the money that you provided us, Mr. Chairman.
    Mr. Porter. Is the additional $5 million for additional 
grants? Is that what the $5 million is for?
    Dr. Fox. Yes. And actually to take the lessons learned out 
of the first grants--the money initially for the $5 million is 
to look at what are the things that work. It is not money to 
replicate it. The $5 million will be a combination of new 
grants to try to look at best practices and implementation of 
the things we find that work.
    Mr. Porter. Thank you, Dr. Fox. Mr. Hoyer.

                         DENTISTRY TRAINING CUT

    Mr. Hoyer. Thank you very much. I am sure there will be a 
lot of other questions on the organ transplants. I noticed you 
said Mr. Nelson had the noncontroversial items of that which 
led me to believe he must have a very, very small 
responsibility if you are only doing the noncontroversial 
aspects of that.
    Dr. Fox. His hair was coal black 2 years ago.
    Mr. Hoyer. All of us, I know, dealt with that extensively 
last year, and we in Maryland as you know are very, very 
concerned as well as I know an awful lot of other states are in 
terms of availability.
    Let me go, however, to some other issues. Dentist and 
dentistry training. My understanding, because of our success, 
is that we have now cut back on the program. Is that correct?
    Dr. Fox. Well, it is an issue that the administration felt 
possibly the market would take care of. There is a number of 
things going on in the dental area, as you may be aware. There 
are some 10 dental schools that have closed over the last 
several years at the same time that we have had an increased 
demand to get into dental schools, primarily because the cost 
of dental education. We are also facing an increased need with 
the SCHIP program with kids coming in that are going to need 
dental services and with all of us baby boomers who are going 
to go into retirement hopefully with our teeth, not maybe like 
our parents did. We are going to want dental services. There is 
obviously a need there. I think it was an area that the 
administration felt with the budget restraints was not 
something they were going to be able to fund this year.

                            DENTAL SERVICES

    Mr. Hoyer. Without asking you your analysis of the 
consequences of that, let me go to another subject which you 
sort of referenced on the SCHIP program. Other than Head Start 
where we have a specific--my wife always thought it somewhat 
ironic that the most specific Federal program we had dealing 
with dental services dealt with baby teeth. And as soon as we 
got the permanent teeth, we no longer gave much attention to 
them. Other than the head Start program, what dental services 
do we have available?
    Dr. Fox. Well, there is a lot of dental services available 
through this agency. Dr. Gaston's community health centers, a 
large number of them have direct dental clinics where we have 
corps, National Health Service Corps dentists who provide care 
to both adults and children. We do not have enough dental 
clinics, but we certainly have dental clinics in a number of 
the community health centers. We have, as you have already 
alluded, dental training programs through the Bureau of Health 
Professions.
    We have a dental component to the Ryan White program. We 
actually fund dental care to people with AIDS through the Ryan 
White program, and then we support through the Maternal and 
Child Health program funding not only for services to children 
with special needs but also some of the preventive aspects like 
fluoridation and sealants.
    I might also mention we are also in discussions with ACF, 
the Administration for Children and Families, in trying to look 
at, trying to increase our interface with Head Start and doing 
a better job with that.
    Mr. Hoyer. Doctor, let me ask, because we had ACF just 
yesterday, was it--time flies--and I am very, very interested 
in the coordinated services aspect of services, particularly--
well, to children and families and she also indicated that 
there was substantial discussion between ACF and Department of 
Ed. It is my view--you may have heard me say this before--that 
we need to expand our coordinated services through our 
elementary schools. I have referenced baby teeth. We need 
permanent teeth and health services generally in the community 
setting because one of the things I am also concerned about is 
access to health care. It is nice to have it available, but an 
awful lot of people in rural communities in particular have a 
very difficult time accessing them because of transportation.
    Dr. Fox. Mr. Hoyer, I would just tell you that we started 3 
years ago a broad oral health initiative at HRSA. I would be 
glad to get you the details. It includes looking at the 
infrastructure. Do we have public health dentists that are 
looking at the community? Are we doing the things in prevention 
around fluoridation and sealants that we need to? What are we 
doing in the training area? What are we doing in direct 
service? What are we doing with HCFA with the reimbursement 
level? What can we do to encourage private dentists to provide 
more care to Medicaid and other low-income individuals?
    We are basically involved in all of that, and we have spent 
a lot of time on it. In fact, we have actually with HCFA pooled 
together our dental assets into a group that we now have 
identified within each regional office, dental folks that can 
relate to the states. There is a lot going on. I would love to 
have the opportunity to get you that information.

                          COORDINATED SERVICES

    Mr. Hoyer. Good. Let me emphasize that, while I have 
mentioned dental health, my concern on the coordinated services 
aspect is for the whole gamut of health services that are 
available and to the extent that we can focus on availability 
in elementary schools which are the only structures that we 
have in every community in America, now, obviously the more 
rural community, the further the particular structure is from--
or the distances are. But nevertheless, they are the only 
structure that we have in every community in America. To the 
extent that we can coordinate your services, HHS generally, 
Department of Education, Department of Transportation, we can, 
I think, facilitate accessing those services.
    Dr. Fox. We would love to do that. As you know, we have 
also between two, the bureau's primary health care and MCH, we 
fund school health services per se and actually go in and help 
schools set those up; and this committee has been very gracious 
in supporting that. And again, we are trying to think about, 
particularly with ACF and other agencies, what we can do 
together. We actually had a retreat with ACF about a month ago 
and have agreed to put together a series of work groups to 
follow up to make sure we have a staff dialogue to look at ways 
we can work better together across all of the programs. We are 
serving a lot of the same populations. We are not duplicating 
services, but we are providing different things to the same 
folks. We need to do a better job of coordinating that. I think 
you are going to see that happen.
    Mr. Hoyer. Excellent. I do not know what my time is.
    Mr. Porter. 31 seconds.

                         BENEFITS FOR CHILDREN

    Mr. Hoyer. Let me ask you the last question. How are the 
community integrated service systems which you, we, have been 
referencing and the children's insurance program in particular, 
which now the administration wants to expand, which I applaud 
and I think is absolutely essential, particularly in light of 
the figures of 100,000 coming off every month as the chairman 
mentioned, how have we met the needs of qualified children?
    Dr. Fox. Well, we are using a portion of those monies as 
you just alluded to look at the--what is happening around the 
SCHIP program, both enrollment and the quality of services. 
HRSA now has taken over the White House hotline, toll-free line 
that people can call in that goes back immediately to the State 
offices to help them get on the program. We are also looking at 
what services are being provided across the States. For 
instance, what is the level of mental health benefits to 
children. This is a real opportunity, particularly with the 
problems with youth violence to have a financing mechanism for 
mental health services for kids. So we are trying to look at 
that. We are trying to look at oral health issues, what are 
States doing around oral health.
    We are actually using those monies to assess what is out 
there, what is the capacity of the providers to give those 
services, particularly in the area of dental. So there is a lot 
going on. We are using those monies to try to basically get at 
those questions, and that is only a part of what we are doing. 
We are doing some other things in child health and other areas, 
but that is a part of what we are doing with those monies.
    Mr. Hoyer. Thank you, Doctor. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Hoyer. Mrs. Northup.

                               UNINSURED

    Mrs. Northup. Thank you. Doctor, first of all let me just 
mention the big picture that concerns me and then I will ask 
you a couple of specific questions. It seems to me like what we 
are doing is plugging holes all the time rather than moving in 
a big picture. Yes, as people come off of Medicaid, there is a 
problem.
    And one of the problems first of all is that it does not 
seem like we have the information as to what percentage of that 
population has access to a health insurance policy but does not 
choose to take it, either because they feel that they cannot 
afford it or the employee takes it for the individual but not 
for the family. Now we are making a huge effort to use Medicaid 
money, public money to provide some sort of co-payment 
assistance, whether it is co-payment in the policy, co-payment 
in the care. And there is nobody that has an incentive to move 
this population into the insurance policy.
    I mean, if an employer offers $100 a month towards the 
care, if an employee does not choose to take it, hey, the 
employer saves $100 a month. Why would he try to push somebody 
into taking the policy? If the employee is used to Medicaid 
where it is a no co-payment system, pays for transportation and 
so forth, it is possible that private insurance does not look 
like a good deal at all to him and he may be young or she may 
be young. She may hope that she will be protected, maybe 
healthy.
    So, number one, it seems to me like we need a real good 
idea of the uninsured, how many have access to a group policy 
but either feel that they cannot afford it or feel that they 
can only afford it for themselves and not their families. And I 
guess my first question is, are there any studies like that and 
I guess I would mean independent studies, not studies that want 
to then prove that what we need is to then expand the Medicaid 
options to people? I mean, my goal, which may be different than 
the administration's goal, is to move as many people as 
possible into the affordable market system, private insurance, 
and to make that affordable by subsidies and tax relief, you 
know, credits and so forth rather than keep expanding the 
Medicaid floor so that fewer people make that transition. It is 
a tough transition.
    Dr. Fox. I would say that our goal is by whatever means 
necessary to make sure that there is the smallest number of 
people that have no health coverage. Obviously, whatever 
mechanism is available--you are aware the SCHIP program 
actually has a prohibition. If there is any kind of insurance, 
even if it is underinsurance that a child has, they are 
disqualified from SCHIP. We know that a lot of the kids in the 
course of getting on SCHIP are actually finding out that they 
are eligible for Medicaid.
    The only place in my agency that we have the ability to 
actually buy insurance or to pay for insurance or something 
along the line which you alluded is in the Title II Ryan White. 
The Congress has given us the authority there to buy insurance 
for people affected with AIDS who can actually then turn around 
and make sure the benefits are inclusive enough that they can 
get medication and health care.

