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



 
                  THE HEALTH CARE FAIRNESS ACT OF 1999

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

                                HEARING

                               before the

                            SUBCOMMITTEE ON
                         HEALTH AND ENVIRONMENT

                                 of the

                         COMMITTEE ON COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 11, 2000

                               __________

                           Serial No. 106-108

                               __________

            Printed for the use of the Committee on Commerce






                      U.S. GOVERNMENT PRINTING OFFICE
64-770 CC                     WASHINGTON : 2000





                    ------------------------------  

                         COMMITTEE ON COMMERCE

                     TOM BLILEY, Virginia, Chairman

W.J. ``BILLY'' TAUZIN, Louisiana     JOHN D. DINGELL, Michigan
MICHAEL G. OXLEY, Ohio               HENRY A. WAXMAN, California
MICHAEL BILIRAKIS, Florida           EDWARD J. MARKEY, Massachusetts
JOE BARTON, Texas                    RALPH M. HALL, Texas
FRED UPTON, Michigan                 RICK BOUCHER, Virginia
CLIFF STEARNS, Florida               EDOLPHUS TOWNS, New York
PAUL E. GILLMOR, Ohio                FRANK PALLONE, Jr., New Jersey
  Vice Chairman                      SHERROD BROWN, Ohio
JAMES C. GREENWOOD, Pennsylvania     BART GORDON, Tennessee
CHRISTOPHER COX, California          PETER DEUTSCH, Florida
NATHAN DEAL, Georgia                 BOBBY L. RUSH, Illinois
STEVE LARGENT, Oklahoma              ANNA G. ESHOO, California
RICHARD BURR, North Carolina         RON KLINK, Pennsylvania
BRIAN P. BILBRAY, California         BART STUPAK, Michigan
ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
GREG GANSKE, Iowa                    TOM SAWYER, Ohio
CHARLIE NORWOOD, Georgia             ALBERT R. WYNN, Maryland
TOM A. COBURN, Oklahoma              GENE GREEN, Texas
RICK LAZIO, New York                 KAREN McCARTHY, Missouri
BARBARA CUBIN, Wyoming               TED STRICKLAND, Ohio
JAMES E. ROGAN, California           DIANA DeGETTE, Colorado
JOHN SHIMKUS, Illinois               THOMAS M. BARRETT, Wisconsin
HEATHER WILSON, New Mexico           BILL LUTHER, Minnesota
JOHN B. SHADEGG, Arizona             LOIS CAPPS, California
CHARLES W. ``CHIP'' PICKERING, 
Mississippi
VITO FOSSELLA, New York
ROY BLUNT, Missouri
ED BRYANT, Tennessee
ROBERT L. EHRLICH, Jr., Maryland

                   James E. Derderian, Chief of Staff

                   James D. Barnette, General Counsel

      Reid P.F. Stuntz, Minority Staff Director and Chief Counsel

                                 ______

                 Subcommittee on Health and Environment

                  MICHAEL BILIRAKIS, Florida, Chairman

FRED UPTON, Michigan                 SHERROD BROWN, Ohio
CLIFF STEARNS, Florida               HENRY A. WAXMAN, California
JAMES C. GREENWOOD, Pennsylvania     FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia                 PETER DEUTSCH, Florida
RICHARD BURR, North Carolina         BART STUPAK, Michigan
BRIAN P. BILBRAY, California         GENE GREEN, Texas
ED WHITFIELD, Kentucky               TED STRICKLAND, Ohio
GREG GANSKE, Iowa                    DIANA DeGETTE, Colorado
CHARLIE NORWOOD, Georgia             THOMAS M. BARRETT, Wisconsin
TOM A. COBURN, Oklahoma              LOIS CAPPS, California
  Vice Chairman                      RALPH M. HALL, Texas
RICK LAZIO, New York                 EDOLPHUS TOWNS, New York
BARBARA CUBIN, Wyoming               ANNA G. ESHOO, California
JOHN B. SHADEGG, Arizona             JOHN D. DINGELL, Michigan,
CHARLES W. ``CHIP'' PICKERING,         (Ex Officio)
Mississippi
ED BRYANT, Tennessee
TOM BLILEY, Virginia,
  (Ex Officio)

                                  (ii)


                    ------------------------------  



                            C O N T E N T S

                               __________
                                                                   Page

Testimony of:
    Bau, Ignatius, Director, Health Policy, Asian Pacific-
      Islander American Health Forum.............................   118
    Cohen, Jordan J., President and CEO, Association of American 
      Medical Colleges...........................................    74
    Friedell, Gilbert H., Director Emeritus, Markey Cancer 
      Center, University of Kentucky; Member, Institute of 
      Medicine Committee on Cancer Research Among Minorities and 
      the Medically Underserved..................................    69
    Harley, John B., Oklahoma Medical Research Foundation........   107
    Hayworth, Hon. J.D., a Representative in Congress from the 
      State of Arizona...........................................    22
    Jackson, Hon. Jesse L., Jr., a Representative in Congress 
      from the State of Illinois.................................    13
    Lewis, Hon. John, a Representative in Congress from the State 
      of Georgia.................................................    12
    Peterson, Anne, Health Commissioner, Commonwealth of Virginia    83
    Rios, Elena, President, National Hispanic Medical Association   110
    Rodriguez, Hon. Ciro D., a Representative in Congress from 
      the State of Texas.........................................    18
    Satcher, Hon. David, U.S. Surgeon General, Department of 
      Health and Human Services..................................    26
    Schulman, Kevin A., Associate Professor of Medicine and 
      Director of the Center for Clinical and Genetic Economics, 
      Duke University Medical Center.............................    76
    Sullivan, Louis W., President, Morehouse School of Medicine..    42
    Underwood, Hon. Robert A., a Delegate in Congress from Guam..    15
    Watts, Hon. J.C., a Representative in Congress from the State 
      of Oklahoma................................................    24
Material submitted for the record by:
    Academic Health Centers, letter dated May 10, 2000, to Hon. 
      Michael Bilirakis..........................................   126
    Bau, Ignatius, Director, Health Policy, Asian Pacific-
      Islander American Health Forum, response for the record....   175
    Cohen, Jordan J., President and CEO, Association of American 
      Medical Colleges, responses for the record.................   203
    Coordination of Minority Health Activities Within the 
      Department of Health and Human Services, paper entitled....   125
    Davis-Satterla, Loretta, Director, Division of HIV/AIDS-STD, 
      Michigan Department of Community health, prepared statement 
      of.........................................................   127
    Friedell, Gilbert H., Director Emeritus, Markey Cancer 
      Center, University of Kentucky, responses for the record...   196
    Harley, John B., Oklahoma Medical Research Foundation, letter 
      dated June 15, 2000, to Hon. Michael Bilirakis.............   177
    Liberti, Thomas, Chief, Bureau of HIV/AIDS, Florida 
      Department of Health, prepared statement of................   139
    National Alliance of State and Territorial AIDS Directors, 
      letter dated May 11, 2000, to Hon. Michael Bilirakis.......   129
    National Association of Community Health Centers, Inc., 
      letter dated May 11, 2000, to Hon. Thomas Bliley and Hon. 
      Michael Bilirakis..........................................   136
    National Medical Association, letter dated May 11, 2000, to 
      Hon. Michael Bilirakis.....................................   137
    Peterson, Anne, Health Commissioner, Commonwealth of 
      Virginia, response for the record..........................   173
    Research!America, letter dated May 10, 2000, to Hon. Michael 
      Bilirakis..................................................   138
    Rodriguez, Gloria M., Assistant Commissioner, New Jersey 
      Department of Health and Senior Services, Division of AIDS 
      Prevention and Control, prepared statement of..............   138
    Ruffin, John, Associate Director for Research on Minority 
      Health, National Institutes of Health, letter dated July 
      13, 2000, enclosing response for the record................   179
    Satcher, Hon. David, U.S. Surgeon General, Department of 
      Health and Human Services, letter dated June 29, 2000, 
      enclosing response for the record..........................   181
    Schulman, Kevin A., Associate Professor of Medicine and 
      Director of the Center for Clinical and Genetic Economics, 
      Duke University Medical Center, response for the record....   175

                                 (iii)

  


                  THE HEALTH CARE FAIRNESS ACT OF 1999

                              ----------                              


                         THURSDAY, MAY 11, 2000

                  House of Representatives,
                             Committee on Commerce,
                    Subcommittee on Health and Environment,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 11:48 a.m., in 
room 2322, Rayburn House Office Building, Hon. Michael 
Bilirakis (chairman) presiding.
    Members present: Representatives Bilirakis, Whitfield, 
Coburn, Greenwood, Brown, Waxman, Green, Strickland, Barrett, 
Towns, and Eshoo.
    Staff present: Carrie Gavora, professional staff; Marc 
Wheat, majority counsel; Kristi Gillis, legislative clerk; and 
John Ford, minority counsel.
    Mr. Coburn [presiding]. Let me, first of all, apologize to 
all those in the room and my fellow members for the tardiness 
for the beginning of this. The votes this morning did change 
our schedules and then the briefings on China in which a lot of 
members are involved could not be missed.
    We are going to have opening statements and I am going to 
dispense and enter mine in the record.
    [The prepared statement of Hon. Tom A. Coburn follows:]
Prepared Statement of Hon. Tom A. Coburn, a Representative in Congress 
                       from the State of Oklahoma
    Mr. Chairman, I am pleased to welcome Dr. John Harley from my home 
state of Oklahoma. Dr. Harley serves as both the Head of the Arthritis 
and Immunology Department at the Oklahoma Medical Research Foundation 
and as a Professor of Medicine at the University of Oklahoma Health 
Sciences Center, where I received my own medical degree. Since my 
congressional district includes the Cherokee Nation, the second largest 
Indian nation in the country, I am anxious to hear about his work 
concerning the Native American Biomedical Research Center at OMRF.
    I am also pleased to welcome my friend and colleague J.C. Watts as 
well as the Surgeon General, Dr. David Satcher, whom I have the 
greatest respect and admiration for and have had the privilege of 
getting to know and work with over the past several years on numerous 
public health issues.
    The majority of the patients I see in my medical practice tend to 
be women and ethnic minorities and the issue of health care disparities 
for any group is a very important issue for me, both as a practicing 
physician and a member of Congress. While there are numerous reasons 
for the disparities that exist, some have been created as a direct 
result of misguided federal policies. One obvious example is the 
federal response to HIV/AIDS.
    Along with Commerce Committee Chairman Tom Bliley, last year I 
requested an investigation by the U.S. General Accounting Office (GAO) 
to determine if racial inequities existed within federal HIV/AIDS 
programs. The GAO found that ``African Americans, Hispanics, and women 
are served by the Ryan White CARE Act in higher proportions than their 
representation in the AIDS population,'' yet ``they generally receive 
less appropriate health care for their disease.''
    This disparity is a direct result of the CARE Act's inappropriate 
focus solely on AIDS, the end stage of HIV infection. The CARE Act does 
not recognize those with HIV who have not yet developed AIDS. Women, 
African Americans and Hispanics--all of whom have significantly higher 
HIV rates--are therefore largely ignored by this oversight.
    States and cities with relatively new epidemics are not receiving 
the federal support they need to care for all of those in their 
communities that are infected. Because it may take ten or more years 
for someone infected with HIV to develop AIDS, it will therefore take 
more than a decade for the CARE Act to recognize the extent of the 
epidemic as it exists today.
    The failure to recognize HIV has another significant negative 
impact on women and communities of color at the local level. Planning 
Councils which largely determine how funds will be spent and set care 
and service priorities are required by law to reflect the demographic 
make-up of the epidemic in an area. As long as only those with AIDS are 
represented, women, minorities and other groups that are being 
increasingly affected by HIV will be largely excluded from this 
decision making process and denied access to many of the available 
health care services.
    In testimony submitted for this hearing, Ms. Loretta Davis-
Satterla, the Director of Michigan's Division of HIV/AIDS-STD, states 
that ``AIDS case surveillance alone done not accurately reflect the 
extent of the HIV epidemic among African Americans, women, adolescents 
and young adults.'' She notes that ``in Michigan, confidential HIV 
reporting has been required by statute since 1989.'' And ``as a direct 
result of having HIV case data available for planning efforts, current 
prevention efforts supported by the Michigan Department of Community 
Health emphasize racial/ethnic minorities, women and at-risk youth.''
    Davis-Satterla explains that ``when seeking to address these 
issues, with the goal of achieving 100% access and 0% disparity, it is 
essential that systems are utilized that allow identification of 
emerging trends relative to race/ethnicity, gender and behavioral risk 
factors. Planning based on trends in HIV infection provides a more 
accurate assessment of the distribution of the infected population, the 
number of individuals in need of access to treatment, and the type of 
medical and support services required to meet client needs. In 
Michigan, HIV case reporting and the Uniform Reporting System have been 
effective tools in addressing the current epidemic by facilitating 
planning of appropriate prevention, early intervention and care 
services.''
    In addition to HIV/AIDS care services, the federal prevention 
policies have also disadvantaged women and minorities. This failure can 
be seen in the fact that the number of infected African Americans and 
women has continued to increase in recent years. Perhaps the single 
most tragic failure of the existing prevention policy was the decision 
to allow children, mostly African American and Hispanic children, to 
become hapless victims of HIV--despite the fact that the capability 
exists to virtually eliminate pediatric AIDS.
    In 1994, it was discovered that administration of the drug AZT--now 
known as ZDV--during pregnancy and childbirth could dramatically reduce 
the chance that a child of an HIV-positive mother would be infected. 
Another study showed that HIV transmission from mother-to-child can be 
nearly eliminated when Caesarean section is coupled with ZVD at birth. 
A more recent study has found that even if treatment begins shortly 
after birth, transmission can still be considerably reduced.
    Despite these medical miracles, a significant number of women are 
still not tested for HIV during their pregnancy and many children are 
being allowed to become needlessly infected with an incurable, 
devastating disease that will prematurely claim their lives. Half of 
these infected children will be die before their third birthday and 
nearly all will be dead by age 5 unless they are promptly diagnosed and 
receive proper medical treatment which can prolong and improve an 
infant's life.
    Nearly all of the 382 children reported with AIDS last year--84 
percent--were African American and Hispanic. Our government owes an 
explanation to the mothers and families of these children as to why 
they were allowed to become infected with a disease that could have 
been prevented.
    I would expect that any legislation we consider this year to 
address the issue of health care disparities must ensure that not one 
more child is allowed to become infected by HIV and die of AIDS.
    I also intend to introduce a bill to reauthorize the Ryan White 
CARE Act, the federal HIV/AIDS care program, which will address the 
issue of disparities in HIV/AIDS care. It will do this by ensuring 
increased involvement by all communities affected by the disease on 
planning councils and by better targeting of federal funds to 
underserved communities. I hope that every member of this committee 
would sign onto this bill to ensure increased access to life saving 
care for all Americans impacted by HIV, regardless of their race or 
gender.