                         HEALTH CARE INSURANCE

    Mrs. Northup. Let me go back to the children. Is it not 
true that states have the option to use Medicaid monies to 
subsidize insurance policies?
    Dr. Fox. You would have to ask HCFA that. I am not sure 
about that.
    Mrs. Northup. I just asked the Secretary, I thought, this 
question yesterday. I think that they really drove the SCHIP 
money away from private insurance. They are now beginning to 
give waivers to allow that, but in fact they originally turned 
down Kentucky. Now I think it might be reopened. But I am 
almost sure that I have asked this question in Kentucky and up 
here and that they cannot.
    Here is what my problem is. You are a planning agency. You 
are a big-picture agency, and I would ask you to use all of the 
efforts you can to help us expand the available insurance. 
Let's face it. We need all the medical money we can. And if 
employers of small businesses who all tell me they are not 
dropping their availability to health insurance plans--it is 
just that fewer employees are opting to take it because they 
either feel that they cannot afford it, which is the number one 
issue, or cannot expand it to their family. Let me say again 
employers have no incentive to encourage their employees to 
take it because they save the money they would have paid for 
their portion of the payment. Think if every business 
contributed their share for every employee as they do for the 
ones that opted how much medical money we would add to the 
system.
    Dr. Fox. Again, I think philosophically we would agree with 
you that we need to maximize every opportunity for people to 
get health care coverage. Again, I would say that is probably 
an HCFA question about whether or not that is allowable under 
Medicaid, but I don't know the answer to that.
    Mrs. Northup. When you say you would maximize every 
opportunity, do you have a preference to maximize the expanding 
of the government-run programs, or do you mean to try to 
transition people in--making it as easy as possible into a 
private program?
    Dr. Fox. I think, again, we want to utilize whatever is 
there and maximize the resources. I will tell you that the 
programs in Alabama where I was State health commissioner for 6 
years went with a non-Medicaid SCHIP program, and they have 
done quite well in enrollment. They have done quite well in 
provider recruitment because of a lot of reasons, one because 
it is not perceived as a Medicaid program.
    Two, it is also the rates they are paying are equivalent to 
Blue Cross-Blue Shield. My only concern would be that whatever 
we do that we do not place barriers to low-income families. To 
many of these people $5 to $10 a month is a significant amount 
of money to them. That would be my only concern. Other than 
that, I think again, if we can maximize private resources so 
that public resources can go to those who do not have 
availability, I would be supportive of it.

                         PATIENTS RIGHT TO SUE

    Mrs. Northup. Let me ask you another question. There is 
quite a debate in this Congress right now about what every 
single health insurance policy should include. One of them is 
the right to sue your HMO. So now we have Medicaid HMOs. For 
example, in Louisville. Would you believe that it would help 
expand services and quality of coverage if everybody in those 
programs are able to sue the government, sue the community 
health centers that make those decisions? Do you believe the 
same provisions, for example, direct access to any specialist, 
any willing provider, any level of licensure should be 
included? For example, if you want to go to the chiropractor 
instead of the orthopedist, or to see an optometrist, marriage 
counselor, if you cover any mental health, would you want to 
put exactly those same provisions on all of our public 
services?
    Dr. Fox. We have supported a patient's ability and right to 
sue community health centers. We have never been opposed to 
that.
    Mrs. Northup. But that is for somebody that is a doctor 
that is in there. I am talking about services that you would 
turn down. For example, in our HMO in Louisville, if you have a 
certain illness or if you have a need, you might decide that 
you want to go to the marriage counselor. They might decide 
that there would be another way to handle it. Could somebody 
sue you if then----
    Dr. Fox. Again, I don't know exactly how to answer the 
question except to say I think certainly we are supportive of a 
patient's right to recourse of an adverse medical event. I 
think that ought to be true because I think in essence that 
keeps the system honest.
    Mrs. Northrup. And if you are in the public health system, 
you have access to any willing provider, any level of 
licensure, direct access to specialists.
    Dr. Fox. This is an issue this country and this Congress 
has not grappled with. We have a limited amount of medical 
resources in this country. My own personal belief is that we 
should start with funding primary comprehensive preventive and 
early treatment so that we prevent people from navigating to 
the other. If somebody even at 90, 95 can get a bypass or get a 
transplant, I think it is an issue where you put the resources. 
That is a huge public debate. I do not think we have resolved 
it in this country. I do not think what you are talking about 
is really a component of this.
    Mrs. Northup. I agree. I just think if we argue that the 
private sector should pay for things that we are not willing to 
pay for, for the services that we actually purchase as a 
government, then we are being duplicitous here. Thank you. I 
know my time is up.
    Mr. Porter. Thank you, Mrs. Northup. Ms. Pelosi.

                       MINORITY AIDS INITIATIVES

    Ms. Pelosi. Thank you very much, Mr. Chairman.
    Dr. Fox, welcome. Thank you for your excellent testimony 
and your fine service. It is always a pleasure to welcome Dr. 
O'Neill. I take pride in our UCSF alumni in Washington, D.C., 
and Steny and I both take pride in Dr. Rogers from Baltimore.
    Dr. Fox, I am just going to continue a line of questioning 
that I have had with others in the administration about 
minority health initiatives. Last year we built on our efforts 
to target funding to fight HIV and AIDS in minority 
communities. Can you provide an update on the implementation of 
HRSA's minority AIDS initiatives and what you are doing with 
the additional Ryan White CARE ACT Title III funds? Do you have 
sufficient funds to transition Title III planning grants and 
funding for actual programs in needy communities?
    Dr. Fox. I will comment and Dr. O'Neill may want to come in 
and supplement. We actually have about $74 million that we 
placed into minority health issues to the Ryan white program. 
That is really sprinkled throughout all of the titles of Ryan 
White. Specifically in Title III, this current year we are 
funding 60 planning grants to communities of color for Title 
III for the early intervention primary care and as I recall 27 
grants to rural and underserved areas.
    In the 2001 budget, what we have proposed is actually 
transitioning those grants, those 70 some-odd grants into 
service so the first year--generally what we do on the Title 
III is the first year's planning and then we move to 
implementation where they actually are providing service. So we 
are proposing to actually move those 60 grants, the planning 
grants, to communities of color to service grants and then 
funding another 60 planning grants to communities of color that 
obviously depend on the following year, we would move to 
service as well.
    So we have, I think, a very good plan in Title III, are 
specifically making an effort with those 60 grants. I would 
share with you statistics you probably already know but maybe 
some others do not, that is, in the Ryan White program about 65 
percent of the total clientele are minorities and in Title IV 
the mothers and children it is about 80 percent. So overall we 
are serving a large percent of minorities, but we are putting 
money above and beyond that into the efforts that I just 
mentioned. I do not know if Joe will want to supplement.
    Dr. O'Neill. I just had a couple of additional comments on 
the overall performance of the Ryan White Act in this arena. We 
were able to this year conduct our own analysis of the--there 
was a large national study, which I know, Congresswoman, you 
are familiar with, the HCFA study that looked at all people 
with HIV disease in this country who are in CARE to try and 
understand what their situation is. It is a very important 
study and it has given us some very important information. We 
were able to do our own analysis of those data to look at the 
Ryan--to look at the group of people in this country who are in 
CARE who receive their care from Ryan White-funded providers. I 
think we all have a lot to be proud of when we look at that 
data.
    What we have learned is that the annual income of more than 
half of CARE Act supported clients has never exceeded $25,000 a 
year. The CARE Act clients are less likely to have a college 
education than even clients on Medicaid, that Ryan White 
clients are more likely to be minorities, more likely to be 
poor, more likely to be women. So we have I think been 
successful with the support of this committee in really getting 
in addition to the important work from the minority--
categorical minority initiatives just with the CARE Act in 
general are really places these resources where they are most 
needed in this country.
    Ms. Pelosi. I appreciate your contribution to this 
discussion because we try to make it very clear as we do 
outreach into the minority community about the minority AIDS 
initiative that this is a resource, but it is by no means the 
only resource; and that it is a gateway to the fuller Ryan 
White CARE money, because if you look at it as additionally, it 
looks like a good amount of money; but if you look at it as 
their pot, it looks like very little. Do not think of it as 
that is ours and the rest is everybody else's. It is all yours. 
This is yours in addition.