    Mr. Coburn. I will now recognize the ranking member, Mr. 
Brown for his opening statement.
    Mr. Brown. I want to thank my colleagues, Mr. Thompson, Mr. 
Lewis, Mr. Jackson and others for joining us today. I would 
also like to extend a special welcome to Mr. Satcher, who among 
his many accomplishments throughout his career, was first in 
his class at the Case Western Reserve University Medical School 
some not too many years ago in Cleveland, Ohio. Dr. Sullivan, 
it is nice to have you with us also.
    I am a co-sponsor of the Health Care Fairness Act, as all 
the witnesses are today. This legislation makes sense. We need 
the research that H.R. 3250 fosters to make decisions about the 
health care system; we need the education 3250 facilitates to 
reduce disparities in health; we need the training 3250 
supports to reduce disparities in health care.
    It is as simple as that and as complicated as that. If I 
polled everyone in the room on the criteria that should be used 
to evaluate the U.S. health care system, my guess is the 
answers would not vary all that much. Most of us would mention 
access, quality, cost, the system should provide more 
Americans, all Americans access to high quality care at a 
reasonable cost. I hope equity would work its way into the 
formula.
    A health care system that perpetuates significant and 
reversible racial, ethnic or socioeconomic disparities in 
health and life expectancy is not my idea of a good health care 
system. In a Nation like ours, one that is increasingly defined 
by the diversity of its population, it is my idea of a system 
on its way out.
    The way we judge our health care system is not logical or 
is not explicit. If we actually use standards like access, 
quality, efficiency and equity to guide health care policy and 
health care spending, we would not need this legislation. 
Universal coverage would be the priority. Research and 
disparities in health care, strategies to minimize those 
disparities would be a priority.
    Let us look at the way the U.S. health care system actually 
works. Forty-four million people are uninsured. Certain 
minority populations, especially Hispanics, are far more likely 
to be uninsured than white Americans. The Nation subsidizes 
health insurance for individuals fortunate enough to be 
employed by a firm that offers health coverage; their premiums 
are pre-taxed.
    We also cover low income children and a few other discrete 
categories of very poor people and we provide incomplete but 
valuable coverage to the elderly. If you do not fall into one 
of those categories, tough luck.
    The Nation funds enormous amounts of research, very little 
of it devoted to understanding why there are significant 
disparities in health and health care between populations in 
the United States, and even less of it devoted to doing 
something about those disparities.
    Mr. Satcher did his best at CDC. Ed Towns and others on 
this subcommittee have done their best but it is changing much, 
much too slowly.
    Over time, enough evidence has accumulated so that there is 
no doubt about it, there is significant disparities in health 
and health care. Minority populations, as we all know, have 
higher rates of cancer, heart disease, diabetes, HIV AIDS and 
that is just a partial list.
    Minorities have shorter life expectancies, higher infant 
mortality rates and higher incidence of premature death. 
Minorities are less likely to receive cancer screening and less 
likely to receive monitoring. Minorities are less likely to 
receive childhood and adult vaccinations, doctors are four 
times more likely to correctly identify a heart attack and 
hospitalize a patient if that patient is white. According to 
recent research, doctors are getting better at treating cancer 
pain unless you are a Hispanic or African-American.
    We have a top notch health care system, what this Nation is 
spending money on, subsidizing health insurance for millions of 
working Americans and other select groups, financing 
groundbreaking research that fuels medical advancement 
throughout the world. What this Nation is spending money on is 
not wrong, but it is not 100 percent right either. We need to 
work on the system until it does not matter what your race is, 
what your ethnicity is, what your employment status is, you 
should still be a beneficiary of medical advancement and a 
recipient of the highest quality care this Nation has to offer.
    The Health Care Fairness Act sets the stage for that 
system. I am thrilled the subcommittee is finally paying 
attention to this very important legislation.
    Mr. Coburn. The gentleman from New York?
    Mr. Towns. Thank you very much.
    Also, let me thank the ranking member, Mr. Brown, for his 
outstanding work in this area. Also, I am delighted to see the 
former Secretary of Health, Dr. Sullivan, and Surgeon General 
Satcher and my colleagues, Mr. Thompson, Mr. Lewis, Mr. Jackson 
and Mr. Rodriguez.
    Let me just say that we have undoubtedly made tremendous 
advances in the area of health in the last few years in the 
areas of treatment and new technology--gene therapy vectors, 
new antibiotics, surgeries, unborn children to reversed birth 
defects. Even with all these wonderful developments, there are 
still inequities in our health care system.
    There is a growing mountain of evidence that not all 
patients with the same signs and symptoms are being treated 
equally under our system of care. There is compelling evidence 
that there are racial and ethnic health disparities and now is 
the time to address this issue.
    A number of studies published in the New England Journal of 
Medicine, the Journal of American Medical Association by the 
Kaiser Family Foundation demonstrates the extent of racial and 
ethnic health disparities in our medical system. These studies 
range from decreased aggressive cancer care in blacks to 
perception of minority groups that they receive lower quality 
of health care.
    We cannot continue to allow our health care professionals 
to treat patients differently because of the patient's ethnic 
background. That is unacceptable in the United States of 
America.
    This complex problem suggests the need for a comprehensive 
answer and the answer is H.R. 3250, the Health Care Fairness 
Act. This bill addresses the issue of health disparities from a 
number of different and crucial vantage points. First and 
foremost, it establishes the center at the NIH to increase the 
breadth and depth of research in this area. I think it is of 
the utmost importance that a premiere research center such as 
NIH take a leadership role in addressing health disparities and 
aiding the transfer of research information to patient-friendly 
and useful data.
    The bill also deals with the education of physicians across 
skill ranges to begin to highlight their biases and change 
them. These are only two of the points I wanted to highlight in 
this bill. Along with the comprehensive approach to this bill, 
I want to mention our community health centers and the 
important role they play in treating many of the patients who 
this bill will positively impact.
    Our Nation's community health care centers provide care to 
over 7 million minorities each year. The culturally sensitive 
care provided at these health centers is delivered in an 
efficient and effective manner, leading to documented decreases 
in preventable illnesses and increased rate of childhood 
immunization and reduction in inappropriate usage of hospital 
emergency rooms and a dramatic drop in infant mortality rates 
to name just a few.
    I think we should look at service delivery models such as 
community health centers are currently working to decrease 
these disparities. I also want to acknowledge again both our 
Surgeon General and the former Secretary of Health, Dr. 
Sullivan, now President of Morehouse Medical School on their 
leadership in the area of reducing health disparities.
    I am looking forward to the enlightening testimony coming 
first, from our colleagues and others who will be giving us 
information as to why we might need to move very rapidly with 
H.R. 3250.
    On that note, I yield.
    Mr. Coburn. Thank you.
    Recognize the gentleman from California.
    Mr. Waxman. For years this subcommittee has led 
congressional efforts to eliminate the persistent health 
disparities in communities of color. I hope that today's 
hearing marks a renewal of these efforts to improve access to 
care and expand research of importance for all Americans.
    The last time we addressed this issue was in the 103d 
Congress when Senator Kennedy and I sponsored the NIH 
Revitalization Act which established the NIH Office of Research 
on Minority Health and the Minority Health Improvement Act, 
which would have established national priorities in improving 
the health status of minorities.
    I am pleased we are going to hear from Surgeon General 
Satcher and Mr. Louis Sullivan to testify to our Government's 
current and past efforts. They can attest to the progress which 
has been made.
    As one measure of the long road ahead of us, I want to read 
two conclusions from the Institute of Medicine's recent report 
on the ``Unequal Burden of Cancer'' on communities of color. 
``One, the research priority-setting process at NCI and NIH 
fails to serve the needs of ethnic minorities and medically 
underserved groups.'' ``The committee found little evidence 
that NCI or NIH has undertaken a thorough assessment of 
training programs to determine whether these programs are 
producing adequate numbers of ethnic minority researchers in 
all appropriate cancer research fields.'' I think these 
conclusions speak volumes about the need for congressional 
action.
    The Administration is certainly not idle. I know the NIH 
has convened an internal working group on health disparities 
but I am certain every member and witness here today will agree 
that there is little danger of doing too much for Americans who 
have historically had to settle for too little attention and 
too few resources.
    As a co-sponsor of H.R. 3250, I believe this bipartisan 
legislation would be of enormous help. I strongly encourage 
you, Mr. Chairman, to schedule a markup for next week or at the 
earliest possible date. The remaining time in the session is 
very short but the need for health care equity is very great.
    Mr. Coburn. I thank the gentleman.
    Ms. Eshoo?
    Ms. Eshoo. Thank you and good afternoon everyone.
    Thank you for holding this very important hearing on H.R. 
3250. I think the legislation really marks a historic effort to 
improve the health of minorities across our country.
    I want to commend our colleague, Congressman Bennie 
Thompson, for introducing the bill. It is a solid piece of work 
and it is thoughtful. I have gone over it section by section 
and I salute you for the work you have done on this and also 
our distinguished Chairman for taking the first important step 
toward the enactment of this legislation by holding today's 
hearing.
    In February 1998, President Clinton challenged our Nation 
to an ambitious goal. By the year 2010, we must eliminate 
longstanding disparities in health status experienced by all 
racial and ethnic minority populations in our Nation. His 
challenge followed a series of disturbing findings that despite 
significant improvements in the health of Americans, minority 
Americans continue to suffer from certain diseases at up to 
five times the rate of white Americans.
    Here are some examples. African-American men under 65 
suffer from prostate cancer and heart disease at nearly twice 
the rate of whites. Vietnamese women suffer from cervical 
cancer at nearly five times the rate of whites. Latinos have 
two to three times the rate of stomach cancer. Native Americans 
suffer from diabetes at nearly three times the average rate 
while African-Americans suffer 70 percent higher rates than 
white Americans.
    That is astronomical when you stop and think about that. I 
want to repeat that. African-Americans suffer 70 percent higher 
rates than white Americans in that area.
    We have to close these gaps. Much more needs to be known 
about why minority populations are experiencing such 
desperately high rates and other diseases that we really can 
target much needed resources toward eliminating the 
disparities.
    This legislation tackles the problem by establishing a new 
National Center for Research on Minority Health and Health 
Disparities at NIH which I am very fond of calling our National 
Institutes of Hope. I think if we can build this legislation 
into our National Institutes of Health, it really is going to 
give hope to so many Americans across our country.
    The bill also authorizes the Agency for Health Care 
Research and Quality to conduct and support research which is a 
very, very important part of this effort. We have to learn more 
so that we can do better.
    I am especially excited about the provisions in the 
legislation aimed at education and outreach surrounding 
minority health. Too few health care professionals today are 
really aware of the special health care needs of minority 
populations or even how to provide them. Under this bill, 
grants will be available to medical schools and nursing schools 
to incorporate the cultural awareness programs in that very 
special education.
    Community and rural health centers will receive incentive 
payments to develop innovative strategies to reduce ethnic 
health disparities for health professionals.
    Finally, the bill directs the Secretary to develop a system 
to evaluate the performance of Medicare and Medicaid and how 
they are doing.
    I want to welcome the very, very distinguished people here 
to testify today. We are fortunate to have the Surgeon General, 
Dr. Satcher, and to hear his enlightened views and a very warm 
and special welcome to the former Secretary of Health and Human 
Services, Dr. Sullivan. He has participated in more than one 
conference I have attended on health care.
    To each and every one of you, it is not very often we come 
into this hearing room and I see a very long line out in the 
corridor, so this is an issue that I think all Americans care 
about. This Congress can do something about it and I hope after 
the hearing we will move to markup and to the floor.
    Thank you.
    Mr. Coburn. I just want to make a couple of comments.
    Much of what I have heard in our opening statements, as a 
practicing physician, I agree with. There is a tremendous 
disparity but not all is despair. There are lots of minorities 
that get great care. I think it is very important that we focus 
on those who do not because there are lots of non-minorities 
who do not get great care too.
    What we want to do is keep in balance. One of your 
statements, even though it is meant, in a lot of communities--
Muskogee, Oklahoma--you do not just have tough luck if you do 
not have health insurance because the physician community, the 
hospital community, the nursing community, the pharmacist 
community work to take care of the people. That does not mean 
they are all taken care of as great as we can.
    I want to make sure as we hear our testimony and put our 
words in the record that where credit needs to be given, there 
are a lot of communities, communities of color and noncolor, 
that are doing a great job taking care of those folks that do 
not have what we want everyone to have.
    For us to say that the problem is without that light, there 
is light. We just have to do a whole lot better and there are a 
lot of people who we need to care for that are not being cared 
for today.
    [Additional statements submitted for the record follow:]
 Prepared Statement of Hon. Mike Bilirakis, Chairman, Subcommittee on 
                         Health and Environment
    My thanks to all of the witnesses who have taken the time to 
testify at today's hearing on H.R. 3250, the Health Care Fairness Act. 
The purpose of this legislation is to identify and rectify health 
disparities that occur among minorities.
    I am especially pleased that upon the rescheduling of this hearing, 
the Administration was able to send three witnesses, including Dr. 
Satcher. Hopefully, this hearing will provide a clear picture of the 
Administration's perspective on the Health Care Fairness Act and 
proposals related to the Office of Minority Health in particular. I 
would ask unanimous consent at this point to enter into the record a 
letter of support from the Association of Academic Health Centers in 
support of H.R. 2391 and H.R. 3250, bills to elevate the Office of 
Research on Minority Health at the National Institutes of Health.
    In preparing for this hearing, I have reviewed with concern the 
health disparities that persist between some minority groups and the 
non-Hispanic white population. Hepatitis C, heart disease, diabetes, 
lupus, lung cancer, and cervical cancer are but a few of the diseases 
that disproportionately affect minorities in this country.
    I was alarmed by the very significant disparities found in those 
infected with HIV, the silent killer of so many Americans. I would ask 
unanimous consent to enter into the record the testimony of Mr. Thomas 
Liberti, Chief of the Bureau of HIV/AIDS for the Florida Department of 
Health. Mr. Liberti could not join us today in person due to a back 
injury, and we all wish him a safe recovery.
    Likewise, Hepatitis C has also been identified at significantly 
higher rates among minorities. For example, available data indicates 
that the rate of Hepatitis C infection among African-Americans is 2 to 
3 times higher than the general U.S. population.
    Of course, some health care providers--including community health 
centers--are acutely aware of this problem from their day-to-day work 
on the front lines of medicine. Community health centers are the 
leading providers of health care to over 7 million minorities in 
medically under-served urban areas each year. As a strong supporter of 
their vital mission, I believe it is important to recognize the 
critical role they play in attempting to reduce minority health 
disparities. I would ask unanimous consent to enter into the record a 
statement on these issues by the National Association of Community 
Health Centers.
    We have made every attempt to accommodate a broad variety of 
witnesses today, and I would appreciate the Subcommittee's help in 
managing our time. Again, I want to welcome all of our witnesses and 
thank them for their time and effort in addressing this concern.
                                 ______
                                 
Prepared Statement of Hon. Cliff Stearns, a Representative in Congress 
                       from the State of Florida
    Thank you, Chairman Bilirakis, for holding this important hearing. 
I look forward to hearing from our distinguished witnesses, which 
include several of our colleagues as well as our current Surgeon 
General David Satcher and former Secretary of Health and Human 
Services, Dr. Louis Sullivan.
    H.R. 3250 addresses how we can improve access to health care for 
minorities. This goal would be achieved in the bill in several 
important ways. First, it would establish a New Center for Research on 
Minority Health and Health Disparities at NIH. This center would award 
grants for research in areas that are currently underserved.
    In conjunction with this the Agency for Health Care Research and 
Quality would conduct outcomes research so that we can identify why 
such disparities occur. This would be coupled with data collection 
relating to the effects of race and ethnicity on access to health care. 
We need to know what the current roadblocks are before we can bridge 
the gap.
    This information will help to address why there is such a higher 
rate of heart disease, diabetes and cancer in the African-American, 
Hispanic and Native American communities than in other ethic 
populations. I was particularly interested in the testimony submitted 
by Dr. Fridell on the higher rate of prostate cancer among African-
Americans than white men. Dr. Fridell also points out that we need to 
find out why Chinese American men have such low rates of prostate 
cancer compared to African American men.
    We need to look at variety of critical issues when evaluating why 
certain groups in our population have higher rates of cancer, diabetes 
and cardiovascular disease. More importantly, we need to look the roles 
that diet, customs, and environmental factors might play in the higher 
incidences of certain diseases in our minority communities.
    There is one other area that merits discussion and that is the role 
genetics play in why certain diseases strike some and not others. In 
that regard, the new area of NIH research opportunity ``Genomics'' is 
one of the most exciting and promising developments in molecular 
medicine. Once the map of the normal function of human genes is made 
available, which is imminent, we will then be able to make comparisons 
with our own unique genetic blueprint. This will herald a new area of 
computer collaboration with molecular medicine to develop a ``DNA 
Chip,'' transferring the functions of the human genome to a computer 
chip to be run for comparison for diagnostic and treatment purposes 
against our own genetic map. The software and hardware will need to be 
developed by the cooperative efforts of genome biologists, 
mathematicians and engineers to make the new field of Genomics a 
reality. We must ensure that our minority communities are not left out 
of this important aspect of future research efforts. It could very be a 
key to finding the answers to the many questions we have about why 
certain populations are more prone to certain types of diseases.
    Thank you, Mr. Chairman, and I look forward to hearing our 
distinguished group of panelists.
                                 ______
                                 
Prepared Statement of Hon. Barbara Cubin, a Representative in Congress 
                       from the State of Wyoming
    I think the intent of this bill is admirable. We all want equity in 
the health care system when it comes to access to services, 
availability of health insurance, and fair treatment for ALL patients.
    Studies show us that disparities do exist within the health care 
system when it comes to race and ethnicity, and that concerns me. But 
substantial inequities in health care can also be found between males 
and females, children and adults, and urban versus rural areas.
    What I question in this legislation is whether or not we're going 
too far, too fast with something that could very easily wind up to be 
another link in the chain of big government.
    This bill creates an entirely new ``Center'' to study the health of 
minority populations. How exactly does this ``Center'' fit within the 
structure of NIH? This is not clear to me. It is, in essence, its own 
institute within NIH but it would receive its funding outside of the 
HHS or NIH budget allocation. This amounts to earmarking federal 
dollars to a ``Center'' with, correct me if I'm wrong, a rather unique 
status while other NIH institutes are forced to fight for their dollars 
in the NIH allocation????
    To me, this essentially provides a carve-out for this ``Center,'' 
perhaps to the detriment of other NIH institutes. And where does the 
Administration stand on this bill? We don't even know that.
    Have we reached that point in time when the only answer to the 
problems facing the health of minority populations is to create another 
government program that will most assuredly cost billions of dollars to 
the American taxpayer??
    I'm not convinced that we've reached that point and that's 
precisely why I'm here today. I look forward to hearing from our 
witnesses today and hope they can shed some light on this issue.
    Thank you, Mr. Chairman, and I yield back the balance of my time.
                                 ______
                                 
 Prepared Statement of Hon. Tom Bliley, Chairman, Committee on Commerce
    I'm pleased that the Subcommittee is holding this hearing today on 
HR 3250, the Health Care Fairness Act. This legislation seeks to 
enhance research and education to address disparities in health care 
for minorities.
    African Americans have a 70 percent higher rate of diabetes than 
whites. Hispanics suffer at a rate nearly double that of whites. 
African Americans have a cancer death rate about 35 percent higher than 
that for whites. Vietnamese women suffer from cervical cancer more than 
5 times the rate of white women. We need to know why this is the case 
and I hope today's hearing will help.
    I'm particularly pleased that Dr. Anne Peterson, the Commissioner 
of Health with the Commonwealth of Virginia will be here today to 
testify.
    The State of Virginia began mandatory reporting of HIV back in 
1989. Collecting this data, as you will hear from Dr. Peterson, has had 
a positive impact on Virginia's ability to identify and treat people 
with HIV.
    This Committee is looking into reauthorizing the Ryan White CARE 
Act this year and I think it is timely to look at how minority 
populations are currently impacted by the way the Ryan White Act 
distributes funds.
    I'm also interested in learning more about minority health 
professional education programs. GAO reported in the past that there 
have been some problems ensuring that funds allocated for minority 
health education are adequately targeting the minority health 
professionals they were designed to help.
    I hope as we consider enhancing programs for minority populations, 
we make a full assessment of the programs that exist today, how they 
are working in meeting their goals and how they will coordinate with 
the new programs proposed in this legislation.
    While I understand that the Administration does not have an 
official position on this legislation yet, I'm hopeful that the 
Administration will be able to provide us with their position soon.
    I thank the Subcommittee Chairman for holding this hearing. And I 
welcome all our witnesses today. I appreciate so many of my colleagues 
taking time out of their day to testify at this hearing and I look 
forward to receiving all the witnesses testimony.
                                 ______
                                 
    Prepared Statement of Hon. Ted Strickland , a Representative in 
                    Congress from the State of Ohio
    Mr. Chairman, I want to thank you for holding this hearing today on 
what I think is one of the most important and most overlooked issues in 
health care. I am thankful that we are pursuing this issue, and I 
certainly hope that the subcommittee and the full committee will move 
this legislation forward as quickly as possible.
    I am struck and saddened by the findings reported in HR 3250: that 
for almost every serious or life-threatening disease, minorities are at 
increased risk for contracting that disease and dying from it. Cancer, 
infant mortality, SIDS, cardiovascular disease, hypertension, diabetes 
and HIV all confront minority ethnic groups with greater ferocity than 
the white population. And we know some of the reasons for this deadly 
disparity: lack of health insurance, low income, lack of access to 
primary care physicians and specialists, geographic isolation, low 
literacy levels, and the list goes on.
    These are some of the same demographic characteristics that 
describe the rural Appalachian population that I represent, and, not 
surprisingly, many of the same disparities in health status exist among 
the poor, white population of Appalachia. In fact, research done in 
Kentucky shows that, among the Appalachian white population, incidence 
rates for cervical cancer and lung cancer are significantly greater 
than the rates for those cancers among the white population as a whole. 
In fact, the cancer incidence rates among white Appalachians in 
Kentucky is much more closely aligned with the rates for black 
individuals in Kentucky.
    That this disparity exists at the end of the twentieth century is 
cause for grave concern and immediate action.
    But I am concerned that our federal institutions charged with 
health care research have not been doing all they can to eradicate this 
disparity. Clearly, this is a problem that has many complex causes and 
even more complicated solutions, a problem that cannot be solved 
overnight. But I have read with great concern some of the discoveries 
of the Institute of Medicine's report, ``The Unequal Burden of 
Cancer.'' In this study, the IOM reports that ``while NCI (National 
Cancer Institute) reports that it allocated $124 million to research 
and training programs relevant to ethnic minority and medically 
underserved groups in fiscal year 1997, the committee believes that the 
actual figure allocated for these groups is only slightly more than $24 
million, or approximately 1% of the total NCI budget.''
    I hope that this hearing on HR 3250 will be the beginning of a 
process where we will enact legislation that will correct these 
inequities for all Americans.
                                 ______
                                 
    Prepared Statement of Hon. John D. Dingell, a Representative in 
                  Congress from the State of Michigan
    Mr. Chairman, thank you for holding today's hearing on the 
important issue of disparities in health care amongst the diverse 
ethnic groups that comprise our nation. I regret that floor action on 
the Conservation and Reinvestment Act precludes my delivery of this 
statement in person.
    America's health care enterprise has three responsibilities: 1) 
providing preventive health services and treating disease; 2) 
conducting biomedical research; and 3) training health care 
professionals to meet the needs of today, and anticipate the needs of 
tomorrow. Unfortunately, minority populations have been unequally and 
inadequately recognized and represented in all three health-related 
activities. H.R. 3250 makes tremendous strides on all three fronts.
    As you are about to hear from the Surgeon General, Dr. David 
Satcher, ``as we look at the state of minority health in America, we 
are really looking at the future of our nation's health.'' The future 
of our nation's health will be influenced, in large measure, by 
advances in genetic medicine, a subject that will resonate through much 
of the expert testimony we will hear today. The human genome project 
has already shown us that there is greater genetic variability within 
ethnic groups than between ethnic groups. Research is now on the brink 
of unlocking the keys to ethnic differences in susceptibility and 
resistance to such common health problems, such as heart disease, 
diabetes, cancer, and stroke. These discoveries will allow us to target 
screening, treatment, and prevention more effectively, thereby 
minimizing health disparities.
    As the world's leader in biomedical research, we must supplement 
our new technologies with a workforce of culturally competent 
physicians and health professionals. H.R. 3250 addresses this by 
calling for the development of educational tools and programs that will 
sensitize health professionals to a variety of health belief systems 
and enhance provider communication skills in areas ranging from simple 
health history-taking and education to recruiting and enrolling members 
of minority groups in appropriately designed clinical trials.
    This year's census, for the first time in our nation's history, is 
expanding the available data on the ethnic origins of Americans from 
the five categories formerly used. I am optimistic that the 
availability of this new, expanded data about target populations will 
help close the information gaps we will hear about from Dr. Fridell on 
behalf of the Institute of Medicine, as well as other witnesses. The 
Institute of Medicine's study, ``The Unequal Burden of Cancer: An 
Assessment of NIH Research Programs for Ethnic Minorities and the 
Medically Underserved,'' provides a compelling brief for legislation 
such as H. R. 3250.
    This hearing also provides an opportunity to thank our nation's 
community, migrant and homeless health centers, along with the other 
organizations that comprise America's primary healthcare safety net, 
for the important role they play in providing culturally-sensitive 
health care to over seven million minority individuals. Without this 
important resource, many of our nation's poorest citizens would have no 
access to health care, and the disparities we are discussing here today 
would be even worse.
    Last year I fought hard to have the Balanced Budget Refinements Act 
include some relief for community health centers from the phase-out of 
the Medicaid cost-based reimbursement, but the job is only partially 
done. One way to sustain the vital safety net the community health 
centers provide to minority communities would be for this Committee to 
pass H.R. 2341, the Safety Net Preservation Act, which assures them a 
stable Medicaid funding system. I hope this can be accomplished this 
session.
    In closing, I urge us to move forward with H.R. 3250. This 
legislation will strengthen the health care safety net for minority 
residents, their families, and underserved communities, by translating 
the enhanced research discoveries provided for in this bill into 
improved health care outcomes. Moreover, it is a bold step forward in 
marking the next decade with the highest achievable level of health 
care fairness in primary medical care and treatment, biomedical 
research, health professional education, and public awareness, for all 
citizens.