                                  ADAP

    I would like to pursue the ADAP--we all know the importance 
of the ADAP program and the drug therapies. Last year's 
hearing, Dr. Fox, you informed the subcommittee that several 
States lacked ADAP resources to provide therapeutic drugs to 
all low-income people needing them. For example, Kansas and 
Kentucky. I am sorry our colleague has gone, have announced 
plans to close ADAP enrollment and South Dakota's formulary 
does not include protease inhibitors. Can you update us on this 
situation and what other States have individuals in need of 
ADAP who are not able to obtain services.
    Dr. Fox. Certainly. I just want to say at the beginning I 
am not sure that the data we have is indicative of what is 
going on out there. We certainly have a lot of information 
around ADAP. We know from the number of States just from 1997 
to 1999 that now participate in ADAP have doubled. We have gone 
up to 45, 47 States now that participate in ADAP/Ryan White. 
And that is double what it was 2 years ago. So we have done a 
good job there.
    We have a prime vendor program now where we actually 
further lowered the cost of drugs for ADAP, and we also provide 
some other technical--so we have done some things both to 
increase the number that are involved and lower the cost. 
Having said that, they are--as far as we know, there are very 
few states that have a waiting list and no States have asked 
for an advancement on their ADAP money. And I think it is for a 
combination of reasons. The reason I say I am not sure it is 
reflective of what is going on is, our supposition from what 
our staff tell us out there, there are a lot of States because 
they know more funds are still limited do not keep waiting 
lists or the waiting list is very small.
    We believe based on the number that--I mean, if you look at 
Medicaid serves 160,000 on ADAP and we served last year I think 
it was around 65,000. It is going up every year. Based on the 
CDC numbers for the number that we know, estimated number that 
are out there, that have AIDS and then the number that know it, 
there is still a significant population of people who would 
benefit by ADAP and the fact we do not have a waiting list is 
really almost an anomaly; but we are very concerned, and we 
think that again there is still a lot of people that are not 
in, and I think Joe can give you the figures. We believe there 
is still a fair number of people not even in medical care, much 
less getting the medications.
    Dr. O'Neill. I would just add a few points to this really 
important question. The first thing is all States, just to be 
clear, all States participate in the ADAP program. One of the 
accomplishments that Dr. Fox was referring to this year is in 
the area of States becoming more efficient in getting the 
lowest cost possible of purchasing those drugs. So now it is 47 
out of the 50 States are participating in the 340B drug pricing 
programs. All States participate in ADAP. Almost all States are 
now participating in the Federal Cost Saving Program. Those 
that are not are required to prove to us that they can get even 
a lower price than that.
    We actually have just to give you the specific numbers--
five States are reporting to us that they have waiting lists 
for ADAP. Two States in addition are reporting to us that they 
have waiting lists for protease inhibitors. As Dr. Fox said, 
just looking at the issue of a waiting list is not really an 
adequate way of understanding the need for the ADAP program. I 
call your attention to the fact--and this is an important 
concept when we think about the overall HIV-AIDS epidemic--we 
are still seeing about 40,000 new HIV cases every year in this 
country. That is new infections.
    These new treatments that we have have enabled us to 
decrease the mortality associated with that. In 1998 we had 
17,000 deaths from AIDS, which was a decrease because of the 
new treatments. That leaves us with 23 new--23,000 new people 
in this country with HIV disease.
    Ms. Pelosi. Mostly young?
    Dr. O'Neill. They are more typically going to be young. 
They are more typically going to be minority. They are more 
typically going to be women. We can supply you with this data, 
but more typically they are going to be people who are going to 
be in need of public services.
    Ms. Pelosi. When I say young, I mean under 25.
    Dr. O'Neill. Yes. So even looking at that group of every 
year adding 23,000 more people in this country who are more 
likely to be young, more likely to need the ADAP program, right 
there you see a very significant need for continuation of this 
program. I would be happy to supply additional written 
information on that.
    Ms. Pelosi. Thank you very much to all of you for your 
work. Dr. Fox, thank you. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Ms. Pelosi. Mr. Miller.

                           RICKY RAY PROGRAM

    Mr. Miller. Good morning, Dr. Fox. Let me start with a 
question about the Ricky Ray program. Rick Ray was a friend of 
mine. His family was. He actually died in December 1992, my 
first election. I actually got sworn in in January. But the 
family lived there and has moved away since then, so I partly 
have a special interest in it. Thank you for including the $100 
million. Would you give me an update of what is going on--where 
are you going with the program?
    Dr. Fox. We are moving forward. We have received some 6,000 
notices of intent to file. We estimate that probably 8 to 
10,000 petitions that we will receive once this program is up 
and running. We are in the process of putting the mechanics in 
place. We have consulted the Office of General Counsel and the 
Department. As you probably know, there has been some question 
about should we pay a little bit to everybody or pay the full 
amount to the first comers and I think it is the opinion of the 
Office of General Counsel that we should probably pay the full 
amount to the ones that we can afford and work down the list. 
So we are in the process of setting that up.
    We fully believe that we will be able to make the first 
payments before the end of this year. We are asking for, 
however, the ability to extend the dollars that Congress gave 
us this year into next year and for the 2001 appropriation to 
not place a time limit on the expenditure of the dollars 
because we are going to have to go through all 8 or 10,000 of 
the petitions. I did not realize how much process is involved. 
We will get this programming up and running, but we want to be 
able to get the money spent and not have any of it lapse. Right 
now we are planning on moving forward with this. We have a plan 
to reimburse at a $100,000 probably 750 of the families that 
come in this year and then probably up to 900 or so next year. 
If there is more money, obviously we will go as far as the 
money goes.
    Mr. Miller. Is that a problem of how you prioritize or is 
it a random process?
    Dr. Fox. Partitioners will be processed in the order they 
are received. As completed petitions are received, we will 
review them and recommend compassionate payments. It is random. 
I think what again the Department has decided to do is it 
really will be a lottery of those that come in that meet the 
qualifications, and we will take a lottery for the first 700, 
750; and we think that is probably the fairest way to go and 
OGC has certainly recommended that.
    Mr. Miller. This program expires in 3 years? 5 years?
    Dr. Fox. In 2003. I think there are 3 more years to file 
and up to 4 years to make the payments, I believe.
    Mr. Miller. It has got to get funded every year to the full 
amount.
    Dr. Fox. Right, if we are to provide payments to all 
eligible petitioners.

                  state child health insurance program

    Mr. Miller. On the SCHIP program, how is it working? How is 
your opinion of it?
    Dr. Fox. It is extremely variable. I think overall we are 
very pleased that Congress saw fit to pass this program. I 
think it was a great expansion. Some states have done a real 
good job of getting the kids in. South Carolina, for example, 
has done a lot through the schools. Other States have moved in 
the right direction. States are shortening their applications. 
California certainly made a significant change in shortening 
the applications. I think quite frankly the kinks are getting 
worked out. Part of the issue, again, has been just the 
mechanics trying to figure out what works on enrollment. It is 
not always the most expensive thing. It is usually some of the 
cheaper things that work and make sure the kids get in. What we 
are finding, for instance, in my State of Alabama, we are 
finding a large number of kids Medicaid eligible that when we 
go out and look for the SCHIP program kids. I think it is 
working generally pretty well.
    Mr. Miller. Would a pharmaceutical coverage program for 
seniors work at the state level pattern to some extent? 
Obviously, a different age population but to provide the drug 
coverage for the prescription needy-type of person, which is a 
person who has got the high prescription costs.
    Dr. Fox. I think the dilemma there would be--the 
mechanics--we were involved in the policy development of the 
SCHIP program. We have 50 different child health programs out 
there and, you know, that--I think that is going to become 
increasingly a problem as we have a mobile society. And one of 
the dilemmas for us, for instance, in our migrant health 
centers is as people move from State to State in a migrant 
stream, a lot of them come to Florida, they lose their coverage 
and I think that--my own druthers would be try to do something 
nationally that allowed portability where if you moved across 
state lines, it did not make any difference; you were able to 
maintain your medication coverage. I do not think the 
administration has taken a position on it. If they have, I am 
not aware of it.
    Mr. Miller. Because if it is working, you know, in those 50 
different programs, at least they are trying innovative 
different ways and some are more successful. If there was only 
one way in Washington, you may have picked one that was not 
quite as successful. That is the advantage of having 50 to 
give--the best ones surface and the States learn from each 
other.
    Dr. Fox. The States are the laboratory. Some States are 
charging premiums. Some are not. Some are charging more 
premiums. Some are not. There is some difference in the 
benefits, the co-pays. So again, I think we are anxious to 
learn from what works and what does not work.

                          SENIOR DRUG BENEFIT

    Mr. Miller. It seems like that model has some possibility 
for the seniors. We are talking about the senior drug benefit. 
Would you comment on what programs you have for drug purchasing 
that could be applied for seniors. You do some through the 
states. You were talking with Ms. Pelosi about it.
    Dr. Fox. Again, the ADAP program is a huge drug program for 
low income uninsured persons with HIV and AIDS. Of course, most 
of those are not involving seniors. I guess the major one 
involving seniors would be through our community health 
centers.
    Mr. Miller. I am talking about the concept of being able to 
buy them at discount and pass it on to the consumer, basically.
    Dr. Fox. I think it is a great idea. When I was deputy 
commissioner, State of Mississippi, we actually bought high-
pressure drugs for low-income patients in the State, and we 
bought them for a fraction of what--in fact, we could treat a 
patient for a year for $100. So we really could lower the cost. 
I would certainly think that would be something that the 
Government ought to look at because you just stretch the dollar 
a little bit further than you could otherwise. If you do 
competitively, I would think you could bring the cost down.
    The Whip program is a prime example of a national program 
that has gone competitive and again we were paying $1.56 a can 
for Whip formula when I was in Alabama; and when we bid it, we 
bid it down to 29 cents a can. So you can achieve some cost 
savings. Again, I think it just stretches the dollar further so 
you can serve more people.
    Mr. Miller. Thank you. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Miller. Mr. Bonilla.

                             HEALTH CENTERS

    Mr. Bonilla. Thank you, Chairman. Dr. Fox, I am going to 
probably sound like a broken record because we have talked 
about this before, year in and year out. This subject in the 
broken record will be health centers again. I want to also 
thank my friend, Dr. Gaston, for all of the help that she has 
been in this area over the years.
    Once again, I feel very strongly that the budget request by 
the President is not enough. We have seen what the health 
centers are doing out there in impoverished areas, how much of 
a wonderful increase there has been in the number of people 
that have been served by the health centers. We do appreciate 
the request for $50 million more; but I would strongly suspect 
with the work that you all have done in this area that you 
probably agree with me in that that is not enough. That is why 
I am going to ask you on the Record what was your professional 
budget request for health centers.
    Dr. Fox. If you look at the number over the 2000 
appropriation, we asked for $197 million more.
    Mr. Bonilla. So you must be disappointed as well.
    Dr. Fox. The administration had to make some tough 
decisions about where to put the money. That was the 
administration's assessment of where it--there are other needs 
beyond that, but I think that is what we asked for.
    Mr. Bonilla. I want to tell you I am not speaking for 
myself but for all the folks out there being served by the 
health centers appreciate the fact that you see things the way 
we do out on the ground in many of these areas where these 
health centers are making a difference. Did you want to add 
anything to that, Dr. Gaston?
    Dr. Gaston. No.

                           HEALTH PROFESSIONS

    Mr. Bonilla. Thank you. Thank you very much. I have only 
one other question on health professions, which is probably 
another part of my broken record that I sing each year.
    Health professions, as you know, has provided an increase 
and improved access to vital health care for many Americans 
across the nation. On page 137 of your budget justification, 
you make the excellent point that it does, and I quote you 
here, ``it does not matter how well insured an individual may 
be if there is no qualified health care professional available 
and willing to provide health care.''.
    I have some real-life examples as well. For example, health 
centers trying to serve children. There is no pediatrician in 
about a 12-county area back in south and west Texas. So there 
are a lot of real-life stories that we can talk about probably 
all morning if we had time. The health professionals trained in 
HRSA programs are the ones that are willing to be there.
    As you point out, health professions graduates are 3 to 10 
times more likely to practice in medically underserved 
communities. That is why I am also increasingly frustrated that 
the President has a pattern of not supporting health 
professions. I am dismayed the President is again cutting the 
program by about $84 million based on our calculation and 
zeroing out or significantly cutting important programs like 
the primary care and dental program, the allied health program 
and the geriatric program.
    Dr. Fox, what was your professional budget justification 
for the three health professions' clusters as you submitted to 
the Secretary?
    Dr. Fox. The geriatrics program I think we actually asked 
to double that program. You may be aware we estimate there is 
probably the need for three times the number of geriatric 
specialists out there. The population age has doubled in the 
last 30 years, and one of the things that we are concerned 
about is that there are some places where the market is not 
going to take care of this problem and geriatrics is one of 
them. You think with where the demographics is going, people 
would rush to train for geriatrics. It is not happening.
    Our program, I think, is one of the few Federally funded 
programs to train geriatricians so we would ask for a doubling 
of that program. We asked for an increase in the--hang on just 
a second. We did ask for an increase in the primary care 
medicine and dentistry [family practice and internal medicine] 
line item. We asked for $6 million more than in fiscal year 
2000. I actually have some charts if the committee would be 
interested that lay out what you just alluded to that our 
programs do work. They may be small, but they work.
    And half of the family practice, internal medicine and 
pediatricians, that we train at Bureau of Health Professions 
have gone to underserved areas and that is opposed to 10 
percent nationally. We do five times for internists and 
pediatricians and for allied health it is 60 percent of those 
folks go into underserved areas. And as far as them being 
minorities, about a fourth of the internists that we train--
excuse me, 40 percent of the internists we train are minorities 
as opposed to 10 percent nationally.
    I would like to make those charts available to the 
committee if it is agreeable. We did ask for additional money, 
$6 million, in the primary care and medicine. We asked for, 
again, a doubling of the geriatric programs; and I have 
forgotten the other one you asked me about, Congressman. I am 
sorry.
    Mr. Bonilla. I asked you about the primary care and 
dentistry, public health workforce development and community 
based linkages.
    Dr. Fox. The public health, I think the dentistry, primary 
care--and those are in one--and we did ask for a $6 million 
increase there. The public health line item we have--we asked 
for a $56 million increase. That line item is about $9 million 
now. The dilemma there is that in public health, half of all 
deaths in this country are related to lifestyle, public 
health--one-half. And yet we have 400 of the 500,000 public 
health workers in this country that have no formal training. I 
am not talking about a master's degree. I am talking about any 
formal training, certification. Four out of the five.
    The problem is that is a first line of defense. So we asked 
for a $56 million increase in that line item. I think it is a 
huge area of unmet need in this country. My background is in 
public health, as you probably know. I worked for 20-something 
years at the local and State level in public health. Most of 
the workforce is not adequately trained.
    Mr. Bonilla. I am just delighted to know that you all 
recognize programs that are working out there and as you 
pointed out for relatively low cost and for the return we get 
on each dollar, so we will be looking to adjust some of these 
figures and hope that you all will help us do that. And I 
appreciate again what Dr. Gaston and yourself have done to 
support the health centers and health professions throughout 
the years because they do make a difference. I may have some 
additional questions to submit for the Record. I would 
appreciate a response to those. Thank you very much.
    Mr. Porter. Thank you, Mr. Bonilla. Mrs. Lowey.