    Mr. Coburn. With that, I would like to recognize our co-
members in the House and the Honorable Bennie Thompson.
    Mr. Thompson. Thank you, Mr. Chairman.
    I would like to compliment you and this committee for 
conducting this hearing. It is obviously the first step in the 
right direction to address the health care inequities in this 
country.
    I also want to compliment Mr. Lewis, Mr. Jackson, Mr. Watts 
and other members who have also co-sponsored this legislation. 
It is long overdue. As you will hear from my colleagues, and as 
you have heard from my esteemed members of the committee, we 
have a problem. This is America, this is the greatest country 
in the world.
    The statistics quoted to you earlier today should cause all 
of us great concern. We can put people on the moon, we can do a 
number of things, but yet we have absolutely too many people of 
color suffering and dying needlessly in this country. For that 
reason, we offered this legislation and feel that reasonable 
people will, in fact, support it.
    I can give you all the demographics but we know the story. 
We have to fashion and craft a solution. We see this 
legislation as one effort in crafting that solution.
    The district I represent has 24 counties. All 24 counties I 
represent are medically underserved. We need help. This 
legislation addresses that and I look forward to the debate and 
discussion as we move this legislation forward.
    Mr. Coburn. The gentleman from Georgia, Mr. Lewis.

   STATEMENT OF HON. JOHN LEWIS, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF GEORGIA

    Mr. Lewis. Thank you, Mr. Chairman.
    I want to commend you, Mr. Chairman and members of the 
committee, for holding this hearing on such an important piece 
of legislation, H.R. 3250, the Health Care Fairness Act. I also 
want to commend Representatives Watts, Norwood, Thompson, 
Jackson, Rodriguez and Underwood for their commitment to making 
this bill a top priority. They are my friends and they are my 
colleagues and they care. I am glad to be here with them today.
    I especially want to thank Dr. Sullivan and his staff and 
the many others concerned about minority health for all of the 
help they have given me and my staff in developing and 
promoting this legislation.
    As a member of the Ways and Means Subcommittee on Health I 
have long been committed to eliminating health disparities. It 
is my hope that with today's focus on H.R. 3250, we can move 
quickly to eliminate those disparities. We all know how 
important this issue is.
    Over the past few decades we have made great advances as a 
Nation in science and medicine. However, all of our citizens 
have not shared in the benefits of these advances. Minority 
populations have higher rates of death from cancer and health 
disease, as well as a higher rate of diabetes and other severe 
health problems. In fact, in many instances, minorities are not 
offered or given access to treatment. That is why we introduced 
the Health Care Fairness Act, a bipartisan bill supported by 
members of the Hispanic Caucus, the Asian Pacific Island Caucus 
and all members of the Congressional Black Caucus.
    H.R. 3250 is also supported by the American Hospital 
Association, the National Medical Association, the National 
Asian Women's Health Organization, the Association of Minority 
Health Professional Schools, Association of Black 
Cardiologists, American Association of Medical Colleges, 
National Association of Community Health Centers, and many 
other organizations.
    The Health Care Fairness Act includes an increased 
commitment to research minority health, improved data systems, 
culturally sensitive health care delivery and public awareness 
of the existence of minority health disparities.
    We must make the commitment, the necessary commitment to 
eliminate minority health disparities. We must do it for the 
sake of not just the minority community but for the sake of our 
Nation. By focusing attention and Federal resources on this 
problem, the Health Care Fairness Act gives us a chance to 
bridge the health care gap.
    Mr. Chairman and members of the committee, I ask for your 
commitment and your help to not only mark up H.R. 3250, but to 
pass this bill before the end of the 106th Congress. I look 
forward to working with you in a bipartisan manner to make sure 
we pass H.R. 3250.
    Thank you very much.
    Mr. Coburn. Mr. Jackson?

  STATEMENT OF HON. JESSE L. JACKSON, JR., A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF ILLINOIS

    Mr. Jackson. I want to thank you for the opportunity to 
discuss with you the issue of minority health research at NIH. 
I am very pleased to be joined by my colleagues, Mr. Rodriguez, 
Mr. Underwood, Mr. Lewis and Mr. Thompson, on this panel to 
share ideas and concrete steps this Congress may take to 
address health disparities in this country between blacks and 
other ethnic minorities in the general population.
    In this time of national economic prosperity and in 
particular, double digit growth for the National Institute of 
Health, Chairman Porter has set a single goal of increasing 
appropriations for NIH by 15 percent every year.
    I am disappointed to report that the health status gap 
among blacks and other underserved populations is getting worse 
and not better. In my view, the National Institute of Health 
could, and should, be doing more to address health care needs 
of all Americans.
    At the beginning of the 106th Congress, I was very pleased 
to be appointed to the Appropriations Committee and to its 
Labor, Health and Human Services and Education Subcommittee. 
Congressman Lewis Stokes of Ohio made gigantic steps and 
strides in improving minority health during his long and 
distinguished service on the panel. I hope to make a similar 
contribution.
    One of the many benefits of serving on the subcommittee is 
the opportunity to carefully review the program activity and 
priorities of the Institute and to question the health care 
professionals and researchers that carry out this vital work.
    In fact, the subcommittee held more than 40 hearings just 
this year alone and about 20 half-day sessions on which those 
hearings were dedicated to the oversight of NIH. I was 
privileged to attend almost all of those sessions this year as 
well as last year.
    In January 1999, I had the privilege of meeting with Mr. 
Louis Sullivan, the former HHS Secretary and current President 
of the Morehouse School of Medicine. He shared with me 
testimony he gave before the Senate Labor Health and Human 
Services Appropriations Subcommittee concerning the Institute 
of Medicine's report that demonstrated a disturbingly low level 
of support for cancer research among minorities through the 
National Cancer Institute.
    The cornerstone recommendation made by Dr. Sullivan in his 
testimony was to elevate the existing NIH Office of Research on 
Minority Health to Center status. What became increasingly 
clear across my inquiry at NIH was that the problem was not 
specifically centered in the National Cancer Institute, that 
amongst its 23 institutes, three centers and three offices, a 
general lack of coordination on these fundamental problems was 
clear and existed.
    He contended that the existing structure in NIH did not 
adequately address or prioritize the issue of health 
disparities. After asking scores of questions to the NIH 
Director and the Directors of the Institute and Centers during 
last year's hearings about these disparities, I became more 
convinced than ever that Dr. Sullivan was right, the Office of 
Research on Minority Health needed to be elevated to center 
status.
    Consequently, I worked with Dr. Sullivan and other health 
care professionals to fashion a bill which I also support with 
Congressman Thompson and Congressman Lewis. The product of that 
bill, H.R. 2391 or Title I of 3250 which I introduced on June 
30, 1999.
    In plain terms, the bill provides the Director of the 
Center a seat at the table when NIH Institutes and Center 
Directors meet to discuss NIH policy and priorities. Presently, 
the Office of Research on Minority Health, when all of the 
Directors and Institutes meet, is not even in the room. They do 
not have a seat at the table to coordinate across the 23 
Institutes, three Centers and three Offices, general 
coordination on these critical issues. The current Director 
does not attend these meetings.
    Second, calls for health status disparities to be 
prioritized at NIH through the establishment of an NIH-wide 
strategic plan for health disparities with the Center playing 
the key role in that strategic plan.
    Third, it establishes a grantmaking authority for the 
National Center which the office presently does not have. That 
is, researchers who might pursue issues such as health 
disparities and diabetes, cancer research or any other 
necessary and needed form of study, there presently is no 
grantmaking authority in that office to encourage researchers 
to study these various disparities.
    Right now, the office director cannot spend his own budget 
unless an Institute Director allows him to fund a grant through 
his or her institute. This is unacceptable.
    Mr. Coburn. Can you summarize, Mr. Jackson?
    Mr. Jackson. I am just one paragraph away, sir.
    Fourthly, H.R. 3250 provides institutional support for 
those minority health professional schools which have a history 
and mission to serve and train minority health professionals 
and conduct research on health disparities. If we are ever 
going to solve the problem of health disparities, institutions 
which have a mission to solve these problems must be strong and 
viable.
    I urge the subcommittee to move forward on legislation that 
would elevate the Office of Research on Minority Health to a 
Center. Elevating this office would better coordinate these 
efforts at NIH and therefore, save lives and families from 
being strapped by illness and anguish.
    Together we can ensure that health care needs of all 
Americans are adequately addressed.
    Thank you, Mr. Chairman, Ranking Member Brown and members 
of the subcommittee for this opportunity to present my views.
    [The prepared statement of Hon. Jesse L. Jackson, Jr. 
follows:]
 Prepared Statement of Hon. Jesse L. Jackson, Jr., a Representative in 
                  Congress from the State of Illinois
    Mr. Chairman, Ranking Member Brown and Members of the Subcommittee, 
thank you for the opportunity to discuss with you the issue of minority 
health research at the National Institutes of Health (NIH). I am very 
pleased to join my colleagues on this panel to share ideas and concrete 
steps this Congress may take to address the health status disparities 
in this country between blacks and other ethnic minorities and that of 
the general population.
    In this time of national economic prosperity, and double digit 
growth for the National Institutes of Health, I am disappointed to 
report that the health status gap among blacks and other underserved 
populations is getting worse, not better. In my view, The National 
Institutes of Health could and should be doing more to address the 
health care needs of all Americans.
    At the beginning of the 106th Congress, I was very pleased to be 
appointed to the Appropriations Committee and to its Labor, Health and 
Human Services, and Education Subcommittee. Congressman Louis Stokes of 
Ohio made gigantic strides in improving minority health during his long 
and distinguished service on the panel, and I hope to make a similar 
contribution.
    One of the many benefits of serving on the subcommittee is the 
opportunity to carefully review the program activity and priorities of 
the institute and to question the health care professionals and 
researchers that carry out such vital work. In fact, the Subcommittee 
held more than 40 days of hearings just this year, about 20 half-day 
sessions of which were dedicated to the oversight of NIH. I was 
privileged to attend almost all of those sessions this year as well as 
last year.
    In January of 1999, I had the privilege of meeting with Dr. Louis 
Sullivan, the former HHS Secretary and the current President of 
Morehouse School of Medicine. Dr. Sullivan shared with me the testimony 
he gave before the Senate Labor-HHS Appropriations Subcommittee 
concerning an Institute of Medicine Study (IOM) that demonstrated a 
disturbingly low level of support for cancer research among minorities 
through the National Cancer Institute. The cornerstone recommendation 
made by Dr. Sullivan in his testimony was to elevate the existing NIH 
Office of Research on Minority Health to ``Center status.'' He 
contended that the existing structure at NIH did not adequately address 
or prioritizing the issue of health disparities.
    After asking scores of questions to the NIH Director and the 
Directors of the Institutes and Centers during last year's hearings 
about these disparities, I became more convinced than ever that Dr. 
Sullivan was right--the Office of Research on Minority Health needed to 
be elevated to ``Center'' status.
    Consequently, I worked with Dr. Sullivan and other health care 
professionals to fashion a bill that would do just that. The product of 
those efforts is H.R. 2391, which I introduced on June 30, 1999. 1 am 
pleased to report that this bill has 87 bipartisan co-sponsors 
including Reps. Charlie Norwood, Nathan Deal, Sherrod Brown and Ed 
Towns of this subcommittee.
    The bill, in plain terms would:
    1) Provide the director of the Center a seat at the table when NIH 
Institutes and Center directors meet to discuss NIH policy and 
priorities.
    Currently the director of the office does not attend those 
meetings.
    2) Calls for health status disparities to be prioritized at NIH 
through the establishment of an NIH-wide strategic plan for health 
disparities, with the Center playing a key role in the strategic plan.
    3) Establishes direct grant making authority for the National 
Center, guided by the work and scientific expertise of a national 
advisory council.
    Right now the office director can't spend his own budget unless an 
Institute director allows him to fund a grant through his or her 
Institute.
    4) Provides institutional support for those minority health 
professions schools which have a history and mission to serve and train 
minority health professionals and conduct research on health status 
disparities. If we are ever going to solve the problem of health 
disparities, institutions which have a mission to solve these problems 
must be strong and viable.
    Mr. Chairman, I urge this Subcommittee to move forward on 
legislation that would elevate the Office of Research on Minority 
Health to a National Center. Elevating this office will help to save 
more lives and families from being sapped by illness and anguish. 
Together, we can ensure that the health care needs of all Americans are 
adequately addressed.
    Thank you Mr. Chairman, Ranking Member Brown and members of the 
Committee for the opportunity to present my views.

    Mr. Coburn. Mr. Underwood?

 STATEMENT OF HON. ROBERT A. UNDERWOOD, A DELEGATE IN CONGRESS 
                           FROM GUAM

    Mr. Underwood. Good afternoon, Mr. Chairman, Ranking Member 
Brown, distinguished members of the committee.
    Thank you for the opportunity to speak before you today on 
a matter of great importance to us in this room, our health. I 
am here in my capacity as Chairman of the Congressional Asian 
Pacific Caucus and join in strong support with other members of 
this panel to urge the committee's support of H.R. 3250.
    The Asian American-Pacific Islander community is the most 
ethnically and racially diverse community in our country. AAPIs 
are comprised of both immigrant populations as well as 
indigenous populations from the Pacific Islands. Census data 
reports that Asian American-Pacific Islander community is the 
fastest growing community in our country today. We can expect 
to grow from a population of about 10 million or 5 percent of 
the total U.S. population to 10 percent by the year 2050.
    Asian Americans and Pacific Islanders are often labeled as 
the model minority with health or social problems. This is a 
myth and a gross misrepresentation of the situation. Within 
this population alone, there exists divergent economic and 
academic achievement rates and ethnically and racially diverse 
cultures.
    Large subpopulations of East Asians and South Asians often 
skew the reality for small sub populations of Southeast Asians 
and Pacific Islanders.
    Recent Department of Health and Human Services data shows 
that AAPI has experienced the highest rates of tuberculosis and 
Hepatitis B in the country. In fact, cervical cancer incidences 
are five times higher for Vietnamese women. Liver cancer among 
Vietnamese is found to be 11 times higher than the general 
population. Native Hawaiians have the second highest mortality 
rate to lung cancer. Diabetes affects tomorrow's natives of 
Guam at five times the national average and infant mortality 
rates in the U.S. and insular Pacific areas are more than 
double the national average.
    It is clear that the face of America has become 
increasingly diverse as its minority populations continue to 
grow and as our minority populations increase, so will the 
complexity of our health situation, which means that we need 
innovative approaches to deal with this issue.
    The Health Care Fairness Act lays out a play to reducing 
racial and ethnic disparities in health care and health care 
outcomes by elevating the Office of Research on Minority Health 
to create a center for health disparities research at the 
National Institutes of Health. We will significantly increase 
the support of research on health care disparities, improving 
data collection relating to race and ethnicity and funding 
major increases in minority medical training and curriculum 
development. The NIH needs a strong and effective coordinating 
body to focus research and awareness on the health care needs 
of all minorities.
    There is also much room for improvement in the methods of 
data collection. Within the Asian American and Pacific Islander 
community there exists scant local and Federal data to document 
the needs of our communities. It is only with the emergence of 
more recent and improved data collection that we are beginning 
to realize the unique needs of the AAPI communities.
    The Health Care Fairness Act represents a comprehensive, 
bipartisan effort to effectively address the health care needs 
of all our communities. As Chairman of the Congressional Asian-
Pacific Caucus, I strong urge your support and commitment to 
bridge the gap which denies minority Americans from receiving 
fair access to health care, health care that has meaning in 
their cultures and their lives, and other quality of life 
services.
    I join with my colleagues on this panel to urge you to move 
forward with this bill.
    Thank you very much.
    [The prepared statement of Hon. Robert A. Underwood 
follows:]
  Prepared Statement of Hon. Robert A. Underwood, a Delegate from Guam
    Good afternoon, Chairman Bilirakis and Members. Thank you for an 
opportunity to speak before the Committee today on a matter of great 
importance to many of us in this room--our health. I am here in my 
capacity as Chairman of the Congressional Asian Pacific Caucus and join 
in strong support with my fellow colleagues on this panel to urge the 
Committee's support for H.R. 3250, the Health Care Fairness Act.
    The Asian American and Pacific Islander (AAPI) community is the 
most ethnic and racially diverse community in our country. It is also 
the most heterogenous community. AAPIs are comprised of both immigrant 
populations (including East Asians from Japan and China, Southeast 
Asians from Vietnam, Cambodia, and Laos, and South Asians from India) 
and indigenous populations of Pacific Islanders (Native Hawaiians, 
Chamorros from Guam and the Commonwealth of the Northern Mariana 
Islands, and American Samoans). Census data reports the Asian American 
and Pacific Islander community is the fastest growing community in our 
country today. We expect to grow from a population of 10.4 million or 5 
percent of the total U.S. population to 10 percent by 2050.
    Asian Americans and Pacific Islanders are often labeled as the 
``model minority'' with few health or social problems. This is a myth 
and a gross misrepresentation of AAPIS. Within this population alone, 
there exists divergent economic and academic achievement rates and 
ethnic and racially diverse cultures. The large subpopulations of East 
Asians and South Asians often skew what the reality is for the smaller 
subpopulations of Southeast Asians and Pacific Islanders, who 
traditionally do not parallel the same rates of the larger 
subpopulations.
    Department of Health and Human Services data shows:

 AAPIs experience the highest rates of tuberculosis and 
        Hepatitis B in the country;
 Although new cancer cases declined for all racial and ethnic 
        groups from 1990 to 1995, the rates for AAPI women remained 
        level;
 In fact, cervical cancer incidences are 5 times higher for 
        Vietnamese women;
 Liver cancer among Vietnamese is found to be 11.3 times 
        higher;
 Chinese Americans have the highest rate of nasopharyngeal 
        cancer in the country;
 Native Hawaiians have the second highest mortality due to lung 
        cancer;
 Diabetes affects Chamorros at 5 times the national average; 
        andInfant mortality rates in the U.S. Pacific insular areas are 
        more than double the national average.
    It is clear that the face of America is becoming increasingly 
diverse as its minority populations continue to grow. And, as our 
minority populations increase, so will complexity of our health 
situation.
    The Health Care Fairness Act lays out a plan to reduce racial and 
ethnic disparities in health care and health care outcomes. By 
elevating the Office of Research on Minority Health to create a Center 
for Health Disparities Research at the National Institutes of Health 
(NIH), we will significantly increase the support for research on 
health disparities, improving data collection relating to race and 
ethnicity and funding major increases in minority medical training and 
curriculum development. The NIH needs a strong and effective 
coordinating body to focus research and awareness of the health care 
needs of all minorities.
    There is much room for improvement to the methods of data 
collection. Within the Asian American and Pacific Islander community, 
there exists scant local and federal data to document the needs of our 
communities. It is only with the emergence of more recent and improved 
data collection are we beginning to realize the needs of our AAPI 
communities. This lack of data is our greatest impediment to addressing 
health disparities. We support the provision to comprehensively study 
and conduct data collection methods that accurately report the health 
care status of our communities. I also ask that the National Academy of 
Science ensure that data collected for Pacific Islanders be 
disaggregated as directed in the Office of Management and Budget Policy 
Directive 15, which was revised in October 1997 and created a new 
category for ``Native Hawaiian or Other Pacific Islander.''
    The Health Care Fairness Act represents a comprehensive, bipartisan 
effort to effectively address the heath care needs of all our 
communities. As Chairman of the Congressional Asian Pacific Caucus, I 
strongly urge your support and commitment to bridge the gap which 
denies minority Americans from receiving fair access to health care and 
other quality of life services. I join with my colleagues on this panel 
to urge you to move this bill forward.
    For many years, we have fought this battle in the matter of 
education. We have acknowledged that there is a strong necessity to 
address the educational needs of minority communities to level the 
playing field for all Americans. Now is time to level the playing field 
so that all Americans, have fair and equal access to health care and 
health outcomes. I urge you're your strengthened commitment to support 
comprehensive strategies like the Health Care Fairness Act to address 
health disparities among ethnic and minority groups. I urge the 
Committee move this bill forward to markup and passage before we 
adjourn the 106th Congress.
    The Committee's record in addressing the health needs of all 
minority communities is to be commended. I would like to thank the 
Committee for its continuing support. I appreciate the opportunity to 
testify and will remain for any questions.

    Mr. Coburn. Mr. Rodriguez?

    STATEMENT OF HON. CIRO D. RODRIGUEZ, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Rodriguez. Thank you, Mr. Chairman.
    I want to also thank Mr. Bennie Thompson, Congressman 
Lewis, Congressman Jackson and Congressman Underwood for their 
efforts in the area of health care.
    Let me say the Hispanic Caucus, as of last year, had some 
hearings and one of the things we found was that there was five 
areas of concern that we had. One of those was access to health 
care. As you have indicated, Mr. Chairman, it is not only 
minorities in that areas, one of the things we found was there 
is a disparity in terms of Hispanics, that one are one of the 
largest uninsured groups but beyond that, anyone who is working 
for a small company, who is not working for government, not 
working for a major corporation but is making money, doesn't 
qualify for Medicaid, finds themselves without access to health 
care. The need for us to do something in that area is key.
    Second, we found that the area of funding, when it comes to 
Hispanics, there is definitely a disparity. We find a lot of 
community organizations do not have access to those services 
and there is a need for us to be more responsive in terms of 
our governmental entities in reaching out.
    Third, we found that cultural competency information is 
key. I will give you an example of when a doctor testified to 
the fact that we had a woman who was told she was positive when 
it came to HIV and in Espanol when you say ``positivo,'' it is 
like in English, you think everything is okay and that is what 
she thought. Later she had a child and found both were HIV 
positive. That was unfortunate.
    We also found that there is a lack of representation in 
terms of the health profession in terms of Hispanics in all 
fields of the health profession. The need for us to make sure 
that we hold not only agencies accountable but the schools to 
allow individuals to be able to have that opportunity, to meet 
some of the needs of our constituents out there.
    We found there was a lack of data collection and the need 
for us to be able to get some data, for example, in finding out 
why it is that Hispanics are disproportionately hit with 
diabetes and a variety of other issues.
    Those are the five areas we found were critical. This bill 
allows us an opportunity to move forward in some of those areas 
and we are optimistic. We are pleased that you are having this 
hearing to allow us the opportunity to be able to do that.
    There is no doubt that there is a need for us to zero in on 
these areas and make to make sure that we prioritize those 
items. The individuals you see before you are eager to move 
forward.
    Thank you for allowing us this opportunity.
    [The prepared statement of Ciro D. Rodriguez follows:]
   Prepared Statement of Hon. Ciro D. Rodriguez, a Representative in 
                    Congress from the State of Texas
    Good morning and thank you for the invitation to testify before the 
Commerce Subcommittee on Health. It is an honor to be here with my 
colleagues to testify on the health needs of our communities. As 
representatives of districts with diverse needs we welcome the 
opportunity to join you in efforts to improve not only the health 
status of our communities but also of all Americans.
                   the congressional hispanic caucus
    I currently chair the Congressional Hispanic Caucus Health Task 
Force. As you may know, the CHC is an informal group of 18 Hispanic 
Members of Congress dedicated to voicing and advancing issues affecting 
Hispanic Americans in the United States and the insular areas. We have 
nine task forces which tackle issues ranging from immigration to 
economic development. It is primarily out of the CHC's Health Task 
Force that we work to address health concerns affecting the Latino 
community.
    As Members of Congress, it is our individual responsibility to 
educate our colleagues about issues of importance to each of the 
districts we represent. As Members of the CHC, this responsibility 
increases since we speak for the needs and interests of many more 
people than those living in the 18 districts we represent. To achieve 
our collective goals of educating our colleagues and promoting 
legislation, we compile a list of budget and legislative priorities 
each year. These priorities serve as a guideline for our colleagues to 
inform them on issues of importance to their own constituents.
    The CHC health agenda is aimed at meeting the needs of our growing 
and diverse community. There are nearly 30 million Hispanics currently 
in the United States, constituting approximately 11% of the entire 
population. By the year 2025 our numbers are expected to increase to 
nearly 20% of the U.S. population, making Hispanics the largest 
minority group in the country. The origins of our current population 
varies: approximately 64%, are Mexican, 14% Central or South American, 
11% Puerto Rican, 4% Cuban, and the remaining are from mixed origins. 
Within these sub-populations we find unique health needs that vary from 
community to community and neighborhood to neighborhood.
    During this 106th Congress, the CHC as a caucus has followed 
numerous issues related to health care. We worked on issues that range 
from the clarification of immigrants' ability to enroll in programs 
such as the Children's Health Insurance Program (CHIP) and Medicaid 
without jeopardizing their immigration status to participation in 
events to highlight cultural and ethnic issues related to the delivery 
of mental health services. Some of the legislative initiatives 
sponsored by CHC Members include proposals to make health care 
available to legal immigrants, increase health care access in minority 
neighborhoods, and improve generally the quality of patient care and 
rights.
             health disparities and the hispanic community
    Addressing health disparities is a priority for the Hispanic 
Caucus. In September 1999, our caucus sponsored Hispanic Health 
Awareness Week here on Capitol Hill. This effort included a series of 
hearings sponsored by the CHC on Hispanic health disparities that 
focused on three areas: diabetes, HIV/AIDS, and mental health. The 
purpose of the hearings was to gather information from the community 
and educate our colleagues here on Capitol Hill about the unique health 
needs of Latinos.
    Although the hearings focused on the impact of specific diseases 
and highlighted ways to deal with these particular problems, they also 
provided a broader view of the challenges that we must meet to 
effectively address the health care needs of Hispanic Americans and all 
communities of color. These challenges include:

 Access to Health Care. Hispanics constitute \1/3\ of the 
        uninsured population in the United States, which results in 
        large numbers of patients being forced to delay or avoid health 
        care until the problem becomes particularly acute or an 
        emergency.
 Funding. Community based organizations that serve the Latino 
        community require additional resources to strengthen existing 
        programs and develop new initiatives.
 Culturally Competent Information. Culturally inappropriate, 
        difficult to understand and monolingual, health related 
        information prohibits Latinos from making educated decisions 
        about their well-being and health care options.
 Representation of Latino Health-Care Professionals. Latinos 
        are under-represented in the health professions, which 
        increases the barriers related to culturally competent 
        education programs, messages and health care delivery.
 Data Collection. Data collected at state and federal levels 
        must be adapted and improved to reflect the needs of the 
        growing and diverse Hispanic population.
    The findings compiled from our hearings present a grim reality of 
the health status of the Latino community. Some of the alarming 
examples of these problems are:

 type 2 diabetes impacts Latinos at a rate approximately twice 
        that of the non-Hispanic population;
 retinopathy, a debilitating eye disease and a leading 
        complication of diabetes, is 80% higher among Mexican-Americans 
        than among non-Hispanic whites;
 20% of new AIDS cases occur among Hispanics,
 in 1997, AIDS was the third leading cause of death among 
        Hispanics between 25 and 44; and
 Hispanic girls lead the nation in the rates of suicide 
        attempts, alcohol and drug abuse.
    These findings are specific to the Hispanic community but the 
disparity exists in all communities of color whether it is diabetes, 
HIV/AIDS, cancer, or mental health. We share the common bonds of 
despair, fear, and hope that in working together we will not reduce 
health disparities but rather eliminate them within our lifetime.
    The CHC has compiled the information from our hearings into a 
report that has been officially released. Although we have provided a 
short summary of the findings and recommendations outlined in our 
report, we respectfully submit a copy of this report for the 
committee's review.
      the health care fairness act--addressing health disparities
    The recommendations presented during our hearings offer options to 
improve the health care status of Latinos and all Americans. These 
recommendations included funding for existing programs, genetic 
research studies to establish why Hispanics are more prone to 
developing Type 2 diabetes, and adequate representation of Hispanic 
health care professionals through culturally competent medical and 
health profession education. Many of the issues raised during the 
hearings would be addressed through the implementation of H.R. 3250, 
the Health Care Fairness Act, specifically through the research, data 
collection and the proper education of our health professionals.
Research
    The research component to addressing health disparities plays a 
critical role for our communities. For example, I mentioned before that 
Hispanics suffer disproportionately from diabetes and in particular 
Type 2 diabetes. Type 2 diabetes accounts for 90 to 95 percent of 
diabetes cases nationwide, and it is the most common form in the 
Hispanic community. With these statistics on just one disease, many 
wonder why Hispanics are more prone to acquire diabetes.
    The proposal within this legislation to establish the National 
Center for Research on Minority Health and Health Disparities at the 
National Institutes of Health would address this and many other 
questions, by working with biomedical institutions, community based 
agencies, and nonprofit entities that target all minority communities 
in the United States. Through the Center, we would be able to establish 
consistent federal support for issues that affect Hispanics and other 
communities, as well as hopefully include Hispanics in the medical and 
health services research. Creating this research pipeline for Hispanics 
and other minorities is key to ensuring that the health care needs of 
all minorities will always be on the radar screen at places like the 
NIH.
    These two components go hand in hand in addressing health 
disparities. If we are to research the specific health needs of 
minorities communities we must provide opportunities for minorities to 
be included in the process every step of the way. This includes 
creating the research pipeline for Hispanics and others of color to 
become intimately involved in the research process. Along with the loan 
forgiveness in this section of the legislation, we would advocate 
aggressive recruitment of all minorities that are under-represented in 
biomedical research fields. It is our hope that through this 
legislation, the Center would be able to play a leadership role in 
increasing NIH's focus on domestic health disparities that have long 
been ignored.
Data Collection
    Knowing where the health problems are within all of our communities 
is one of the greatest challenges we face in addressing health 
disparities. The lack of specific and accurate data on the health and 
medical needs of Hispanics is particularly challenging given our great 
diversity. Currently, most data is collected and segregated using 
Hispanic or Latino without any subdivisions. For example, Mexican 
Americans may be more prone to diabetes while Cubans may not. Central 
and South Americans may be more prone to cardiovascular diseases but 
Puerto Ricans may not. This information is not necessarily available 
because not all current systems collect along sub-population lines. 
Accurate data collection with sub-divisions win allow us to target 
precious resources to the communities in need while at the same time 
predicting health outcomes.
    The issue of data collection is a challenge acknowledged by the 
Department of Health and Human Services. The Healthy People program has 
worked to address data collection short falls by establishing critical 
baseline numbers on more than just the Hispanic community and various 
subpopulations. However, improved collection and use of standardized 
data to identify all high risk populations and monitor progress will be 
needed if we are to make any true strides in eliminating health 
disparities.
    The study proposed in the legislation will allow us to move forward 
with HHS on furthering data collection efforts and will provide 
Congress with recommendations on what more can be done. With this study 
we hope to provide the necessary evidence on the need for strengthened 
data collection efforts and eventually provide targeted resources to 
HHS to achieve this goal.
Cultural Competency
    An overwhelming barrier to accessing health care especially for the 
Hispanic community has been the ability of health professionals to 
adequately communicate with patients. During the Hispanic Health 
Awareness hearing, Dr. Barbara Naranjo told a story of a woman in South 
Texas who was told by a health clinic doctor that her HIV test was 
positive, or as it was told in Spanish ``positivo.'' No further 
explanation was given to the woman about what positive or ``positivo'' 
meant, therefore she went on with her life, without treatment and 
critical services. Nearly a year later, Dr. Naranjo was visited by the 
woman who by that time was pregnant. When an HIV test was done and 
found to be positive, Dr. Naranjo spoke to the woman about the disease 
and what it meant. The woman had no idea that she was diagnosed with a 
life threatening disease that could be transferred to her baby. Nine 
months later, the baby was born with HIV, something that could have 
been avoided if the mother had had the disease properly explained to 
her along with the options in treatment she could receive.
    No matter how heart breaking this story is, it is not uncommon. 
Millions of individuals who lack the basic understanding of medical 
``lingo'' are unable to make informed decisions on what is the best 
treatment for their diagnosis. Many of these barriers in communication 
may be eliminated by increasing awareness through cultural competence 
training for all health professionals and increasing the presence of 
minorities in all the health profession fields.
    Providing cultural competence training in health professionals 
education curriculum is urgently needed, especially given the 
tremendous diversity in our population here in the United States. By 
educating our health professionals on how to deal with the various 
traditions and cultures within our communities we can be assured that 
services will be more accessible and effective in reaching communities 
in need.
    Hispanics in general are less likely to seek services because they 
lack health insurance. Hispanics are also less likely because of the 
difficulties in navigating the health care system. For instance, 
hospitals or clinics commonly do not have health professionals that can 
only speak English. In some cases hospitals have been known to bring in 
janitors or other support staff to translate to a patient but not 
necessarily communicate. All too often we mistake translation for 
effective communication and this is especially true in the health 
field. Just because we have spoken to a patient in Spanish or given 
them a translated document, does not necessarily mean they understand 
better. Time, patience, and skills acquired from quality cultural 
competence training must be used in communicating with patients.
    Effective and structured curriculum on cultural competence, as 
suggested within H.R. 3250, would resolve many of the obstacles our 
communities face on a day to day basis. To further help many of those 
in the Hispanic community, I would hope we could embrace innovative 
curriculae that deal with the complex needs of communities of color.
                               conclusion
    All of the areas I have focused on are aimed at addressing the 
health disparities within our communities, and more importantly, in 
improving access to quality health care. Hispanics are the largest 
uninsured minority population at nearly 40% without health insurance. I 
ask that this Committee take into consideration the health needs of 
millions of Americans as we work on the health disparities within our 
communities.
    For far too long we have failed to truly address the needs of 
communities disproportionately suffering from health disparities. H.R. 
3250 is the first step we must all take in finally addressing the 
health care needs of a large segment of our population. If we fail to 
act on this legislation we fail far too many people. Do not forget that 
these individuals are not faceless or nameless. They are the people we 
have been elected to represent. Let us do our job and work to pass this 
legislation.
    I applaud the efforts of this Committee to address minority health 
and the needs of the Hispanic community. I look forward to working with 
you and ask that you use the Hispanic Caucus as a resource for any 
future legislation the Committee may consider. I appreciate the 
opportunity to testify and will remain for questions from members of 
this Committee.

    Mr. Coburn. The gentleman from Arizona, Mr. Hayworth.