                        COMMUNITY ACCESS GRANTS

    Mrs. Lowey. I want to join my colleagues in welcoming you, 
Dr. Fox, and thank all the colleagues that you have brought 
along and your outstanding and important work. I want to 
revisit a topic you and I discussed last year, which is 
coordination among safety net providers. We have appropriated 
$25 million for the community-access grants to enhance 
coordination among community-based providers, like community 
health centers, teaching hospitals, public hospitals. This is 
something I think is so critical. I have been talking about it 
for years and I support it very, very strongly.
    My understanding is that since most of these institutions 
are partially funded through other Federal programs, this 
probably is intended to provide funds directly to communities 
without a lot of strings and the dollars can be used to cover 
some of the gaps between existing programs. I know that two 
providers in my area, Queens Hospital and Westchester Medical 
Center, have welcomed this initiative. They are very positive 
about it.
    Two questions. I wonder if you can inform us of models of 
locally directing funding that are already at work. I know this 
is a new program, but are there good models upon which this can 
be based? And two, how will HRSA reach out to communities to 
let them know that community-access grants are available to 
them and give them the kind of technical assistance they will 
need to make it work the way we would all like it to work?
    Dr. Fox. I would like to answer the second question first, 
and then I will comment on the first part. I am going to 
probably flip it to Dr. Gaston. Let me say, to begin with, we 
are going to have six preapplication workshops across the 
country, regional workshops, where we will invite people to 
come in, talk about the program, what are going to be the 
requirements and basically answer questions to provide that. We 
are also working directly with the groups. For instance, we 
have met with the Public Hospital Association; we have met with 
the Ascension Health Group, the Catholic charities hospitals. 
These are some groups that we normally do not deal with very 
much.
    We have a whole series of organizations both--some that 
have reputations here in D.C., Community Health Centers is one; 
but there are others as well that we have already met with that 
we will be providing. We have actually used these groups to 
help us think through what are going to be the requirements. So 
we will be providing information back to them as well as going 
to the six preapplication workshops regionally we will be 
announcing and publicizing.
    We also, let me just tell you, envision this program as 
being very flexible. I think there are some criteria. One is we 
want to look at actually minimizing dollars for direct service 
at least on the front end. We are not saying we would not 
provide for any direct, but it is really more--because this 
money we envision it as maybe 1 or 2 years, and it is really to 
try to put the pieces out there. If you have a community that 
lacks one piece and they could with that piece add care to 
another 3,000 patients or whatever and something that could be 
funded; and then you can take the money and go somewhere else 
or we do not know if the money will be there 5 years from now, 
that really we envision that maybe 12, 24 months of funding.
    The second is what--how can we leverage other money. Is 
there other monies could be brought to bear if we put our money 
in. The third is sustainability. The fourth is collaboration. 
We do not plan to fund competing applications from the same 
community for the same population. What we want is to see the 
providers get together. We want to fund broad systems that look 
at the whole spectrum of care from primary care; and I use the 
example of a woman who has a prevention exam and finds a knot 
in her breast who then has to have surgery and then has to have 
chemotherapy so everything from prevention to tertiary care, 
how can we tie that together. So there are a series of things 
like that.
    We are going to be very flexible. We are realizing, for 
instance, in rural communities that the amount of grant money 
needs to be smaller in order to give a rural community some 
money to do some things they need to do; in a bigger community 
or with a bigger system, there may be more money needed. So we 
plan to have a lot of flexibility in this program. It is going 
to be real interesting I think to see the applications. There 
are communities that have done this.
    We actually have an effort within the agency called 100 
Percent Access Campaign that is in Dr. Gaston's bureau where we 
actually are going in and now working with communities, for 
instance, one in North Carolina where what we have done is gone 
in with the doctors and said--there are 20 doctors, 50 doctors 
in the community and say, if everybody--what we have said for 
years, if everybody took one piece of the uninsured and 
committed to see these number of patients and we spread it so 
nobody gets killed, that, you know, it is doable. And we 
actually have a community where that has been done, where the 
medical society has done that. We have Tampa, where Tampa has 
gone in and passed a local tax that is funding urgent care.
    So there are some, I think, examples of communities where 
that has been done; and we actually are even before this money 
came down the pike we are moving in this area in our primary 
health care bureau. So it is very constant with what we were 
already involved in, and Dr. Gaston may want to comment.
    Dr. Gaston. I am as excited as you are in talking about the 
models. There is one of a number in New York, and Sunset Park 
in Brooklyn which is an excellent example of everyone in that 
community working together from the public hospital, community 
health centers, et cetera. But even extending to the churches, 
to the business community, everyone in that community is 
involved in trying to get access to care and decrease those 
disparities. As a matter of fact, at this point in time, they 
are 90 percent of the 100,000 people in that area that wouldn't 
have access if they weren't all doing this together. That is an 
excellent example.
    Another one is Denver Health and Hospitals out in Colorado. 
Dr. Fox mentioned the Hillsborough one. There are a number of 
rural ones also. One in southern Ohio. So there are models all 
across the country. For the past 3 years, we have made a 
concerted effort to try to find them. That is why we are so 
excited about your question, and try to replicate them to match 
communities that want them to replicate and then we take a 
small amount of dollars, and again the glue money to try to 
help that happen.
    Mrs. Lowey. I am getting more and more excited because I 
can--based upon your response, Dr. Fox, we have a group in 
Queens County actually which has grown to about 60 physicians, 
and all they need is very little money for office space, little 
personnel. They are now servicing, doing exactly what you are 
suggesting those who are caught in the middle who are not on 
Medicaid, who can't afford insurance, and most of the doctors 
in the area are happy to help provide the services. They just 
don't want to be bothered with paperwork. So all they want to 
do--not all they want to do. They have an office set up and 
they were looking for some seed money, and I couldn't find it, 
but this is perfect. We are going to pursue it. So I thank you. 
This is exactly what we want. I am delighted about that and I 
am sure we will be following up with you. I thank you.
    Another area, the state of New York is in its third year of 
implementing a Medicaid 1115 waiver. The movement of patients 
into mandatory managed care has been tough on Medicaid 
recipients, and, frankly, on the health centers that primarily 
serve them. Community health centers receive less than their 
cost because Medicaid managed plans, as you know, do not pay 
health centers the full cost of care. Have you used any funding 
increases to compensate health centers for care that has not 
been reimbursed?
    Dr. Fox. Yes. We committed to do that to this committee and 
to the Congress. We used $40 million last year of the increase 
that you gave us, and we are proposing to use $40 million this 
year if you give us the $50 million increase or if it is more, 
whatever. But we did use a significant part of and actually 
back in '99 we used 44 million in '99. So we have used a 
portion of each one of the increases that Congress has given 
us, and we actually have seen a difference. I think it was last 
year in--go back to '98, about 55 percent of the centers were 
at some risk. Now it is 45 percent and there are only 7 percent 
of the centers that are at serious risk today. So it has made a 
difference. It has helped.
    There are still centers out there that are having a 
problem. Quite frankly what we don't want to see happen, we 
don't want to see States get to the point where the medical 
reimbursement, whether it is through managed care or otherwise 
is so low that we are supplementing the Medicaid patients out 
of 330 money that you are providing us. That is our concern. In 
New York, some of the States are reimbursing what is called 
cost related through the 1115 waiver, and that cost related can 
be as little as 50 percent of the cost of providing care to a 
patient, so it is a real concern of ours. We are working with 
the State and with others. There is a lot of effort going on in 
New York to address that, but the money you provided us has 
been used for that and we appreciate it.
    Mrs. Lowey. I think I am out of time.
    Mr. Porter. I am afraid so. Thank you, Ms. Lowey.
    Mr. Jackson.

                      HEALTH PROFESSIONS PROGRAMS

    Mr. Jackson. Thank you, Mr. Chairman. Thank you, Dr. Fox. 
Welcome to our hearing today. Your health professions budget 
has some very small increases for the health careers 
opportunities program and centers for excellence. Everything 
else is either straightlined or reduced. In fact, you are 
proposing to eliminate three of your programs, training and 
primary care, geriatrics, and health administration. I assume 
you have the evidence that the programs you intend to eliminate 
are ineffective and others are operating at their maximum 
potential.
    Dr. Fox. Mr. Congressman, the programs that we operate in 
the Bureau of Health Professions are quite effective. I guess 
the analogy I would use is we spend in this country about $10 
billion a year in graduate medical education. That is, for the 
most part, non-directed, and yet the $300 million we spent in 
the Bureau of Health Professions is very targeted, and I think 
someone has already alluded that for distribution, that our 
graduates of our programs across the bureau are three to ten 
times more likely to practice in an underserved area, and as 
far as the racial diversity of which we think is a significant 
issue because of the culture competency issues within the 
community, we are two to five times more likely to graduate 
somebody in a racial minority group than a training program 
that is not funded by HRSA. So our programs are very effective 
and we have the data to prove it.
    Mr. Jackson. That is where I am confused. If these programs 
are so effective, why are you eliminating three of them, and in 
effect capping others?
    Dr. Fox. Congressman, this was, again, an administration 
decision about resource allocation and about all the needs that 
exist within the Federal budget. It is certainly not an issue 
about the effectiveness of the programs.
    Mr. Jackson. We recognize, I think, that there are certain 
budget tradeoffs. If these programs are clearly as effective as 
you are saying that they are, I am equally concerned that we 
might be missing some pretty important opportunities. Does the 
President's budget represent your thinking on these programs 
and does it reflect what you requested of the administration?
    Dr. Fox. We actually requested a good bit more in a number 
of the areas. We requested actually for the COEs, for the 
Centers of Excellence, and HCOP we requested about--$17 million 
for COE and $19 million for HCOP. For the primary care and 
medicine and dentistry, we asked for $6 million more. Public 
health work force we asked for $58 million more.
    So again, I would just say it is a small program and we are 
kind of like the salmon swimming upstream; there is a lot of 
water coming against us, but I will tell you the HRSA programs 
work. We feel like Congress gets a good dollar value for what 
it spends in the Bureau of Health Professions.
    Mr. Jackson. I appreciate you clearing that up for us. I 
also want to know your thinking about the National Health 
Services Corps. I read in your budget you are concerned about 
access, about getting scarce health professionals to inner 
cities and rural areas, yet the National Health Services Corps 
budget remains the same every year. Is this because you can't 
expand the corps to take care of some of these needs or is 
there going to be another story about the Administration's 
priorities not allowing a needed program to expand?
    Dr. Fox. Well, I think, again, it is an issue of priorities 
and where to put money. I will tell you on the corps, we fund 
only 15 percent of the scholarship applications that we get. We 
fund 60 percent of the loan applications we get so that if we 
had the dollars, we could fund a good bit more. One of the 
things that the committee may not be aware of, we lose 800 
physicians a year in this country due to death and retirement, 
whatever, and we are only replacing that with 400 corps 
physicians. So you ask me why we have the same number of HPSA 
designations, we are only putting about 400 corps physicians 
back a year; at the same time, we are losing 800 just through 
death and retirement.
    So we are not keeping up with even the attrition that is 
happening in our communities. The corps, I have used the 
example, the corp's rapid response team, if rapid is not a term 
inconsistent with government, but we can actually put corps 
physicians, dentists, nurses out there in a very responsive 
fashion and get them into the communities that are needed but 
again the funding, you are right, the funding has been level. 
It is estimated if we wanted to totally eliminate the HPSA, the 
health profession shortage areas tomorrow, we would need 20,000 
corps personnel, and right now we are putting out about 800 a 
year.

               CONGRESSIONAL BLACK CAUCUS-HISPANIC CAUCUS

    Mr. Jackson. I have one more question in this round if I 
could squeeze it in before we recess. Dr. Fox, last year I 
worked very hard on behalf of the Congressional Black Caucus 
and the Congressional Hispanic Caucus to increase funding for 
minority HIV-AIDS initiative, which, as you well know, provides 
funds for communities of color severely impacted by HIV and 
AIDS. Last month the CDC released a report indicating that men 
of color now account for a greater proportion of AIDS cases 
among men who have sex with men than do white men. With this 
information, I am interested in why HRSA's level of funding for 
the minority HIV-AIDS initiative remains essentially at level 
funding.
    Dr. Fox. Well, the specific targeted dollars is at $74 
million, but we are proposing within the Title III program to 
not only add 60 new planning grants specifically to communities 
of color next year, but we are also proposing to take the 60 
planning grants that were already funded and move them to 
service grants. So we would actually, over time, move to 120 
new primary care sites that would be specifically targeted to 
communities of color. So one of the things I would point out is 
that about 65, 66 percent of our overall funding of Ryan White 
is for minorities.
    Mr. Jackson. It is not necessarily an increase in funding. 
It is a shift in emphasis that is accounting for the 
adjustments.
    Dr. Fox. There are two different components to what we do 
around minorities and AIDS. One is for the Congressional Black 
Caucus. That is about $74 million. But if you take that and put 
that aside, of the rest of the funding, almost 66 percent of 
the rest of our funding is to minorities. So we had a huge 
amount of money go and we are not going to decrease that at any 
point. In fact, a large percent of what Congress gives us in 
the 2001 budget will go for minority funding.
    Mr. Jackson. Thank you, Dr. Fox. Thank you, Mr. Chairman.
    Mr. Porter. Would the gentleman yield.
    Mr. Jackson. Mr. Chairman, I would be happy to yield.
    Mr. Porter. Let me give you my perspective on funding for 
the health professions in the Administration's budget and for a 
number of other items in the Administration's budget. We find 
that the way the President does this is, if it is a priority 
for us, he doesn't fund it or he funds it at a low level 
knowing that we are going to put the money back in. That then 
frees up the money to be put into other accounts so he can 
cover the whole field, so we are not surprised by this at all. 
Whatever is a priority for us, you will find he keeps it very 
low.
    The subcommittee will stand in recess for the vote and then 
we will return.
    Mr. Porter. The subcommittee will come to order. The Chair 
recognizes Mr. Dickey.
    Mr. Dickey. Dr. Fox, are you related to Charles Fox?
    Dr. Fox. I am not.
    Mr. Dickey. Do you know who he is?
    Dr. Fox. This is the guy with the Coast Guard?
    Mr. Dickey. He is now with EPA I think and I am having all 
kinds of problems with him.
    Dr. Fox. No relation whatsoever.

                        COMMUNITY HEALTH CENTERS

    Mr. Dickey. I am concerned about the community health 
centers. 1 million uninsured are going on the market every 
year. I am in the 4th District of Arkansas, the southern part 
of Arkansas. And we have got just all kinds of problems. It is 
like a collision that is taking place. And you have already 
stated that you asked for more money, and we have got an 
inadequate amount. As Henry Bonilla and I try to get more money 
and the chairman, what is the most compelling reason for trying 
to get an additional increase, in your opinion?
    Dr. Fox. Because we will do it when nobody else will. We 
are out there in the communities where nobody else will go. We 
are serving populations nobody else wants to see. And we are 
effective at what we do. I will tell you, Mr. Chairman, and Mr. 
Dickey, we have looked at our performance measures, and I will 
tell you for the health centers, African-American men that come 
in to see us, their blood pressure is controlled three times 
better than anywhere else. We do a better job at controlling 
diabetes. We have I think it is 22 percent less inappropriate 
hospitalizations for Medicaid patients. We know that women that 
come in to see our doctors and our staff in the community 
health centers, high risk women, we are talking about low 
income women who have transportation problems, more of those 
women get screened for breast and cervical cancer than the 
average population.
    Now that is saying something. We do a great job and I would 
say if we have money in this country to put out, we need to put 
it in comprehensive, primary and preventive care that prevents 
the complications down the road, and we do that and we do it 
well.
    Mr. Dickey. Is there any rule of thumb about--let's say if 
we increase--we are not talking about increasing the number 
of--if we add money, we are not talking about increasing the 
number of community health centers, are we?
    Dr. Fox. What we do primarily, Mr. Dickey, is we look first 
at expanding a site the most efficient way, and we want to use 
the money the best we can. The most efficient way is to expand 
a site of an existing health center so that we can go in and 
put--we don't have to rebuild an administrative structure and 
we can go in and do that. So that is what we try to do as long 
as it is within a geographic distance where that can happen. If 
not, then we can go in and put a new center. But we like the 
idea of expanding the existing site of a health center.
    Mr. Dickey. Expanding meaning what?
    Dr. Fox. It is under the same administrative structure 
but----
    Mr. Dickey. More people who are serving?
    Dr. Fox. We expand the number people served.
    Mr. Dickey. No, serving.
    Dr. Fox. Depends again on what you can do. If you have the 
ability to go out and add another site with the same providers, 
we do that.
    Mr. Dickey. I am not getting it across. What I am saying 
is, the money that we would increase being as far as an 
increase, would it add people at each site?
    Dr. Fox. People being served?
    Mr. Dickey. No, people who are serving.
    Dr. Fox. Probably both. It would do both.
    Mr. Dickey. Do you have a comment on that, ma'am?
    Dr. Gaston. Only that I agree. There is no question that we 
do it most efficiently by giving an existing health center 
additional resources for a new access site. It costs less, it 
happens faster, it is more effective and you get the same 
results in this brand new site as you are getting in the older 
sites.
    Mr. Dickey. Is there a rule of thumb about how many miles 
somebody will go to a site--I have 210 miles across my 
district. But is there something that we can use in our arguing 
about this that you need to be so many miles in proximity to 
the needed service area?
    Dr. Fox. I might defer that to Dr. Gaston. I am sure there 
is some rule we use in trying to look at site expansions. We 
don't want to expand beyond the ability of somebody to drive to 
get there. Both the patients as well as the staff--it needs to 
be something that is within a reasonable distance, and I know 
there are some guidelines. I just don't know what they are. I 
think the bottom line is what we want to do is whatever works 
for that community. And if it requires a new site with a new 
health center, with a new corporate structure, if that is what 
has to happen, then we will fund that, but we know it is less 
expensive if we can just fund the site expansion.
    Mr. Dickey. I know how I can do this. I think you asked for 
$196 million.
    Dr. Fox. $197 million.
    Mr. Dickey. What were you going to do with that? How is 
that money going to show up on the ground level?
    Dr. Fox. Again, the way the funding goes now is we fund 
it--the last 3 years are an example. We fund a portion of it 
for those centers that are in economic distress, and we want to 
try and prevent any of it going down the tubes. We fund a 
series of new starts. A portion of that goes for homeless.
    The general money, we have a percent that goes to fund our 
homeless grants. We have a percent that goes for migrant health 
centers. And then we have a percent that goes for school 
health. And then we use portions of it to improve quality of 
care. For instance, we have a major initiative in the area of 
diabetes to make sure that patients that come in are controlled 
the best possible to prevent complications. I can get you the 
breakdown of exactly what we spent, and then we use a portion 
to help integrate the health centers into whatever health 
network is within that community. So it would be a similar 
breakdown the way we fund it, unless the committee has 
instructed us to do otherwise.

                       CRITICAL ACCESS HOSPITALS

    Mr. Dickey. You mentioned one thing about--I want to call 
it critical access hospitals. Is that in that figure?
    Dr. Fox. No, sir. The critical access hospital program is 
actually administered through our Office of Rural Health. I 
pointed the wrong way. Jon is wondering why he has the program 
now. We actually--that program we have seen 67 new hospital 
conversions since we have started with that program. We are 
continuing to work with states, with communities.
    Again, we have not asked for an increase in that. You have 
provided us $25 million. We have asked for another $25 million, 
and we will continue to try to work with States to move that 
along. We have not asked for an increase. It is not part of the 
$197 million that we have asked for for primary care.
    Mr. Dickey. Well, it is going to be a very big--have an 
impact in our area. There is some pros and cons to it but from 
what I have been told, that we are going to have to go into 
that pretty heavily or we are going to lose our hospitals.
    Dr. Fox. Mr. Dickey, I am from Mississippi and I am going 
to meet with the Mississippi governor tomorrow. Let me just 
tell you what I am going to tell him, and that is one of the 
things that States can do is States have the option, through 
Medicaid, also funding at cost for hospitals. The whole idea 
behind the critical access hospital program is that if 
hospitals downsize and limit their services, they can get cost 
base Medicare reimbursement, but States also have the option to 
pull their own lever and to do cost based reimbursement for 
Medicaid. That is under their control as opposed to Medicare 
being under the congressional control. So that is a State 
option if a State wishes to exercise it. Again, Medicare and 
Medicaid together are the two major funding sources for small 
rural hospitals, and those are the two, if you wanted to 
maximize and help them survive, you would want to do. So the 
point being that a State can make its own decisions about 
Medicaid.