 STATEMENT OF HON. J.D. HAYWORTH, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF ARIZONA

    Mr. Hayworth. Thank you. It is a honor to be here with you.
    I am here today in my capacity as co-chairman of the 
Congressional Native American Caucus. I want to thank you, Mr. 
Chairman, for offering all of us this opportunity to testify on 
H.R. 3250, the Health Care Fairness Act. I would like to 
commend all of you for holding this hearing on ways to address 
minority health disparities and health research education and 
access to health care in minority populations.
    In 1976, Congress enacted the Indian Health Care 
Improvement Act. The Act is one of the most comprehensive 
efforts by Congress to address the health needs and health 
status of American Indian and Alaska Natives. Although 
improvements in the health status of American Indians and 
Alaska Natives have been accomplished, the unmet health needs 
of this population continue to be staggering.
    As indicated in recent studies by the Centers for Disease 
Control and Prevention, the disparity between the health of 
Native Americans and the rest of the population is ever 
widening. Native Americans suffer the worse health status of 
any racial or ethnic group in America with a diabetes rate that 
is three times greater than the general population and a death 
rate 4.3 times greater than the general population from 
complications of diabetes.
    In addition, Native Americans suffer rates of heart disease 
two times as high as the general population. Cancer and 
alcoholism are six times the national rate. Hepatitis is two 
times as high as the general population and tuberculosis at 
five times the rate of the general population.
    A stunning example of the disparity is the Gila River 
Indian Community in the 6th Congressional District of Arizona 
whom I represent. The community is well known to medical 
officials for its shockingly high rate of Type II adult onset 
diabetes. According to the World Health Organization, the Pima 
Indians who make up the majority of this community's 
population, have the highest known rate of diabetes in the 
world. Community members are 12 times more likely to die of 
diabetes and its severe complications than the average 
American.
    For over three decades, members of the community have been 
studied by the National Institutes of Health and outside 
parties. The National Institute for Diabetes and Digestive and 
Kidney Diseases has supported a field research station in 
Arizona since 1965. Community members have been weighed, poked, 
prodded, x-rayed and screened at a cost to taxpayers more than 
$100 million.
    Based on the data obtained, NIH was able to develop new 
approaches to the treatment of Type I diabetes, juvenile 
diabetes. The NIH research program findings failed to study the 
treatment prevention of Type II diabetes, the type of diabetes 
that affects the very people who were used to obtain the data.
    Despite three decades of research, the Type II diabetes 
epidemic within the community continues to accelerate. In a 
disturbing development, the age of onset of Type II diabetes 
has been decreasing steadily. In fact, within the community, 
the term adult onset diabetes is rapidly becoming a misnomer. 
The community also has the largest known cluster of children 
with Type II diabetes in the world.
    Congress has a special trust responsibility to assure the 
highest possible health status is achieved for Native 
Americans. Despite the trust responsibility, Native Americans 
and Alaskan Natives continue to bear a disproportionate burden 
of illness and premature mortality in comparison with other 
American populations.
    The lesson to learn from the Gila experience is that tribal 
self interests must be taken into consideration. Congress must 
look for ways to give tribes more direct control over the 
prevention, intervention and treatment of serious diseases 
affecting their populations.
    We look forward to working with the committee to develop 
solutions for innovative and culturally sensitive methods to 
address health disparities for Native Americans and Alaska 
Natives.
    Again, I thank the Chair and the committee.
    [The prepared statement of Hon. J.D. Hayworth follows:]
Prepared Statement of Hon. J.D. Hayworth, a Representative in Congress 
 from the State of Arizona on Behalf of Himself and Hon. Dale E. Kildee
    Mr. Chairman, good morning. As Co-chairman of the Congressional 
Native American Caucus, I want to thank you for giving me this 
opportunity to testify on H.R. 3250, the Health Care Fairness Act. I 
commend the Chairman and other distinguished committee members for 
holding a hearing today on ways to address minority health disparities 
in health research, education, and access to health care in minority 
populations.
    In 1976, Congress enacted the Indian Health Care Improvement Act. 
The Act is one of the most comprehensive efforts by Congress to address 
the health needs and health status of American Indian and Alaska 
Natives. Although improvements in the health status of American Indians 
and Alaska Natives have been accomplished, the unmet health needs of 
this population continue to be staggering.
    As indicated in the recent studies by the Centers for Disease 
Control and Prevention (CDC), the disparity between the health of 
Native Americans and the rest of the population is ever-widening. 
Native Americans suffer the worst health status of any racial or ethnic 
group in America with a diabetes rate that is 3 times greater than the 
general population, and a death rate 4.3 times greater than the general 
population from complications of diabetes. In addition, Native 
Americans suffer rates of heart disease 2 times as high as the general 
population, cancer and alcoholism 6 times the U.S. rate, hepatitis 2 
times as high as the general population, and tuberculosis at 5 times as 
high as the general population.
    A stunning example of this disparity is the Gila River Indian 
Community in Arizona. The Community is well-known in the medical 
community for its shockingly high rate of Type 2 (adult-onset) 
diabetes. According to the World Health Organization, the Pima Indians, 
who make up the majority of the Community population, have the highest 
known rate of diabetes in the world. Community members are twelve times 
more, likely to die of diabetes and its severe complications than the 
average American.
    For over three decades, members of the Community have been studied 
by the National Institutes of Health (NIH) and outside parties. The 
National Institute for Diabetes and Digestive and Kidney Diseases 
(NIDDK) has supported a field research station in Arizona since 1965. 
Community members have been weighed, poked, prodded, x-rayed, and 
screened at a cost to taxpayers of more than $100 million.
    Based on the data obtained, NIH was able to develop new approaches 
to the treatment of Type I diabetes, juvenile diabetes. The NIH 
research program findings failed to study the treatment and prevention 
of Type 2 diabetes, the type of diabetes that affects the very people 
who were used to obtain the data. Despite three decades of research, 
the Type 2 diabetes epidemic within the Community continues to 
accelerate.
    In a disturbing development, the age of onset of Type 2 diabetes 
has been decreasing steadily. In fact, within the Community the term 
``adult-onset'' diabetes is rapidly becoming a misnomer; the Community 
also has the largest known cluster of children with Type 2 diabetes in 
the world.
    Congress has a special trust responsibility to assure the highest 
possible health status for Native Americans. Despite the trust 
responsibility, American Natives and Alaska Natives continue to bear a 
disproportionate burden of illness and premature mortality in 
comparison with other U.S. populations. The lesson to learn from the 
Gila experience is that tribal self-interest must be taken into 
consideration. Congress must look for ways to give tribes more direct 
control over the prevention, intervention, and treatment of, serious 
diseases affecting their population,
    We look forward to working with the committee to develop solutions 
for innovative and culturally-sensitive methods to address health 
disparities in Native Americans and Alaska Natives.

    Mr. Coburn. Mr. Watts.

   STATEMENT OF HON. J.C. WATTS, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF OKLAHOMA

    Mr. Watts. Thank you very much for holding this hearing.
    I am going to have to leave shortly after my testimony so I 
do appreciate you being with me.
    I would again like to thank you for holding this hearing 
today concerning H.R. 3250, the Health Care Fairness Act. I 
would also thank my colleagues who are present today, 
especially Mr. Lewis, Mr. Norwood and Mr. Jackson and all the 
other members who have championed this critical legislation.
    I am also proud testifying here today is Mr. John Harley, a 
member of the Oklahoma Medical Research Foundation. OMRF is 
truly a beacon of excellence in scientific research for the 
State of Oklahoma and the Nation. The scientists at OMRF play a 
significant role in uncovering clues to the origin of human 
disease and thereby building a biomedical industry. OMRF 
discoveries are helping to lead the way in the fight against 
cancer, heart disease, stroke, diabetes, lupus and other 
diseases that plague mankind, and especially minorities.
    Just as biomedical research is helping to address the 
disparities in health, so will the Health Care Fairness Act. 
The Act comprehensively addresses health disparities by 
elevating the existing Office of Research on Minority Health at 
the National Institutes of Health to a National Center for 
Research on Minority Health. It also addresses bias in health 
care through education and an improved data system, and 
strengthened public awareness.
    Despite continued advances in research and medicine, 
disparities in health care are an ever increasing problem and a 
concern. This is evidenced by the fact that minority Americans 
lag behind on nearly every health indicator including health 
care coverage, access to care, life expectancy and disease 
rates.
    Ethnic minorities and individuals in medically underserved 
rural communities continue to suffer disproportionately from 
many diseases such as cancer, diabetes and cardiovascular 
diseases.
    There have been numerous studies in scientific journals 
showing the severity of racial and ethnic health disparities 
and the need for action in order to remedy this grave problem. 
As previously noted, disease rates and access to health care 
are two of the many different facets of disparity.
    In October 1999, the Henry J. Kaiser Family Foundation 
found that many studies have repeatedly documented that 
African-Americans were significantly less likely than whites to 
receive diagnostic and surgical interventions for heart disease 
and stroke. Numerous studies have also found that racial and 
ethnic minorities were more likely than whites to be diagnosed 
with cancer at advanced stages and less likely to receive major 
therapeutic intervention.
    With regard to diabetes to which I lost a mother several 
years ago, racial differences have been documented and the 
degree and method of diabetes control.
    In closing, I would like to point out the obvious. Access 
to quality health care is crucial. We must all work together to 
see that the health care needs of everyone, including 
minorities in rural populations, are met. There is no single 
cause of racial disparities in health and there is no single 
solution but there is no doubt that greater public awareness is 
mandatory if we are going to have an impact on this problem.
    Elimination of health disparities must be a higher 
priority. The Health Care Fairness Act will increase our 
knowledge of the nature and causes of health disparities, 
improve the quality and outcomes of health care services for 
minority populations and aid in bringing us closer to our 
mutual goal of closing the longstanding gap in health care.
    I am deeply committed to this piece of legislation and I 
urge all Members of Congress to support us in our effort to 
rectify this inequality in health care.
    Mr. Chairman, Mr Coburn, and members of the committee, I 
thank you for your time and your sincere interest in addressing 
this critical issue.
    Mr. Coburn. Thank you.
    I believe the committee is not going to be asking questions 
of this panel. I do want to tell you that I think all members 
of the subcommittee see the problem is real and we will be 
making every effort to support you in your efforts.
    Mr. Bilirakis. Certainly, the details of the larger bill, 
Mr. Lewis' and Mr. Thompson's bill, are significant, however, 
the Center might be a stumbling block. We would hope it would 
not be.
    I wanted to suggest to you knowing that--and Mr. Jackson 
and I have had long discussions about this--you may want to 
gather together your ammunition to address the things Mr. 
Jackson and I spoke about. Some of us feel very strongly about 
creating the Center and there are others who raise 
technicalities, the fact that the director apparently--maybe we 
will find out more in a little while--is not supportive or at 
least is not expressing any support.
    Thank you.
    Not knowing whether Mr. Coburn has placed into the record 
the opening statements of all members of the subcommittee, I 
will now say that without objection, all opening statements are 
made a part of the record.
    First, I do want to apologize. I had a Veterans Committee 
markup on an education bill for veterans and that was scheduled 
for 10 a.m., so we scheduled this hearing for 11:30 a.m., 
figuring I would be able to get out of that. Then they called 
the votes shortly after 10 a.m. and we had six votes which 
meant that markup was delayed, consequently everything was set 
back for me. I appreciate Mr. Coburn taking the time to come 
over and get things started so we did not get started too late.
    Panel two will consist of the Honorable David Satcher, U.S. 
Surgeon General, accompanied by Mr. Kermit Smith, Chief Medical 
Officer, Indian Health Service and Mr. John Ruffin, Associate 
Director, Research on Minority Health, National Institute of 
Health. Thank you gentlemen. Welcome to our hearing.
    Mr. Satcher, you are testifying on behalf of the 
Administration. The clock ordinarily is 5 minutes. You have 10 
minutes and hopefully you can get your point across within that 
period of time but we will extend it if we have to.
    Please proceed, sir.

     STATEMENT OF HON. DAVID SATCHER, U.S. SURGEON GENERAL, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Mr. Satcher. Thank you very much. I want to express my 
appreciation for the invitation to testify at this very 
important hearing on ways to improve the quality of health and 
health care for minorities and H.R. 3250, the Health Care 
Fairness Act of 1999.
    As you pointed out, with me today are experts from the 
Indian Health Service, Dr. Kermit Smith, and Dr. John Ruffin, 
the Associate Director of the Office of Research on Minority 
Health at NIH.
    Let me say how much we appreciate the testimony of Panel I 
and the presence of Secretary Sullivan and his outstanding 
contributions in this area before, during and since he served 
as Secretary of the Department of Health and Human Services.
    I also want to acknowledge Jordan Cohen from the 
Association of Medical Colleges who in the face of incredible 
odds has worked so hard to improve the representation of 
minorities in the health profession.
    Your topic could not be more appropriate as we examine the 
state of minority health in America. We are really addressing 
the status of our Nation's health overall and the strength of 
our public health system.
    Despite notable progress in overall health of the Nation, 
there are continuing disparities in the burden of illness and 
death experienced by African-Americans, Hispanics, American 
Indian and Alaska Natives and Pacific Islanders compared to the 
U.S. population as a whole. These disparities are not explained 
by biologic or genetic characteristics of racial and ethnic 
groups. Instead, they are believed to be the results of a 
complex interaction among genetic variation, environmental 
factors, economics, specific health behaviors and 
discrimination in access and quality of health care.
    The Department of Health and Human Services adopted the 
commitment to eliminate disparities in health on the basis of 
race and ethnicity by the year 2010. I think we did this first 
in response to President Clinton's request that a health 
component be added to the Race Initiative which he announced in 
1997.
    Second, the goal of eliminating disparities in health is 
one of the two goals of Healthy People 2010. We will focus 
initially on six key areas that reflect areas of disparity 
across multiple racial and ethnic minority groups. They are 
infant mortality, breast and cervical cancer screening and 
management, cardiovascular disease risk factor reduction, 
diabetes complications, adult and childhood immunizations and 
HIV infections and AIDS.
    We want to make it clear, however, that we are not limiting 
our efforts to these six areas with which we will begin. There 
are many other areas of disparity. Sunday, we will celebrate 
Mother's Day. Earlier this morning, I was with Congresswomen 
Nita Lowey and Cynthia McKinney to talk about safe motherhood. 
African-American women are four times more likely to die during 
and around pregnancy than the majority of women in this 
country.
    We could talk about asthma. There are several areas of 
disparity and the idea here is to begin with these six where we 
have the kind of data base that we can measure our progress and 
we believe we can have a great impact. All of these areas are 
of concern to us.
    I want to speak briefly about what we are doing since you 
have heard the statistics relative to these disparities. We 
have begun a program to address disparities starting with 
President Clinton's announcement in February 1998 shortly after 
I became Surgeon General. One component of the Department's 
initiative is the Racial and Ethnic Approaches to Community 
Health, REACH-2010. It is designed to help communities mobilize 
and organize their resources in support of effective and 
sustainable programs that will eliminate health disparities.
    So far, 32 communities have been funded to develop plans 
for eliminating disparities in 1 of these 6 areas, some of them 
more than one. The communities with acceptable plans will 
receive programmatic funding during Phase II and new 
communities will be funded later this year.
    The Office of Civil Rights has played a very critical role 
in the Department's initiative to eliminate disparities in 
health. They have focused on enforcement, education and 
outreach and I think are doing a great job. I want to give you 
a few examples of the work of the Office of Civil Rights. These 
cases illustrate the discrimination that regrettably still is 
alive and well in the health care setting.
    The Office of Civil Rights recently reached a settlement 
with the National Home Health Agency that had engaged in 
medical redlining, that is, it refused to serve a predominantly 
minority area of New Haven, Connecticut. The Office of Civil 
Rights reached an agreement with a national pharmacy chain that 
had repeatedly failed to fill prescriptions of an African-
American Medicaid recipient in Texas. The Office of Civil 
Rights reached a settlement with a hospital in South Carolina 
that had a policy in effect of not giving epidurals to women 
who did not speak English.
    There were several of these kinds of experiences but I 
think we are finding that through a process of enforcement, 
education and communication, that we can, in fact, make 
significant progress.
    The NIH has established a Working Group on Health 
Disparities that is currently developing a strategic plan to 
expand training programs for minority researchers to set 
priorities and to synchronize multidisciplinary research. That 
strategic plan will be reviewed by the Office of Research on 
Minority Health and its Public Advisory Committee.
    I do want to point out that after much discussion, the 
former Director of NIH, Dr. Varmus, has written a letter in 
support of the development of the Center and certainly the 
present Acting Director of NIH, Dr. Ruth Kirschstein supports 
the development of the Center. I wanted to make that point 
because I think it is important as you pointed out in terms of 
their positions.
    Addressing the challenge of health improvement is a shared 
responsibility that requires the active participation and 
leadership of the Federal Government, State and local 
government, other policymakers, health care providers, 
professionals, business leaders, et cetera. The Agency for 
Health Care Research and Quality plans to establish four 
centers of excellence this summer that will identify practical 
tools and strategies to eliminate racial and ethnic disparities 
in the health care system. HRSA is leading a campaign for 100 
percent access and zero percent disparities by the year 2010.
    An area of development that I think is really important is 
the development of partnerships between our department and many 
private sector groups. We are partnered with Grantmakers in 
Health which represents over 200 health-related foundations in 
this country. They are working with foundations and corporate 
giving programs to improve the Nation's health. They have made 
elimination of disparities a priority.
    The California Endowment has initiated a program in 
multicultural health aimed at eliminating health disparities 
and through collaboration with the CDC Foundation, has already 
funded three additional Reach 2010 projects in California.
    Likewise, the Robert Wood Johnson Foundation, the 
Commonwealth Foundation, the Kaiser Family Foundation and 
others have funded programs for the elimination of disparities 
in health.
    On April 24, 2000, our department and the American Public 
Health Association announced a partnership to eliminate racial 
and ethnic disparities. The partnership includes a three phase 
plan to develop a charge or blueprint of guidelines for our 
collaboration, develop a detailed comprehensive national plan, 
and third, to implement that plan by 2002.
    It is important to note the American Public Health 
Association represents 55,000 members, many of them leaders in 
public health throughout this country. When asked to rank 
issues for the year 2010, they listed elimination of 
disparities as their No. 1 priority. We are happy to be 
partnering with the American Public Health Association.
    The role of the Health Care Fairness Act of 1999 in 
improving minority health is significant, and I will close with 
these comments.
    We thank you for your support of our initiative to 
eliminate racial and ethnic disparities in health and its 
parallel emphasis with Healthy People 2010. The proposed Health 
Care Fairness Act of 1999 addresses several key elements the 
department has identified as essential to a comprehensive 
approach toward eliminating disparities. They include the 
development of a balanced and comprehensive research agenda 
that addresses the unequal burden of morbidity and mortality in 
racial and ethnic minorities.
    Supporting efforts to improve the quality and outcome of 
health care services as well as addressing the social 
determinants of health including but not limited to access to 
care, the ten leading health indicators of Healthy People 2010, 
five of which deal with lifestyle and five with health care 
system issues; strengthening the data collection infrastructure 
of HHS; recognition of the important role of the Office of 
Civil Rights; and support for graduate health education 
curriculum development and continuing medical education efforts 
to reduce disparity in health and health outcomes as well as 
increasing the knowledge base with respect to cultural 
competency.
    Mr. Chairman and members of the committee, as Surgeon 
General of the United States and as one who has a major 
responsibility in this area, I am encouraged by the evidence of 
the bipartisan, public-private, and Federal, state and local 
commitment that is developing in this country.
    As we continue our work to improve the lives of our fellow 
Americans, let me leave you with the premise upon which the 
U.S. Public Health Service was founded in 1798 as the Marine 
Hospital Service. That premise is, ``to the extent that we 
respond to the needs of the most vulnerable among us, we do 
most to promote and protect the health of the Nation.'' Thank 
you for the opportunity to share with you some of our 
department's activities and our perspectives. We appreciate 
your support and we look forward to our continuing partnership 
to improve health and the health care system in this country.
    We would be happy to respond to any questions.
    [The prepared statement of Hon. David Satcher follows:]
Prepared Statement of David Satcher, Assistant Secretary for Health and 
 Surgeon General, U.S. Public Health Service, Department of Health and 
                             Human Services
    Good morning. I am David Satcher, Assistant Secretary for Health, 
Department of Health and Human Services (HHS), and Surgeon General of 
the United States. I thank you, Mr. Chairman and members of the 
Committee, for your invitation to testify at this important hearing on 
how to improve the quality of health care for minorities and H.R. 3250, 
The Health Care Fairness Act of 1999. With me today are technical 
experts from the HHS agencies involved in ensuring the quality of 
health care for all Americans. They are: Kermit C. Smith, D.O., the 
Chief Medical Officer of the Indian Health Service; and John Ruffin, 
Ph.D., Associate Director Office of Research on Minority Health at the 
National Institutes of Health.
    Let me say that the topic of your hearing could not be more 
appropriate, for indeed, as we look at the state of minority health in 
America we are really looking into the future of our nation's health.
                     background on minority health
    In the 1985 Report of the Secretary's Task Force on Black and 
Minority Health, Secretary Margaret M. Heckler wrote these words, ``In 
January 1984--ten months after becoming Secretary of Health and Human 
Services--I sent Health, United States, 1983 to the Congress. It was 
the annual report of the health status of the American people. That 
report--like it predecessors--documented significant progress: 
Americans were living longer, infant mortality had continued to 
decline--the overall American health picture showed almost uniform 
improvement. But, and that ``but'' signaled a sad and significant fact, 
there was a continuing disparity in the burden of death and illness 
experienced by Blacks and other minority Americans as compared with our 
nation's population as a whole. That disparity has existed ever since 
accurate federal record keeping began--more than a generation ago. And 
although our health charts do itemize steady gains in the health of 
minority Americans, the stubborn disparity remained--an affront both to 
our ideals and to the ongoing genius of American medicine. The report 
is comprehensive. Its analysis is thoughtful. Its thrust is masterful. 
It sets the framework for meeting the challenge--for improving the 
health of minorities. It can--it should--mark the beginning of the end 
of the health disparity that has, for so long, cast a shadow on the 
otherwise splendid American track record of ever improving health.''
    It is now the year 2000.
    Compelling evidence that race and ethnicity correlate with 
persistent, and often increasing, health disparities among U.S. 
populations demands national attention. Indeed, despite notable 
progress in the overall health of the Nation, there are continuing 
disparities in the burden of illness and death experienced by African 
Americans, Hispanics, American Indians, Alaska Natives, and Asian 
Pacific Islanders, compared to the U.S. population as a whole. Current 
information about the biologic and genetic characteristics of racial 
and ethnic groups does not explain the health disparities experienced 
by these groups compared with the white, non-Hispanic population in the 
United States. These disparities are believed to be the result of the 
complex interaction between genetic variations, environmental factors, 
economics, specific health behaviors, and discrimination.
    Even though the Nation's infant mortality rate is down, the infant 
mortality rate among African Americans is still more than double that 
of white citizens. Heart disease death rates are more than 40 percent 
higher for African Americans than for whites. The death rate for all 
cancers is 30 percent higher for African Americans than for whites; for 
prostate cancer, it is more than double that for whites. African 
American women have a higher death rate from breast cancer despite 
having a mammography screening rate that is higher than for white 
women. The death rate from HIV/AIDS for African Americans is more than 
seven times that for whites; the rate of homicide is six times that for 
whites.
    Hispanics living in the United States are almost twice as likely to 
die from diabetes as are non-Hispanic whites. Although constituting 
only 11 percent of the total population in 1996, Hispanics accounted 
for 20 percent of the new cases of tuberculosis, and have higher rates 
of hypertension and obesity than non-Hispanic whites. There are 
differences among Hispanic populations as well. For example, whereas 
the rate of low-birth-rate weight infants is lower for the total 
Hispanic population compared to whites, Puerto Ricans have a low-birth-
weight rate that is 50 percent higher than that for whites.
    American Indians and Alaska Natives have an infant mortality rate 
almost double that of whites. The rate of diabetes for this population 
group is more than twice that for whites. The Pima of Arizona have one 
of the highest rates of diabetes in the world. American Indians living 
in North and South Dakota have an average life expectancy that is 11 
years less than that for the rest of the U.S. population. Overall, the 
life expectancy for American Indians and Alaska Native is 71 years of 
age--nearly five years less than the U.S. Races populations.
    Asian and Pacific Islanders, on average, have indicators of being 
one of the healthiest population groups in the United States. However, 
there is great diversity within this population group, and health 
disparities for some specific groups are quite marked. Vietnamese women 
suffer from cervical cancer at nearly five times the rate of white 
women. New cases of hepatitis and tuberculosis are also higher in 
Asians and Pacific Islanders living in the United States than in 
whites.
    The Indian Health Service (IHS) and Native American Tribes have 
made much progress improving the American Indian and Alaska Native 
health status over the years. Infant mortality rates, maternal death 
rates, morbidity and mortality from infectious diseases have all 
decreased dramatically over the past 40 years. However, during the last 
five years, this progress has stalled and indeed regressing in some 
areas. American Indian infant mortality is beginning to increase in 
some communities. During 1992-1994, the infant mortality rate for the 
IHS Phoenix Regional Area was 9.4 deaths per 1,000 live births. The 
rate increased to 9.7 from 1994-1996. In the IHS Nashville Regional 
Area, the rate increased from 11.6 per 1,000 live births to 11.7 over 
the same time frame.
    Behavior-related mortality rates for the American Indian population 
residing in the IHS regional service areas are rising. For example, 
age-adjusted mortality rates for AI/ANs due to alcoholism, suicide, and 
homicide during 1992-1994 were 45.5, 19.2, and 15.1 deaths per 100,000 
persons, respectively. The 1994-96 data indicate these numbers 
increased to 48.7 deaths per 100,000 for alcoholism, 19.3 for suicide, 
and 15.3 for homicide. During this time period, the age-adjusted 
mortality rate for AI/AN for HIV infections rose 59 percent, and for 
diabetes mortality, an increase of 13 percent. Increases in age-
adjusted mortality rates are also noted for this population in 
malignant neoplasms and cerebrovascular disease.
    Slight improvement has been made between 1992-1994 and 1994-1996 in 
age-adjusted mortality rates for AI/ANs due to Tuberculosis (a rate of 
2.3 improved to a rate of l.9) and heart disease (a rate of 157.6 
improved to a rate of 156.0). However, increases in age-adjusted 
mortality rates were experienced for AI/ANs deaths due to malignant 
neoplasms (a rate of 112.2 during 1992-1994 increased to a rate of 
116.6 during 1994-1996) and for AI/ANs deaths due to cerebrovascular 
diseases (a rate of 27.8 during 1992-1994 increased to a rate of 30.5 
during 1994-1996). The bottom line figure of life expectancy at birth 
for American Indian and Alaska Native population in the IHS regional 
service delivery areas remained exactly the same between the 3-year 
period 1992-1994 and 1994-1996, 71 years.
           hhs initiative to eliminate disparities in health
    The demographic changes that are anticipated over the next decade 
magnify the importance of addressing disparities in health status. 
Groups currently experiencing poorer health status are expected to grow 
as a proportion of the total U.S. population; therefore, the future 
health of America as a whole will be influenced substantially by our 
success in improving the health status of our racial and ethnic 
minorities.
    In June 1997, President Clinton introduced to the country the 
concept of One America in the Twenty-first Century: The President's 
Initiative on Race. He appointed a national advisory board led by John 
Hope Franklin, and in their September 1998 report to the President, 
``One America in the 21st Century: Forging a New Future,'' they 
included their observations on what they saw and heard about race and 
its impact upon communities throughout the country. The Board report 
also offers recommendations on specific steps that should be taken to 
eliminate racial disparities experienced by people of color.
    Additionally, the President asked each cabinet head to develop some 
strategy supporting the Race Initiative. In the Department of Health 
and Human Services, we adopted the commitment to eliminate disparities 
in health on the basis of race and ethnicity by the year 2010. The 
President announced this unprecedented initiative from the White House 
in February 1998. We focus on six key areas: infant mortality, breast 
and cervical cancer screening and management, cardiovascular disease 
risk factor reduction, diabetes complications, adult and childhood 
immunizations, and HIV infections and AIDS. These six health areas were 
selected for emphasis for they reflect areas of disparity that are 
known to affect multiple racial and ethnic minority groups at all life 
stages and are areas over which we could have direct impact.
    This Initiative marks the first time in the history of our 
government that we have made the commitment to eliminate, not just 
reduce, the health disparities between majority and minority 
populations. Additionally, the Initiative will parallel the second goal 
of Healthy People 2010, the Nation's disease prevention, health 
promotion agenda for the first decade of the 21st century. The other 
goal is to increase the quality and years of healthy life.
    The Initiative is led by the Office of Public Health and Science 
(OPHS) and the responsibility for overall guidance within HHS is the 
Public Health Council (PHC).
    Beginning shortly after the President's announcement, working 
groups comprised of experts from the agencies within HHS met to discuss 
the status of HHS programs and policies in the six health focus areas 
and the data issues relevant to the Initiative. These working groups 
have generated full length reports that review the epidemiology of the 
six focus areas and examine a range of strategies for effective 
interventions for prevention and treatment. The reports offer 
recommendations for future research, policies, and program investments 
that would lead to the elimination of health disparities.
    One of the most visible components of the HHS Initiative is the 
Racial and Ethnic Approaches to Community Health 2010 program (REACH 
2010). REACH 2010 is intended to help communities mobilize and organize 
their resources in support of effective and sustainable programs that 
will eliminate health disparities. In FY 1999, Congress appropriated 
$10 million dollars to the Centers for Disease Control and Prevention 
(CDC) to administer the program. The first year of REACH demonstrations 
was designed as a planning year to solidify the multi-agency, community 
oriented collaboration required of the applicants. Subsequent years 
will involve implementation of the interventions to address one or more 
of the six clinical focus areas within a well-defined population.
    CDC used this appropriation to fund 32 community coalitions and 
three additional community coalitions were funded by the California 
Endowment to participate in REACH 2010. The populations targeted 
include African-American, American Indian, Alaska Native, Hispanic 
American, Asian American, and Pacific Islander. Of the awards, five 
were for infant mortality, five for breast and cervical cancer 
screening and management, four for immunizations, twelve for diabetes 
complications prevention, twelve for cardiovascular disease risk factor 
reduction, and two for HIV infection and AIDS. These awards were spread 
over 18 states and 22 cities.
    The FY 2000 appropriation of $30 million will be used to 
implementation of the community derived strategies and to enlist new 
community coalitions in the effort to eliminate disparities.
    The Office of Civil Rights (OCR) has played a critical role in the 
department's Initiative to Eliminate Racial and Ethnic Disparities. 
Through enforcement, education and outreach, OCR has raised public 
awareness of the role of discrimination as one explanatory factor in 
racial and ethnic disparities. Recent OCR cases illustrate the 
discrimination regrettably is alive and well in the health care 
setting.