                       HEALTH CARE FOR UNINSURED

    Mr. Dickey. One last question. Ms. Lowey talked about 
something she said she didn't know about it, she was going to 
look into, she was talking about getting extra--that her 
doctors just don't want to deal with the paperwork, and there 
could be some extra money. How do we apply for that and what is 
it called?
    Dr. Fox. This is the health care for the uninsured that we 
will be putting out a grant application, and have the regional 
workshops in the spring. Let me give you one example, but some 
of that can be funded possibly through some of our community 
health center money. For instance, in the Mississippi Delta, 
one of the things we are looking at is the ability to go in and 
if we could provide for a set of physicians, let's say, we are 
talking about private doctors maybe will want to take care of 
low income patients. There are a lot of private pharmacy 
programs that are out there that provide medications, but each 
one has a different form, a different process, that if we could 
provide somebody that knew all those different forms and how to 
get at them, so a private doctor could pick up the phone and 
call and say I have a patient who needs medicine for his blood 
pressure, he can't buy it, I am going to see him but he doesn't 
have medication, he doesn't have Medicaid, that we try to look 
at ways to help facilitate that. So we are working through that 
right now in the ten counties of Mississippi Delta. I think 
depending on what your needs are, we have the primary care 
organization in Arkansas could work with you on that. We would 
be glad to help you out in any way we can.
    Mr. Dickey. Who do I contact?
    Dr. Fox. Why don't you just contact Dr. Gaston at the 
bureau and we can put you in contact with the folks in Arkansas 
and get them to working on whatever your specific concerns are.
    Mr. Dickey. Don't forget that Arkansas is in the 
Mississippi Delta, even though we call it Mississippi.
    Dr. Fox. Whatever it takes for the money. The Mississippi 
Delta project actually includes seven States of which even 
Illinois, the tail of Illinois is involved. It is Mississippi, 
Louisiana, Arkansas, Tennessee, Kentucky, and Illinois.
    Mr. Dickey. You will be hearing from me. Thank you. Thank 
you, Mr. Chairman.
    Mr. Porter. Thank you, Mr. Dickey. Dr. Fox, let me thank 
you for adjusting your schedule to meet our needs. We don't 
often go beyond the noon hour, but it was necessary today. I 
have four more quesetions and a request, but since you talk 
very fast, I am sure we can do this fairly quickly. Lst year, 
Members of Congress contacted you and Secretary Shalala about a 
proposed rule that would change the reporting requirements for 
the National Practitioner Data Bank. It is my understanding 
that HRSA decided to withdraw this proposed rule and 
reconsidered the complex issues involved. I understand that the 
Secretary has signed the withdrawal notice. Can you tell me 
wheteher my understanding is correct, and if so, when the 
withdrawal notice will be published?
    Does OMB have a role in this? Would you contact them if 
they are holding it up?
    Dr. Fox. The issue is still being discussed. The agency is 
trying to find a new solution to the problem.

                    NATIONAL PRACTITIONER DATA BANK

    Mr. Porter. Thank you, Mr. Dickey. Dr. Fox, let me thank 
you for adjusting your schedule to meet our needs. We don't 
often go beyond the noon hour, but it was necessary today. I 
have four more questions and a request, but since you talk very 
fast, I am sure we can do this fairly quickly. Last year, 
Members of Congress contacted you and Secretary Shalala about a 
proposed rule that would change the reporting requirements for 
the National Practitioner Data Bank. It is my understanding 
that HRSA decided to withdraw this proposed rule and reconsider 
the complex issues involved. I understand that the Secretary 
has signed the withdrawal notice. Can you tell me whether my 
understanding is correct, and if so, when the withdrawal notice 
will be published?
    Dr. Fox. Mr. Chairman, you are correct. We do plan to 
withdraw the notice. I was not aware the agency has actually 
requested that it be withdrawn. I didn't know the Secretary had 
signed it. I think we can find out when the withdrawal date 
will be, but certainly there was a lot of concern expressed. I 
think a number of the licensing boards were concerned about 
particularly an unfunded mandate about what this reporting 
might require. We met with groups. We have taken the comments 
and we definitely know we have to retool that. And so we are 
going to pull it back and retool it and put it back out again. 
I can get the date for you of the withdrawal. The issue is 
still being discussed. The agency is trying to find a new 
solution to the problem.
    Mr. Porter. Does OMB have a role in this?
    Dr. Fox. They will.
    Mr. Porter. Would you contact them if they are holding it 
up?
    Dr. Fox. I don't think the holdup is with OMB. We can check 
and see. We would be glad to get you the date.

                             HEALTHY START

    Mr. Porter. Has the Healthy Start Program demonstrated 
successful techniques in increasing childhood immunizations?
    Dr. Fox. This is one of the questions you asked me that I 
don't know the answer to. We know there have been a lot of 
positive things with Healthy Start. That is not one that I am 
aware of.
    Dr. van Dyck, do you know?
    Mr. Van Dyck. There is, in preliminary data, that they do 
increase immunizations, but we don't have the final valuation 
yet.
    Dr. Fox. The final evaluation is due in, I think, March of 
this year.

                               RICKY RAY

    Mr. Porter. Okay. For Ricky Ray, we allocated $10 million 
for administration of the program, assuming that it was going 
to take a great deal on the front end to get it set up and 
going. OMB apparently has allocated $5 million for that. Is 
that going to be enough to do what you need to do?
    Dr. Fox. We feel we need $10 million, Mr. Chairman. Quite 
frankly when I saw the $10 million figure, I said $10 million? 
But we have sat down and looked at it. There has been actually 
a detailed analysis around what it is going to require. As I 
said earlier, all the petitions, all of the requests are going 
to have to be thoroughly reviewed. We feel $10 million is going 
to be needed to do the job adequately.
    Mr. Porter. Can you give us a summary of your analysis?
    Dr. Fox. Be glad to.
    [The information follows:]




                             AMERICAN MEDIA

    Mr. Porter. How many times in an average week do you appear 
on TV or do a radio interview?
    Dr. Fox. I don't appear on TV that often. I might do a 
radio interview maybe once every other week.
    Mr. Porter. See, that is what bothers me, because if we 
look at one of the major issues that faces this country, it is 
exactly where you are and it is health care access. There are 
45,000,000 people not in the system, and it seems to me that 
the American media ought to be focusing on this and ought to 
have you out there telling us what it is all about and how we 
can get there and they don't do it. They leave it up to debate 
between the candidates and what they really need is the experts 
who know what is going on to sit down and say--and I have to 
say, the more I see how the media in this country operate, the 
more disappointed I am and the more they are dumbing down our 
society instead of raising our sights and educating us and 
giving us a chance to hear from the experts and giving us what 
we need to know to make good decisions. I guess that is more a 
statement than a question.
    I want to try to initiate a program that would aim--and I 
was very encouraged by your emphasis on prevention, but that is 
not new. We have heard it before, but I agree with you 
completely that that is where we can really help people live 
healthier lives, and in the process, save a good deal of money 
as well. I would like to initiate a way of getting at the issue 
of children's health, particularly with respect to lifestyle 
and prevention and the request I want to make is that I would 
like to get Dr. Koplan at CDC, Dr. Alexander at NICHD, Dr. 
Chavez at SAMHSA and yourself together to discuss this. Would 
you be willing to do that?
    Dr. Fox. Would love to discuss it, Mr. Chairman.
    Mr. Porter. I just think we need a way to get to kids and 
their parents and get them started on the right track in their 
lives, to get engrained healthy habits that could save us a 
great deal, and they will have much better lives as a result of 
it. I don't think we do nearly enough in that regard--to do 
outreach to parents and kids to get them to practice the right 
habits.
    Dr. Fox. I would agree and I think we would love to work 
with you on it.
    Mr. Porter. Thank you very much. Thank you for all your 
testimony. You are doing a wonderful job there. We obviously 
want to provide the resources that you need to do it even 
better and we are going to do our best to do that.
    Dr. Fox. Thank you, Mr. Chairman.
    Mr. Porter. Thank you, Dr. Fox.
    [The following questions were submitted to be answered for 
the record:]






                           W I T N E S S E S

                              ----------                              
                                                                   Page
Arons, B.S.......................................................   461
Chavez, Nelba....................................................   461
Clark, H.W.......................................................   461
Eisenberg, J.M...................................................   771
Fox, Dr. C.E.....................................................  1091
Gaston, Dr. M.H..................................................  1091
Goldstone, Donald................................................   461
Koch, Rita.......................................................   771
Kopanda, Richard.................................................   461
Koplan, J.P......................................................     1
Morford, T.G.....................................................  1091
Myers, Dr. W.W...................................................  1091
Nelson, Jon......................................................  1091
O'Neill, Dr. J.F.................................................  1091
Puskin, Dr. Dena.................................................  1091
Rogers, Dr. V.C..................................................  1091
Sanchez-Way, Ruth................................................   461
Simpson, Lisa....................................................   771
van Dyck, Dr. Peter..............................................  1091
Williams, D.P............................................461, 771, 1091


                               I N D E X

                              ----------                              

               Centers for Disease Control and Prevention

                                                                   Page
Absence of Minority Researchers..................................    16
Accounting Firms Headed by Minorities and Women..................    36
Asthma...........................................................30, 34
Attitudes Among CDC Scientist about CFS.......................... 7, 18
Attitudes of CDC Scientist Regarding Congress....................    18
Auditors Meeting with Subcommittee Staff.........................    35
Bioterrorism.....................................................    22
Birth Defects and Folic Acid.....................................    11
Buildings and Facilities.........................................     6
Cardiovascular Disease...........................................    14
Cardiovascular Disease Among Women...............................    29
CDC's Injury Control and Prevention Center.......................    19
Childhood Developmental Disabilities and Bad Behaviors...........    32
Childhood Lead Poisoning Prevention..............................    17
Chronic Fatigue Syndrome and Hantavirus Expenditures.............     4
Chronic Fatigue Syndrome Research................................    22
Corrective Actions...............................................     4
Coal Mining and Black Lung Disease...............................    25
Designation of Funds for Diseases................................     7
Diabetes and Periodontal Disease.................................     9
Elimination of Racial and Ethnic Health Disparities..............    16
Environmental Health Laboratory..................................    13
Epilepsy.........................................................    35
Expenditure of Funds.............................................     2
FY 2001 Budget Request...........................................     3
Hantavirus....................................................... 1, 31
Health Challenges for the 21st Century...........................     3
Hemophilia and Hepatitis C.......................................    20
HIV/AIDS.........................................................    11
HIV Prevention...................................................    17
Human Papilloma Virus............................................    35
Human Papilloma Virus Education and Research.....................    23
National Center for Health Statistics............................    34
National Institution for Occupational Safety and Health..........    24
Obesity..........................................................    19
Pfisteria........................................................    34
Prevention of Tobacco Use and Bidis Cigarettes...................    30
Privacy of Medical Records.......................................    15
Public Health Emergencies........................................     3
Racial Disparities in Maternal Morbidity and Mortality...........    24
Redirection of Funds.............................................    13
Review of All CDC Programs.......................................     5
Tuberculosis.....................................................     7
Use of Funds.....................................................     8
Wisewoman Program................................................    29
Youth Media Campaign--Public Service Announcements...............     6
Youth Smoking Prevention Programs................................    21