1. OCR reached a settlement with a national home health agency that had 
        engaged in medical redlining, that is, it refused to serve a 
        predominantly minority area of New Haven, Connecticut;
2. OCR reached an agreement with a national pharmacy chain that had 
        repeatedly failed to fill the prescription of an African-
        American Medicaid recipient in Texas;
3. OCR reached a settlement with a hospital in South Carolina that had 
        a policy in effect of not giving epidurals to women who did not 
        speak English; and
4. OCR reached a settlement with a hospital in Philadelphia whose lack 
        of an effective policy for treating patients who do not speak 
        English created serious problems for a pregnant woman who 
        needed emergency care.
    OCR's enforcement, coupled with recent research documenting the 
potential role of racial bias in explaining physician decision-making, 
illustrate that eliminating racial and ethnic disparities is both a 
civil rights and a public health challenge. If we ignore the former and 
focus solely on the latter, we will not be fully successful.
    Addressing the challenge of health improvement is a shared 
responsibility that requires the active participation and leadership of 
the Federal Government, States, local governments, policymakers, health 
care providers, professionals, business executives, educators, 
community leaders, and the American public itself.
    A national partnership is needed to develop a balanced community 
health system that promotes healthy lifestyles and behaviors, and in 
challenges a health care delivery system that allows for unequal 
outcomes on the basis of race and ethnicity. The task of HHS is to 
provide leadership through conducting innovative and balanced research, 
expanding and improving programs to purchase or deliver quality health 
services, developing programs to reduce poverty and provide children 
with safe and healthy environment, and by expanding prevention efforts. 
Currently, our activities include, but are not limited to:

 In October 1997, the Secretary issued the first Federal agency 
        policy requiring the inclusion of racial and ethnic data in all 
        of its data systems, with very few exceptions. The inclusion 
        policy also required compliance with the Federal standards for 
        racial and ethnic data.
 In February 2000, the HHS Data Council's Working Group on 
        Racial and Ethnic Data and the Data Working Group of the HHS 
        Initiative to Eliminate Racial and Ethnic Disparities in Health 
        presented their joint report on ``Improving the Collection and 
        Use of Racial and Ethnic Data in HHS'' to the Data Council. 
        This report builds upon the numerous recommendations developed 
        in the past and presents a long term agenda for improving the 
        collection and use of racial and ethnic data across the 
        Department and its agencies. This report sets the stage for the 
        National Academy of Sciences report which is called for in the 
        Health Care Fairness Act under discussion today.
 The Health Care Financing Administration (HCFA) now requires 
        each state Peer Review Organization (PRO) to include a focus on 
        eliminating racial and ethnic disparities in health. PROs had 
        previously been required to focus on improving quality of care 
        in several other key clinical areas closely related to the 
        Initiative.
 The Agency for Healthcare Research and Quality (AHRQ) plans 
        over the next five years to establish up to four ``centers of 
        excellence'' that will identify practical tools and strategies 
        to eliminate racial and ethnic disparities in the health care 
        system. The research conducted by these centers will go beyond 
        documenting disparities by putting a new emphasis on 
        understanding their underlying causes and developing strategies 
        to eliminate them.
 In February 2000, an important working conference, ``Diversity 
        and Communication in Health Care: Addressing Race, Ethnicity, 
        Language, and Social Class in Health Care Disparities'' was 
        sponsored by the Office of Minority Health, the Health 
        Resources Services Administration (HRSA), AHRQ, the 
        Commonwealth Fund, and the Sergei Zlingoff Fund for Medical 
        Education and Research. The purpose of the conference was to 
        determine the state-of-the-art for improving provider-patient 
        communication, to define its adequacy to increase effectiveness 
        of health care for racial and ethnic minorities, and to develop 
        a work plan to provide needed modifications. A larger 
        conference is called for in the Health Care Fairness Act.
 In addition to the work discussed earlier, the Office of Civil 
        Rights is focusing on a program of dialogue and education of 
        health care providers and patients to increase awareness of 
        civil rights responsibilities. For instance, in New York City, 
        OCR has convened a series of meeting with all stakeholders-
        providers, advocates, faith communities, foundations, medical 
        societies, hospital associations, and others in an effort to 
        develop a greater understanding of the root causes of racial 
        and ethnic disparities, as well as a blueprint for eliminating 
        disparities. This dialogue has been extremely productive, and 
        talk has led to constructive action. At the same time OCR has 
        begun to look at data pertaining to hospitals to determine why 
        some high tech medical procedures do not appear to be performed 
        on minorities at the same rate as non-minorities.
 HRSA has launched a campaign for 100 percent access, 0 percent 
        disparities by the year 2010. As part of its mission to provide 
        quality comprehensive health care to under served and 
        vulnerable populations, HRSA hopes to build and sustain 
        healthier communities by empowering communities to identify and 
        develop solutions tailored to their needs. Currently, 23 states 
        and over 100 communities are engaged in the campaign. 
        Additionally, HRSA has funded 10 communities across the country 
        to address significant disparities in perinatal health 
        indicators. These communities demonstrated significant infant 
        mortality and morbidity rates, had an existing consortia of 
        stakeholders with infant mortality reduction experience, and 
        developed a feasible plan to reduce barriers, improve systems 
        of care, and eliminate disparities.
 As required in the re-authorization of the Office of Minority 
        Health, HHS is establishing its first Advisory Committee on 
        Minority Health. We understand that this advisory committee 
        could serve the role of that called for in the Health Care 
        Fairness Act to provide advice to the Secretary on matters 
        related to the development, implementation, and evaluation of 
        graduate and continuing education curricula for health care 
        professionals to decrease the disparities in health care and 
        health outcomes.
 The National Institutes of Health (NIH) remains committed to 
        conducting research on the diagnosis, treatment, and prevention 
        of diseases resulting in health disparities, including AIDS, 
        cancer, diabetes and heart disease. We recognize that these 
        efforts would be enhanced by a central organization that 
        coordinates and reviews the health disparity research being 
        conducted by the NIH's various Institutes and Centers. 
        Therefore, NIH has established a Working Group on Health 
        Disparities that is currently developing a Strategic Plan to 
        expand training programs for minority researchers, set 
        priorities and synchronize multi-disciplinary research. The 
        Strategic Plan will be reviewed by the Office for Research on 
        Minority Health and its public Advisory Committee. The 
        unprecedented level of coordination and input from the public, 
        including those most affected by health disparities, and the 
        prominent role played the Office for Research on Minority 
        Health, should result in measurable improvements.
 The Indian Health Service, Department of Health and Human 
        Services, and the Administration are working with Indian Tribes 
        to address the disparity in health status among American Indian 
        and Alaska Native people. During the past 3 years the Indian 
        Tribes have identified alcoholism/substance abuse, diabetes, 
        cancer, heart disease, infectious disease, maternal and child 
        health, mental health, injuries and domestic/community violence 
        as the top health problems that must be addressed by the IHS 
        budget requests. Local IHS/Tribal/Urban(ITU) health priorities 
        dovetail with the President's Race Initiative on Health 
        Disparity focus and underpin the Indian health budget 
        priorities set by the Indian Tribes and the Administration in 
        the past 2 years.
 The IHS, tribes and urban health programs have demonstrated 
        the ability to improve the health status of American Indian and 
        Alaska Native people. Improving essential access to health care 
        in order to address health disparities has been a top priority 
        for the I/T/U's annual budget and Government Performance and 
        Results Act performance plan initiatives. The first annual 
        performance report, which was submitted for FY 1999, provides a 
        base performance level for the health interventions/measures 
        that will ultimately lead to improved outcomes in health 
        status. Indian Tribes are becoming increasingly involved in 
        developing the performance targets. Joint Federal-Tribal 
        efforts are directed toward achieving these targets as a means 
        of demonstrating the effectiveness of the I/T/U programs to 
        make a difference in the disparities that exists between the 
        health of American Indian/Alaska Native people and the rest of 
        the Unites States.
         public/private partnerships to improve minority health
    As the Nation enters a new millennium, an unprecedented opportunity 
exists to influence and effect health in a way that is fundamentally 
fair, and more inclusive of all Americans. HHS has ``stepped to the 
plate'' to eliminate disparities in health and has created an 
environment where private foundations and endowments are engaging their 
colleagues to eliminate disparities in health. For example:

 HHS and Grantmakers in Health (GIH), an educational 
        organization that works with foundations and corporate giving 
        programs to improve the nation's health, cosponsored a national 
        leadership conference in September 1998, to discuss strategies 
        for developing and strengthening partnership focusing on 
        eliminating racial and ethnic disparities in health by 2010. 
        Attending the conference were approximately 250 key public 
        policy makers, industry and community leaders, including 
        individuals representing foundations, community-based 
        organizations, national organizations with expertise in key 
        health areas and with a history of serving racial and ethnic 
        groups, providers, insurance companies and managed care plans, 
        the media, business, faith-based organizations, and consumers.
 The California Endowment has initiated a Program in Multi-
        cultural health aimed at eliminating health disparities and 
        through collaboration with the CDC Foundation, funded three 
        additional REACH 2010 projects in California.
 The Robert Wood Johnson Foundation's Investigators Award in 
        Health Policy Research Programs is seeking to improve 
        understanding of the social determinants of health.
 The Commonwealth Fund cosponsored a meeting with managed care 
        organizations on data collection, quality of care measurement, 
        and access to health care. As a result, efforts are being made 
        to educate health plans that the Federal government does not 
        prohibit the collection of racial and ethnic data.
 The Henry J. Kaiser Family Foundation hosted a conference on 
        ``Race, Ethnicity, and Medial Care: Improving Access in a 
        Diverse Society.'' This conference sought to understand the 
        reasons for disparities in access to health and health status, 
        and develop more effective efforts to address them. The 
        Foundation is developing a set of ``leading health indicators'' 
        by which to measure the progress made toward the elimination of 
        disparities.
 The National Policy Association, the Association of Health 
        Services Research, and several HHS agencies cosponsored a 
        conference in April 2000 on ``Income Inequality, Socioeconomic 
        Status and Health: Exploring the Interrelationships.'' The 
        purpose was to bring together business and labor leaders and 
        experts in health and social policy to address critical 
        questions about health and health disparities.
 OCR has worked closely with the United Hospital Fund, the 
        Greater New York Hospital Associate, and the New York Task 
        Force on Immigrant Health to develop a pilot program that used 
        state of the art technology and trained interpreters to enable 
        health care providers to communicate more effectively with 
        persons who are limited English proficient.
 During the 1999-2000 legislative sessions for the States, 
        eighteen states had pending legislation or executive orders 
        that related to the elimination of health disparities or 
        improving the quality of care to minorities. We are working to 
        identify the status of these bills now that most sessions have 
        ended.
 On April 24, 2000, HHS and the American Public Health 
        Association announced a partnership to eliminate racial and 
        ethnic health disparities. The partnership includes a three 
        phase plan to develop a charge or ``blueprint'' of guidelines 
        for our collaboration, develop a detailed, comprehensive 
        national plan, and thirdly, the implementation of the plan by 
        2002.
  role of the health care fairness act of 1999 in improving minority 
                                 health
    We thank you for your support of the HHS Initiative to Eliminate 
Racial and Ethnic Disparities in Health, and its parallel emphasis 
within Healthy People 2010. The proposed Health Care Fairness Act of 
1999 (H.R. 3250) addresses several of the key elements the Department 
has identified as essential to a comprehensive approach towards 
eliminating disparities:

 development of a balanced and comprehensive research agenda 
        that addresses the unequal burden of morbidity and mortality in 
        racial and ethnic minorities;
 supporting efforts to improve the quality and outcomes of 
        health care services and addressing the social determinants of 
        health, including but not limited to, access to health care;
 strengthening the data collection infrastructure of HHS;
 recognition of the important role of the Office for Civil 
        Rights;
 support for graduate health care education curriculum 
        development, continuing medical education efforts to reduce 
        disparity in health and health outcomes, and increasing the 
        knowledge base with respect to cultural competency.
    We particularly appreciate acknowledgment of the importance of 
research into the behavioral and social factors underlying health 
disparities, and support programs which increase educational attainment 
and employment opportunities.
    The section of the Health Care Fairness Act on the Office for Civil 
Rights is supportive of efforts underway to include the Office in 
development of health policy throughout HHS that address civil rights 
observance, program evaluation, and quality assessment.
    Mr. Chairman, and members of this committee, as a physician and 
scientist, administrator and educator, and one charged with the task of 
leading the effort to challenge a health care system that allows for an 
unequal burden of morbidity and mortality among our racial and ethnic 
groups, I am reminded of how the National Institutes of Health explain 
how research and science work. It is said that ``science'' comes from 
the Latin scientia meaning ``known things,'' scientists and the 
practice of science exist because of what we do not know. The aim of 
science is to move what we do not know into the realm of known things 
and then, with a greater store of knowledge, begin again, as if 
advancing to a new frontier.
    The elimination of disparities is an achievable goal that requires 
we bring all our forces to bear--a balanced community health system, a 
comprehensive research agenda that addresses the unequal burden of 
morbidity and mortality in racial and ethnic minorities, training a 
multi-cultural workforce that is sensitive to the culture of its 
colleagues, data collection that reflects the inhabitants of this 
country, and one set of quality health care delivery goals for all. As 
we continue our work to improve the lives of our fellow Americans, let 
me leave you with the premise upon which the U.S. Public Health Service 
was founded in 1798, is . . . ``to the extent we care for those most 
vulnerable among us, we do most to protect the health of the nation.''
    Thank you for the opportunity to share some of the Department's 
activities. We appreciate your support and look forward to continuing 
our partnership to improve our health care system.

    Mr. Bilirakis. Thank you very much, Mr. Satcher.
    The Chair will recognize himself for 5 minutes.
    You mentioned Mr. Varmus' letter which was written after he 
had stepped down as Director of NIH. Believe me, it would have 
made our lives a lot easier if he had written it prior to that 
point.
    You mentioned the Administration is supportive of elevating 
the office to Center or is it the current NIH Director or is it 
both?
    Mr. Satcher. The Administration, as you know within the 
budget submitted by the President, does not have a position on 
the Center proposal and so I am not speaking for the 
Administration in terms of the specific proposal, but as you 
know, the Administration is strongly supportive of strategies 
to eliminate disparities in health and believes that research 
targeted to that is critical.
    Mr. Bilirakis. I would like to think that we are all 
supportive of research of that nature. What we are talking 
about doing is something which is apparently a little 
controversial, though I hate to use the word controversial. You 
would like to think that the people directly affected by 
elevating the office to center status--obviously the public is 
directly affected and minorities are directly affected--but I 
am talking about the Director of NIH and his staff, you would 
like to know what their position is on it. I do not think your 
comments go directly to that.
    Mr. Ruffin, do you have any comment?
    Mr. Ruffin. In all of my conversations with the current 
Director of the National Institutes of Health, she is not 
opposed to the elevation of the office. Mr. Mark Smolonsky, who 
is our legislative individual there, is also accompanying me 
today at this meeting and if I am wrong about that in any way, 
then Mark can correct me, but in all of my conversations with 
the current Director of NIH, there has been no opposition to 
the elevation of the office.
    Mr. Bilirakis. Maybe I am splitting hairs here but Mr. 
Jackson has also basically responded in the same way in the 
sense that the current Director is not in opposition but that 
could be sort of an ambivalence if you will. I think knowing 
the Directors position is significant because as I understand 
it if the office becomes a center, the Director may not have 
any control over the funding of the center--this may be 
acceptable but you would like to hear these things from the 
Director.
    Mr. Ruffin. I certainly would not be able to speak directly 
for the Director of NIH but again, only to translate my 
conversations with her on those issues.
    Mr. Bilirakis. Does the Administration have a position on 
the entire bill, H.R. 3250, and if it does not have a position, 
will it be providing a formal position on this legislation? Can 
you all tell me that?
    Mr. Satcher. I cannot tell you if the Administration will 
submit a formal position because as I said before I think when 
the President submitted his budget, OMB was not in a position 
to speak to this particular legislation at the time.
    I do want to make it clear--I obviously represent the 
Administration--it is my professional opinion and speaking as 
Surgeon General and in that responsibility for dealing with the 
best science, this legislation is consistent with what we are 
trying to do to eliminate disparities in health in this 
country. It is needed in order to do it.
    Mr. Bilirakis. I agree with you, I think it is needed but I 
think the President of the United States should tell us the 
same thing, or at least the Director of NIH. I cannot quite 
understand, how can any of us really understand and I do not 
mean to slight your remarks and your response but it doesn't 
tell us what we need to hear I think.
    Mr. Satcher. So you want a statement from the 
Administration that it supports this specific legislation?
    Mr. Bilirakis. Supports this legislation and if there are 
any areas they do not support, they should let us know and more 
specifically, not to belittle the other areas, but regarding 
the Center.
    The Chair now yields to Mr. Brown.
    Mr. Brown. Mr. Satcher it is a pleasure to have you in 
front of us.
    Your successor at CDC gives a speech about public health 
talking about 100 years ago the life expectancy in this country 
was 46 and now it is some 30 years longer. Some of the success 
he points out is in high tech medicine. Most of the success, 70 
or 80 percent of that, the 30-year lengthening of life span, is 
due to strides in public health, everything from vaccines to 
safe drinking water to better sewage disposal, controlling of 
lead poisoning, seatbelts, all kinds of things like that.
    Your work first at CDC and now in the Public Health Service 
has been exemplary. I would like you to discuss for us the 
disparities in public health delivery of services, whether it 
is inner city hospitals or vaccines or wherever you might want 
to go with the question. Do we know enough about these 
disparities in the public health part of our health care 
system?
    Mr. Satcher. I think we are learning more every day. These 
are the ten leading health indicators for Healthy People 2010. 
As I said, five of them are in lifestyle--tobacco use, physical 
activity, overweight and obesity, substance abuse, responsible 
sexual behavior. Five are in the health system: mental health, 
injury and violence, environmental quality, immunization, 
access to health care.
    In virtually all of these areas, we can identify 
disparities. If you want to start with access to health care, 
as you know and have heard, Hispanics are most likely to be 
uninsured of any group in this country. One out of three 
Hispanics is uninsured. African-Americans are next most likely 
to be uninsured. Even among those who are insured, the 
probability of having a personal physician is lowest among 
Hispanics and African-Americans. Hispanics and African-
Americans together make up 25 percent of the population and yet 
70 percent of the people who live in underserved communities in 
this country.
    In the area of immunization, adult immunization, influenza 
and pneumococcal vaccine where we are not doing as well as we 
should be doing with the elderly. Sixty-seven percent of whites 
in the last year, for which we have data, 1997, received the 
influenza vaccine, 67 percent of whites over 65, 50 percent of 
African-Americans, 58 percent of Hispanics.
    In the pneumococcal vaccine, it is even worse, 47 percent 
whites over 65, 34 percent of Hispanics, 30 percent of African-
Americans. Even in the area of environmental quality, today in 
this country, African-American and Hispanic children are much 
more likely to live within two miles of hazardous waste sites 
than other groups in this country. In fact, 40 percent of the 
people who live within two miles of hazardous waste sites in 
this country are African-Americans and Hispanics. If you add 
American Indians, it is above 50 percent.
    In all of these areas, we can point to disparities and we 
take the position that if we can attack these areas of 
disparities with the health system and we are not just talking 
about the health system, we are also talking about lifestyles. 
We have to be very clear that lifestyles like tobacco use and 
physical activity, substance abuse are areas of opportunity. 
They are not just individual responsibility. In many cases, 
they are community responsibilities.
    If people attend schools where they do not offer courses in 
physical education, they are less likely to be physically 
active. If they live in communities where it is not safe or 
does not appear to be safe to get out and walk or jog on the 
street or bike, where you do not have biking trails, they are 
less likely to be physically active. In all of these areas, I 
think we can identify opportunities for intervention. Many of 
them are public health.
    The only other thing I will say because I have had some 
minor disagreement with some of my colleagues but not major, 
when we say that 50 percent of disparities or variations in 
morbidity and mortality are due to lifestyle, 20 percent to 
environment, 20 percent to genetics and 10 percent to access to 
care, we know that a really concerned physician provider 
influences lifestyle significantly. If every physician would 
ask his or her patient if he or she smoked and then ask them to 
quit without even implementing a smoking cessation program, 2 
million more people would stop smoking in this country every 
year.
    If physicians wrote prescriptions like the Surgeon 
General's prescription, prescribing physical activity and good 
nutrition for their patients, many more would have appropriate 
lifestyles. We believe that a pediatrician who is concerned 
about whether his patient is exposed to lead, does the 
appropriate screening, intervenes with the appropriate 
agencies, makes a big difference in these areas. So I put a 
little more weight on access to care than some of my colleagues 
because I believe that we, as physicians, have tremendous 
opportunities to intervene.
    Dr. Kermit Smith with the Indian Health Service can 
probably speak more to that than I because they have done some 
outstanding things in the Indian Health Service.
    Mr. Bilirakis. The time has expired. You may have an 
additional minute.
    Mr. Smith. Thank you for the opportunity.
    The activities we have been engaged in, our numbers might 
be a little bit different, access, might be a bit better but 
again, we have a large population of Native Americans who live 
in the cities and we don't deal with them in the Indian Health 
Service. Those that are on our reservations are in areas where 
we provide care and we may see only 70 to 75 percent of those 
who live in those areas.
    We have made some real strides in the public health 
activities we have been involved in, sanitation. We still have 
areas where we have no electricity, no telephones, so in those 
areas we are still trying to catch up.
    The activities related to smoking cessation, the behavioral 
activities, we have made some strides but when we look at our 
mortality and morbidity, about 50 percent of the morbidity in 
our people is still related to behavioral activities.
    Mr. Brown. One point of clarification, going back to Mr. 
Satcher. You said at the beginning of your comments even among 
insured Americans, there is a racial disparity between whites 
and minorities over the number of people who actually have a 
primary care physician with whom they have some relationship?
    Mr. Satcher. Or even a personal physician. Ideally, that 
would be a primary care physician but if you just use the word 
personal, there are dramatic disparities.
    Mr. Brown. So minorities are less likely, even insured 
minorities are less likely to hear from a doctor about those 
issues?
    Mr. Satcher. Exactly.
    Mr. Bilirakis. The gentleman's time has expired, Mr. 
Coburn?
    Mr. Coburn. I just want to follow up on that. Is that 
because they are not available or because they don't seek them 
out? Where is the motivation?
    Mr. Satcher. I think that is a good question. You are going 
to hear some of that from the next panel. I know Kevin Schulman 
is here who has done some very interesting research.
    This gets back to the underserved communities. You can have 
Medicaid or Medicare and if you live in a community where you 
don't have access to a physician, you are less likely to get 
the flu shot or even if you have a physician but don't have the 
kind of relationship where they really reach out to make sure 
you get your shot.
    Mr. Coburn. You are describing a doctor instead of a 
physician? A physician always reaches out.
    Mr. Satcher. Especially if it is Tom Coburn.
    Mr. Coburn. That is the difference and I think that is one 
of the things we ought to have a discussion about because part 
of our problem in access to care is not on the receipt end, it 
is on the professional side.
    Mr. Satcher. Exactly.
    Mr. Coburn. We need to do a much better job in our 
profession of knowing what it takes to reach out to get 
somebody to change a lifestyle or to think about it, think 
about the communities. It is not just about money in terms of 
being a doctor.
    Mr. Satcher. I think it is significant that when you have 
such underrepresentation of African-Americans, Hispanics, 
American Indians of physicians, the cultural barriers, the 
reaching out, there is a difference.
    Mr. Coburn. I agree.
    Mr. Satcher. That is one of our major concerns.
    Mr. Coburn. My latest partner is an African-American female 
who graduated from Duke Medical School and she has taught me 
tons with my own patients culturally that I had no knowledge of 
in terms of interacting with them. So she has been a great 
benefit to teach me the cultural things. I didn't get it in 
medical school, that is for sure, so that is the other side of 
it.
    I was saying we are going to have to address the 
professional side of this as well after you bring us the 
research to tell us what we need to do with this bill.
    One of my favorite issues to visit with you about is what 
we saw on HIV and we are getting to reauthorize and we have 
seen this disease move to the minority communities. That is 
where it is shifting. Do you have recommendations for us as we 
do that in terms of making sure we address it because one of 
the things that the Inspector General and GAO reports said was 
``African-American, Hispanic and women are in higher 
proportions than the representation in the AIDS population, yet 
they generally receive less appropriate health care.'' In other 
words, they are there but they are not getting health care 
appropriate for them.
    Do you have any recommendations for us, not just on this 
bill but as we look at what we should do on that?
    Mr. Satcher. I think it is not unrelated to what we were 
just discussing in terms of we know that African-Americans are 
less likely to be insured, we also know they are less likely to 
have that kind of personal physician and the kind of 
relationship where they are more likely to get the care they 
need. I think we are on the right track in looking at this 
whole doctor-patient relationship and making it a part of our 
discussion of access.
    When I use the word access, I am not just talking about 
availability but I am talking about access to a relationship 
that is going to result in your getting the kind of care that 
you need whether it is for AIDS, which it is in this case.
    We have some very, we think, good opportunities under Ryan 
White. When I testified we made recommendations for expanding 
some of those opportunities to communities that tend to get 
left out. We are struggling here with trying to make sure 
people who need a personal relationship with a physician, a 
caring relationship, that they are able to find it. We have to 
come up with some innovative strategies that might go beyond 
physicians to health care teams that are innovative and we may 
need to be a bit more aggressive in terms of some of our 
programs like loan forgiveness programs and things like that, 
loan repayment, to get more physicians into some of these 
communities.
    Mr. Coburn. One of the things we are debating in the Ryan 
White reauthorization is how we allocate the money. This is a 
delayed disease where we have historically measured AIDS cases 
rather than HIV prevalence and I believe we have 33 or 34 
States that have HIV prevalence data. How should we, in terms 
of addressing as this moves to the minority community and the 
communities of color, especially women because that is where it 
is going, how should we allocate the money? Should we use 
prevalence data or should we use the same old average AIDS data 
that we have used in the past? Do you have a recommendation in 
that regard?
    Mr. Satcher. I think we have to go beyond AIDS. As you 
know, I agree with the position and recommendation of CDC that 
we should have HIV name reporting. While I understand the fears 
of people who oppose it saying we still live in a country where 
you can be discriminated against in hiring, et cetera if people 
know you have HIV. I just think somehow we as a Nation have to 
guarantee the confidentiality but also the protection of people 
who are diagnosed as positive for HIV. I don't think we have 
done that yet.
    I agree with you that we need name reporting and we also 
need to be able to track this as easily as we do other sexually 
transmitted diseases including partner, et cetera, but in order 
to get there, we have to get rid of some of the fear and stigma 
surrounding this problem.
    Mr. Coburn. We have to have a bill like this to make sure 
everybody has access.
    Mr. Satcher. Exactly.
    Mr. Bilirakis. Thank you.
    A vote is being called but I believe Mr. Barrett was here?
    Mr. Barrett. I will be brief.
    Mr. Satcher, I want to thank you when you came to Milwaukee 
in December for a women's health conference and I still hear 
people say how wonderful you were, so I appreciate your 
willingness to come to the great midwest to visit with us.
    Mr. Satcher. I enjoyed being with you.
    Mr. Barrett. You will have to excuse my slow, deliberate 
approach but it would be helpful if you could just three 
illnesses or three conditions where you see a disparity between 
the majority community and the minority community where you 
think we could make a difference?
    Mr. Satcher. Let me start with infant mortality. Obviously 
I feel very strongly that as a Nation if there is any area 
where we ought to make a commitment to universal access it is 
to prenatal. We ought to do everything we can to make sure that 
every woman has access to prenatal care beginning in the first 
trimester of pregnancy. We talked about that this morning in 
terms of safe motherhood.
    I believe we could make a difference if we set up systems 
in this country to assure that universal access to prenatal 
care and to really target communities because we are down to a 
few areas where I think we have major problems. As we said this 
morning, we have made dramatic progress in this country in the 
last 50 years in terms of reducing maternal mortality. Yet we 
have not made any progress since 1982. Today, African-American 
women are four times more likely to die during pregnancy.
    While the health of the mother has a lot to do with the 
health of the baby, starting from the beginning of conception 
and even before in terms of folic acid. So we can make a lot of 
difference we believe in making sure every child has an 
opportunity for a healthy start in life in this country by 
really focusing on the health of the mother before and during 
pregnancy, access to quality prenatal care, and involvement in 
systems of care that even go beyond that.
    I want to say diabetes because American Indians are three 
times more likely to suffer diabetes in this country. We spend 
a lot of our resources in that area treating complications like 
end stage renal disease, blindness and the need for lower limb 
amputation. I have visited hospitals on Indian reservations, 
very small hospitals, 24 beds and yet 30 or more people are 
being dialyzed for end stage renal disease.
    We need to aggressively fund programs to prevent the 30 
percent of Type II diabetes that we can prevent with aggressive 
prevention programs but also early diagnosis and tight control 
of diabetes. We have research showing that with early diagnosis 
and tight control of diabetes, we can prevent most of these 
complications, 90 percent of them. We need to move to do that 
because we have the ability to do it.
    Breast cancer is interesting. We made progress in the 
1990's really for the first time in terms of cancer mortality. 
Actually, caucasian women in this country have the highest 
incidence of breast cancer.
    Mr. Bilirakis. Forgive me a moment. Tom, we are going to 
have to go a bit out of order because Dr. Sullivan has a plane 
to catch and we have five votes which probably means a hour or 
close to it.
    Mr. Barrett. I would yield.
    Mr. Bilirakis. I didn't mean that. I did want to ask if you 
all would not mind if we ask Dr. Sullivan to come up right now 
so he can give his testimony so we can hear what he has to say. 
We are not going to have an opportunity to question him.
    Mr. Satcher, I hate to have you cooling your heels for at 
least a hour.
    Mr. Satcher. I have to leave and I apologize.
    Mr. Bilirakis. We apologize but this is the way it is up 
here. This is our life.
    Mr. Satcher. I feel terrible if I took time away from Dr. 
Sullivan.
    Mr. Bilirakis. No, you didn't. Dr. Sullivan, please come 
forward. Dr. Sullivan is President of the Morehouse School of 
Medicine in Atlanta. He has appeared before this committee many 
times.
    Mr. Satcher, I don't like the idea of Ms. Eshoo and Mr. 
Green not having the opportunity to question you but if you 
have to leave, I guess you have to leave.
    Ms. Eshoo. Can I just say something Mr. Chairman. I think 
it is really an honor to have you grace our hearing room and I 
salute our Chairman because he is the one that made this come 
about.
    I would like to ask for unanimous consent that members be 
able to direct questions to our Surgeon General.
    Mr. Bilirakis. Yes, written questions and you certainly 
don't mind that, do you? Without objection, that will be the 
case.
    Dr. Sullivan, please proceed.
    Tom, forgive me for interrupting, I know you understand.