       Substance Abuse and Mental Health Services Administration

Addiction Technology Transfer Centers............................   534
Alcohol Advertising Affects......................................   532
Anti-Drug Advertising Program....................................   600
Bioterrorism Activities..........................................   507
Block Grant:
    Funding for Prevention Programs..............................   561
    Services for Children and Adolescents (Substance Abuse)......   562
    Set-aside Activities.........................................   542
Breakout of the FY 2001 Budget Requests..........................   531
Budget Justification.............................................   774
Children's Health................................................   483
Children's Mental Health Services Program........................   560
Children's Mental Health (Youth Violence Prevention).............   611
Client Outcomes and Program Effectiveness........................   518
Collections from other Sources...................................   533
Colombia Drug Funds..............................................   491
Community:
    Action Grants................................................   507
    Initiated Interventions Grant Program........................   543
    Mental Health Service........................................   490
Consumer Organizations (Mental Health)...........................   583
Co-occurring Disorders...........................................   589
Co-occurring Mental and Addictive Disorders......................   578
Cooperation Among Agencies.......................................   494
Coordination among Agencies in Substance Abuse Activities........   596
Coordination with CDC............................................   483
Core Client Outcome Measures.....................................   499
Corporate Alliance for Drug Education (CADE).....................   537
Cost Effectiveness of Drug Treatment and Prevention..............   685
CSAP's Violence Prevention Activities............................   564
Cultivating a System Responsive to Current and Emerging Needs....   471
Data Collection and Performance Feasibility Assessment...........   508
Data Elements for Block Grant Formula/Allotments...............542, 606
Data on National Mental Health Needs and Services................   607
Definitions for Mental Disorders.................................   540
Delayed Obligations..............................................   558
Drug Abuse Warning Network (DAWN)................................   555
Drug and Alcohol Message.........................................   585
Drugs and Our Young People.......................................   611
Employment Intervention Demonstration Program....................   502
Exemplary Treatment Models Initiative............................   535
Expenditures on Alcohol and Drug Abuse Treatment.................   520
Expired Authorizations...........................................   537
First Time Drug Use..............................................   543
FTE on Mental Health Block Grant Set-aside.......................   542
Funding for Consumer or Peer Support Programs (Mental Health)....   575
Funding for Substance Abuse Prevention...........................   562
Funding for Substance Abuse Prevention and Treatment.............   561
Funds Spent on Domestic Drug Treatment...........................   605
Future of Substance Abuse Problems...............................   493
High Risk Youth Program..........................................   544
HIV/AIDS Activities:
    Funding for HIV/AIDS Prevention..............................   544
    Outcome Cost Study...........................................   498
Homeless Programs................................................   527
Homeless Services for People with Substance Abuse Problems556, 558, 587
Impact of Absorption of Built-in Mandatory Increases.............   610
Improve Nonmental Health Specially Systems.......................   540
Improving System Performance and Service Quality.................   473
Integrated Service Systems for the Homeless......................   499
Integrated Treatment for Co-occurring Disorders..................   572
Knowledge Application Program (Peer to Peer Technical Assistance)   501
Knowledge Development and Application:
    Continuation Projects........................................   540
    Funding for KDA Program......................................   538
    Targeted Capacity Expansion Programs..................503, 509, 543
Learning Disabilities............................................   587
Measuring Performance and Increasing Accountability..............   476
Medical Solutions to Drug Problems...............................   492
Mental Health:
    Block Grant..................................................   495
    Block Grant Services.........................................   559
    Consumer Supported Activities................................   570
    Primary Health Care for the Elderly..........................   525
    Services to Individuals......................................   588
    Targeted Capacity Expansion Program...................567, 573, 582
Minority Fellowship Program......................................   528
National Household Survey on Drug Abuse........................521, 554
National Treatment Outcomes Monitoring System (NTOMS)............   553
Office of National Drug Control Policy...........................   612
Opening Statement................................................   465
Opioid Treatment Program.........................................   520
Plan to Address Pathological Gambling............................   535
Positive Direction for Children..................................   486
Prevention Resources.............................................   586
Protection and Advocacy Program (P&A)..........................507, 578
Restraints and Seclusions........................................   491
SAMHSA Programs..................................................   581
SAMHSA Surveys...................................................   554
State Substance Abuse Prevention.................................   531
Starting Early/Starting Smart Initiative.........................   528
Substance Abuse:
    Border Initiatve...........................................529, 601
    Treatment Facility Locator...................................   539
    Treatment Grants.............................................   552
    Treatment in the Health Insurance Market.....................   605
Support for Psychiatric Survivor Organizations...................   575
Supporting and Maintaining State Systems.........................   470
Surgeon General's Report on Mental Health........................   603
Surveys Funded by the Block Grant Set-aside......................   521
Technical Assistance Publications................................   534
Training Protocols for Mental Health Professionals...............   521
Treatment:
    Improvement Protocols (TIPs).................................   599
    Mentally Ill Americans.......................................   595
    Prevention Sciences..........................................   592
Violence Against Women Program...................................   519
War on Substance Abuse...........................................   581
What Works in Treatment..........................................   493
Witnesses........................................................   461
Youth Violence Prevention Activities.............................   562

               Agency for Healthcare Research and Quality

Agency for Healthcare Quality and Research.......................   771
Biographies...............................................786, 787, 788
Bioterrorism.....................................................   821
Budget Request.................................................805, 806
Cardiovascular Disease...........................................   802
Career Awards....................................................   816
Centers for Education and Research Therapeutics................806, 807
Conclusion.......................................................   785
Congressional Justification......................................   825
Consumer Assessment of Health Plans............................809, 810
Continuing Priorities................................775, 776, 784, 785
Dental Care for the Elderly......................................   824
Diagnostic Errors..............................................792, 793
Early Childhood Caries...........................................   824
EPSCoR Program...................................................   808
Evidence-based Practice Centers................................811, 812
FY 2001 Request......................................772, 773, 779, 780
Grants Table...................................................802, 803
HCSUS Table....................................................803, 804
Health Services Researchers....................................818, 819
Health Insurance Delivery......................................815, 816
HIV Data Coordinating Center.....................................   815
Immunization.....................................................   821
Improving Worker Health.........................783, 784, 796, 797, 798
In Home Renal Dialysis.........................................793, 794
Informatics...............................................794, 795, 796
Information Technology...............................774, 775, 782, 783
International Collaborations.....................................   798
Introduction..............................................771, 778, 779
Investigator-Initiated Research................................808, 809
Laboratories for Change..........................................   801
Long Term Care.................................................819, 820
Managed Care Research............................................   803
Medical Errors...................................................   817
Medical Errors in Nursing Homes..................................   816
Minority Health................................................800, 801
National Quality Report..........................................   808
National Guideline Clearinghouse...............................813, 821
National Guideline Clearinghouse.................................   818
One Percent Evaluation Funds...................................804, 805
Patient Safety and Reducing Errors..............773, 774, 780, 781, 782
Prostate Cancer Research.......................................810, 811
Public Health....................................................   820
Quality Interagency Coordination Task Force......................   811
Racial and Health Disparities Initiative.........................   815
Reauthorization and Mission....................................771, 772
Schizophrenia..................................................807, 808
Success Rate.....................................................   808
Translating Research into Practice...............................   814
U.S. Preventive Services Task Force..............................   813
Uninsured........................................................   820
User Liaison Program.............................................   802
Witness List...................................................771, 777
Women's Health...................................................   822
Worker's Health................................................822, 823

              Health Resources and Services Administration

ADAP.............................................................  1133
American Media...................................................  1153
Benefits for Children............................................  1128
Children's Hospitals GME.........................................  1123
Community Health Centers.........................................  1144
Community Access Grants..........................................  1139
Congressional Black Caucus-Hispanic Caucus.......................  1143
Coordinated Services.............................................  1127
Critical Access Hospitals........................................  1146
Dental Services..................................................  1126
Dentistry Training Cut...........................................  1126
Health Professions Programs......................................  1142
Health Care Insurance............................................  1130
Health Professions...............................................  1137
Health Centers...................................................  1137
Health Care for Uninsured........................................  1147
Healthy Start....................................................  1148
Increasing Organ Donation........................................  1125
Introduction of Witnesses........................................  1091
Minority AIDS Initiatives........................................  1131
National Practitioner Data Bank..................................  1148
Opening Statement................................................  1092
Organ Transplant Regulations.....................................  1124
Patients Right to Sue............................................  1131
Ricky Ray Program............................................1134, 1149
Senior Drug Benefit..............................................  1136
State Child Health Insurance Program.............................  1135
Uninsured........................................................  1123
Uninsured........................................................  1129

                                
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