 STATEMENT OF LOUIS W. SULLIVAN, PRESIDENT, MOREHOUSE SCHOOL OF 
                            MEDICINE

    Mr. Sullivan. Thank you, Mr. Chairman.
    I am pleased to have this opportunity to appear before you 
on this bill that is under consideration. I will abbreviate my 
comments because many of the things I was going to say have 
been said by previous speakers but I would like to commend 
Congressman Jesse Jackson, Congressman Norwood, J.C. Watts, 
John Lewis, Bennie Thompson and Nathan Deal for their 
leadership and commitment to improving the health status of 
Americans.
    Let me say that in 1985, Secretary Margaret Heckler issued 
a report on Black and Minority Health in the United States 
which among other things showed there was 79,000 excess deaths 
in the Nation's minority communities because of health 
disparities. In 1990, the Chronicle of Higher Education also 
pointed out that among the grants from the National Institutes 
of Health, less than 1 percent went to minority investigators, 
whether they were at majority institutions or minority 
institutions.
    In January of last year, I was asked to testify before the 
Senate Appropriations Subcommittee on Labor, Health and Human 
Services and Education and related agencies regarding the 
Institute of Medicine Study, ``The Unequal Burden of Cancer.'' 
This landmark study determined that although ethnic minorities 
and medically underserved populations suffer disproportionately 
from virtually every form of cancer, the National Cancer 
Institute with a $3 billion budget, committed only $24 million 
or less than 1 percent of its entire budget to the study of 
cancer in minority populations.
    Unfortunately this study reinforced what many of us have 
known for years, that the culture, the structure and the 
programs of NIH as a whole serve the majority population very 
well but fall short in addressing the needs of our Nation's 
minority populations.
    The first chart is one that shows what the Chronicle of 
Higher Education has demonstrated. The gray areas represents 
the percentage of grants from NIH going to majority 
investigators, 89.7. The percentage going to African-American 
investigators is 0.4; to Hispanic investigators, 1.5; to Asian 
investigators, 8.1. So it shows the disparity in the granting 
mechanisms at NIH.
    Despite the troubling findings of the IM study the 
Chronicle of Higher Education article and numerous other 
reports on minority health in our country, our society has 
failed to take the necessary steps to adequately address the 
persistent health status gaps in our Nation's population. If we 
as a Nation are to solve these complex problems, we must take 
an aggressive approach on all fronts. At the core of improving 
the health status of all Americans is a strong biomedical 
research effort aimed at understanding the factors which 
contribute to our Nation's health problems.
    That's why when asked by Senator Specter at last year's 
hearing in the Senate what changes I thought were needed at NIH 
to improve the agency's commitment to minority health research, 
I recommended elevating the Office of Research on Minority 
Health to center status, the same that had occurred with the 
NIH Office of Alternative Medicine, which was elevated to the 
Center for Complementary and Alternative Medicine.
    The Genome Project was elevated to center status and the 
institute status. I announced the Genome Project in 1990 during 
my time as Secretary. I was also pleased to work with the 
Congress during my time as Secretary to establish the Office of 
Minority Health Research. Notwithstanding the success of this 
office in addressing health status disparities and supporting 
research focused on improving minority health, the magnitude of 
the health status disparities problem warrants and even more 
aggressive approach.
    Currently, this Office does not have the authority, as 
you've heard, to play a leadership role in advancing the 
priority of minority health research at NIH. I'll not go into 
detail----
    Mr. Bilirakis. Doctor, could it have more authority without 
necessarily elevation to the center?
    Mr. Sullivan. I think that's very difficult to do, Mr. 
Chairman, and my response also is this. We're talking about a 
problem that affects more than 25 percent of our Nation's 
population, one quarter of our population are minorities. By 
the year 2050, as you know, it will indeed be half of our 
population.
    So my position is, this is a major issue. I don't think 
half steps are enough. I think it should be given the full 
authority for grant making authority here, because we have done 
this in other instances.
    So let me say that I applaud Congressman Jesse Jackson, 
Charlie Norwood and the 86 co-sponsors of their bill, 2391. 
This bipartisan legislation would establish at NIH the center 
that we have discussed.
    Mr. Bilirakis. We have less than 4 minutes, Doctor, to make 
our vote.
    Mr. Sullivan. Then Mr. Chairman, let me simply----
    Mr. Bilirakis. Forgive me, it is with great respect.
    Dr. Sullivan. I would like to show, as you leave, one other 
chart. This addresses one of the features of the bill, that is 
to establish the research endowments for supporting research at 
the Nation's four minority medical schools.
    What this chart shows is the endowments at the Nation's 
medical schools, that shows $1.7 billion at Harvard, $1.3 
billion at Washington University, but an average of $133 
million at the Nation's majority schools. The Nation's four 
minority schools have an average of less than $10 million.
    So this bill also would help to give greater capacity for 
research at the Nation's minority medical schools.
    With that, Mr. Chairman, I thank you very much.
    [The prepared statement of Louis W. Sullivan follows:]
Prepared Statement of Louis W. Sullivan, President, Morehouse School of 
                                Medicine
    Mr. Chairman, thank you for the opportunity to testify today in 
support of legislation addressing the critical problem of health status 
disparities between our nation's majority and minority populations. I 
am pleased to be appear before you as President of the Morehouse School 
of Medicine in Atlanta, GA, and President Emeritus of the Association 
of Minority Health Professions Schools (AMHPS).
    AMHPS is an organization comprised of the twelve (12) historically 
black health professions schools in the country. Combined, our 
institutions have graduated 60% of all the nation's African-American 
pharmacists, 50% of African-American physicians and dentists, and 75% 
of African-American veterinarians. Our member schools have a historic 
mission of preparing graduates to practice in medically underserved 
communities, and pursuing research aimed at reducing the incidence of 
health status disparities.
    Mr. Chairman, I thank you and Congressman Brown for convening this 
hearing making the issue of health status disparities a priority this 
year. In addition, I would like to take a moment to recognize 
Congressmen Jesse Jackson, Jr., Charlie Norwood, J.C. Watts, John 
Lewis, Bennie Thompson, and Nathan Deal for their leadership and 
commitment to improving the health status of all Americans, 
particularly some of our most vulnerable citizens.
    In January of last year, I was asked to testify before the Senate 
Appropriations Subcommittee on Labor, Health and Human Services, 
Education and Related Agencies regarding an Institute of Medicine Study 
entitled, ``The Unequal Burden of Cancer: An Assessment of NIH Research 
and Programs for Ethnic Minorities and the Medically Underserved.'' 
This landmark study determined that although ethnic minorities and 
medically underserved populations suffer disproportionately from 
virtually every form of cancer, the National Cancer Institute committed 
only $24 million, or less than 1% of its entire budget, to the study of 
cancer in minority populations in fiscal year 1997.
    Unfortunately, the IOM study reinforced what many of us have known 
for years--that the culture, structure and programs of NIH as a whole 
serve the majority population well, but fall short in addressing the 
needs of our nation's minority populations. In 1993, the Chronicle of 
Higher Education highlighted the chronic lack of support for minority 
health research at NIH by demonstrating that only 0.4% of the total NIH 
budget was dedicated to African American researchers at both minority 
and majority academic institutions.
    Despite the troubling findings of the IOM study, the Chronicle of 
Higher Education article, and numerous other reports on minority health 
in this country, our society has failed to take the necessary steps to 
adequately address the persistent problem of health status disparities 
plaguing our society. If we as a nation are to solve these complex 
problems, we must take an aggressive approach on all fronts. At the 
core of improving the health status of all Americans is a strong 
biomedical research effort aimed at understanding the factors which 
contribute to our health problems.
    That is why, when asked by Chairman Specter at last year's hearing 
what changes I thought were needed at NIH to improve the agency's 
commitment to minority health research, I recommended elevating the 
Office of Research on Minority Health (ORMH) to ``center-status'', in 
the same way that the NIH Office of Alternative Medicine was recently 
elevated to become the Center for Complementary and Alternative 
Medicine.
    During the time I was HHS Secretary, I was proud to work with 
Congress to establish the ORMH. Notwithstanding the success of this 
office in highlighting health status disparities and supporting 
research focused on improving minority health, the magnitude of the 
health status disparities problem warrants an even more aggressive 
approach.
    Currently, ORMH does not have the necessary authority to play a 
leadership role in advancing the interests of minority health research 
at NIH. For example, if the director of the Office wants to fund a 
research proposal he must first find another institute or center to: 1) 
approve the study and 2) co-fund the project. Frequently, these 
requirements have proven to be an insurmountable hurdle that result in 
many worthy minority health projects being set aside. Moreover, the 
director of ORMH does not have a seat at the table when the institute/
center directors and the NIH leadership formally meet to set research 
policy and direction. If we are to see any improvement at NIH in the 
area of health status disparities, the director of ORMH must be in a 
position to help set the agency's overall minority health research 
agenda.
    Given the challenges facing ORMH in its current form, I applaud 
Congressmen Jesse Jackson, Jr., Charlie Norwood and 83 additional co-
sponsors for their leadership in introducing H.R. 2391. This bipartisan 
legislation would establish a National Center for Research on Domestic 
Health Disparities at NIH. I am also pleased that Congressmen Lewis and 
Thompson have incorporated the Jackson/Norwood legislation as Title 1 
of H.R. 3250, the Health Care Fairness Act.
    Under these important bills, the new National Center for Research 
on Domestic Health Disparities would be empowered to:

1) Participate fully with other institutes and centers in determining 
        research policy at NIH with respect to minority health at NIH.
2) Establish a Scientific Advisory Council to assist the director of 
        the Center in charting an institute-wide plan for minority 
        health research for all of NIH.
3) Serve as a catalyst for forward-thinking, strategic planning aimed 
        at bringing all of NIH's considerable resources to bear on the 
        health status disparities crisis.
4) Make peer-reviewed grants for areas of promising research which are 
        not being addressed by existing institutes and centers.
5) Establish research endowment programs at health professions 
        institutions which have a historic mission of studying diseases 
        that disproportionately affect minority and underserved 
        communities. The purpose of the research endowments is to 
        strengthen the research capabilities of these institutions.
    These changes in authority will provide the new National Center 
with the authority and the resources it needs to make real progress 
toward eliminating the daunting gap in health status between white 
Americans and the nation's minority citizens. Anything less than these 
improvements will once again leave us wringing our hands over the 
widening gap in health status of a segment of our population that, in a 
few decades, will. comprise the majority of people in this country. 
Simply stated, if we are to see meaningful, effective changes, at NIH, 
bold steps are necessary. I encourage the subcommittee and the Congress 
to establish a National Center for Research on Domestic Health 
Disparities at NIH this year.
    Once again, thank you for the opportunity to testify this morning. 
I would be happy to answer any questions that you might have.

    Mr. Green. Mr. Chairman, I have a unanimous consent 
request. I'd like to place in the record the Congressional 
Hispanic Caucus report on Hispanic health in the United States 
that was done by the Caucus, and also my opening statement.
    Mr. Bilirakis. Without objection.
    [The prepared statement of Hon. Gene Green and the report 
follow:]
  Prepared Statement of Hon. Gene Green, a Representative in Congress 
                        from the State of Texas
    Mr. Chairman, thank you for calling this hearing on the Health Care 
Fairness Act of 1999.
    As a cosponsor of this bill, I am grateful for the opportunity to 
address minority health issues today and I commend Congressman Thompson 
and Congressman Lewis for their work on this initiative.
    Congress needs to act this year to pass comprehensive legislation 
on minority health.
    We should not be addressing this issue in a piecemeal fashion.
    We have identified how and where research dollars should be 
appropriated, and we should appropriate them.
    We have identified how and where access to health care is needed 
and we should provide that access.
    Perhaps most importantly, we have identified that, although we are 
all Americans, we do have different cultures and those cultures must be 
taken into consideration when developing public policy.
    A ``one size fits all'' approach does not work in health care 
research or in the provision of health care.
    To be truly inclusive, we must address the needs of each of the 
groups that will be represented before us today.
    Nowhere is this more clear than in the Houston area, including my 
Congressional District, where over 60% of the residents are African 
American, Hispanic or other minorities.
    In my district, each social services agency and non-profit group 
uses different approaches to reach their diverse clientele. At the 
Montrose clinic, which assists AIDS patients, caseworkers speak close 
to a dozen languages including Spanish, Chinese, Arabic, Korean and 
Vietnamese. Patients receive services in a culturally sensitive manner.
    Despite new efforts to provide such services, minorities continue 
to fall through the cracks of America's health care system.
    Disparities in access to health care were dramatically illustrated 
in the recent Institute of Medicine study and we will hear more about 
those disparities today.
    This is particularly true in urban areas such as Houston, Atlanta 
and Chicago. I am pleased to have joined forces with Congressman John 
Lewis and others to address the unique health care needs of our cities.
    As we work to increase access to health care services, one of our 
top focuses should be on childhood immunizations--in Houston, more than 
44% of children are not receiving one or more of the recommended 
vaccines.
    During the past four years my office has held a yearly immunization 
clinic,, where we have vaccinated over 300 children.
    After talking to families at this clinic I have learned that they 
avoided getting immunizations in other places because they were afraid 
that their immigration status would be questioned or concerned about 
cost.
    The outbreak of Measles that swept the country in 1989 began in 
Houston--and I am fearful that another such outbreak could occur at any 
time. We must do more to ensure that minority children, and all 
children, have access to immunizations.
    In closing, I would like to give a special thanks to my colleague 
Ciro Rodriguez, who has been a tireless advocate for the Hispanic 
population throughout Texas and the United States.
    As Chairman of the Hispanic Caucus Health Task Force he has done 
much to increase our understanding of, and attention to, the needs of 
Hispanic Children.I want to share with you today his report on Hispanic 
Health in the United States, a report that I hope you will all read and 
take into consideration as the legislative process moves forward.
    Thank you, I yield back the balance of my time.
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    Mr. Bilirakis. And I would hope that we all would have an 
opportunity to read Dr. Sullivan's testimony. It's very 
powerful.
    Mr. Brown. Mr. Chairman, if anyone has questions to submit 
to Dr. Sullivan, I'm sure we could----
    Mr. Bilirakis. Yes, without objection, I'm sure you're 
willing to----
    Mr. Sullivan. Oh, yes, I'd be pleased to.
    Mr. Bilirakis. Thank you so much for being here, Doctor. 
Forgive me for treating you this way, but you know what it's 
like here.
    Mr. Sullivan. I understand. Thank you very much.
    Mr. Bilirakis. Well, we're going to have to adjourn for 
anywhere from 45 minutes to an hour, depending on how long it 
takes us to address five votes.
    [Brief recess.]
    Mr. Greenwood [presiding]. I'll preside briefly.
    Do we have all our witnesses here? All right, if the 
witnesses could take their seats, we'll see how many of them we 
don't have.
    Upon further consideration, apparently the Subcommittee 
Chairman has indicated that at 10 after 2, we would reconvene 
in an hour. So we'll reconvene at 10 after.
    [Brief recess.]
    Mr. Greenwood. The hour of 2:10 having arisen, we will 
start and assume that the other witnesses will hear your 
eloquent testimony and come running in. I'll introduce panel 
three, is that correct? We have Dr. Gilbert Friedell, Director 
for Cancer Control, Markey Cancer Center, University of 
Kentucky, testifying on behalf of the Institute of Medicine. We 
have Dr. Jordan Cohen, President and CEO of the Association of 
American Medical Colleges. Dr. Kevin Schulman is Associate 
Professor of Medicine and Director of the Center for Clinical 
and Genetic Economics, Duke University Medical Center. Dr. Anne 
Peterson is not here yet. Dr. John Harley is a member and 
program head of the Oklahoma Medical Research Foundation.
    Mr. Friedell, if you would start us off, please.

  STATEMENT OF GILBERT H. FRIEDELL, DIRECTOR EMERITUS, MARKEY 
  CANCER CENTER, UNIVERSITY OF KENTUCKY; MEMBER, INSTITUTE OF 
MEDICINE COMMITTEE ON CANCER RESEARCH AMONG MINORITIES AND THE 
                     MEDICALLY UNDERSERVED

    Mr. Friedell. Thank you, Mr. Chairman. I'm delighted to be 
here, and appreciate the opportunity to testify.
    I'm speaking here on behalf of the Institute of Medicine 
Committee, which provided this report on the Unequal Burden of 
Cancer: An Assessment of NIH Research and Programs For Ethnic 
Minorities and the Medically Underserved. I stress those last 
few words, because so far much of the comment has been about 
minority health, where the report for NIH was something a 
little broader than that.
    Much of what I wanted to say has been said, so I'll be 
brief about my remarks. As you all know, one in four deaths in 
the country are attributable to cancer, expected to become the 
leading killer in the next century. People have referred to 
some of these numbers, but I'll repeat them that African 
American men are more likely to be diagnosed with prostate 
cancer than white men. Asian Americans are more likely to 
develop stomach and liver cancer. Cervical cancer is higher 
among Hispanic and Vietnamese American women. African American 
women, though less likely to develop breast cancer are less 
likely to survive it.
    I would point out, though, that the highest incidence in 
mortality rates for lung cancer are in the rural, poor 
population in Appalachian Kentucky. And Native Americans have 
the lowest cancer survival rates of all.
    The key question, then, for researchers and public health 
officials, is why these differences in cancer incidence, 
mortality and survival persist. The 15 member committee that I 
served on looked at these questions, assessed how NIH 
prioritizes cancer research among minority and medically 
underserved populations, how it applies research findings to 
prevention and treatment. We looked at the adequacy of 
procedures related to including minorities in clinical trials, 
and the communication of these results to the general public.
    I'd like to make five particular points this afternoon 
summarizing some of these major findings, and you'll 
appreciate, these are five brief points out of a report of 
several hundred pages. No. 1, better surveillance efforts are 
needed to provide a more complete picture of the burden of 
cancer among minority and medically underserved individuals. 
The report, you understand, was about cancer, not about health 
in general.
    Second, research is needed on the reasons for the 
disparities as reflected by the burden of disease data 
generated by cancer surveillance. Third, that research is 
particularly needed on the medically underserved, a category 
which cuts across race and ethnicity. Four, as currently 
constituted, neither the Office of Special Populations Research 
at NCI nor the Office of Research on Minority Health at NIH 
have the authority, budget or other support mechanisms to 
effectively coordinate, stimulate and facilitate research for 
minorities and medically underserved groups. And five, the 
target for reducing cancer mortality would be achieving the 
lowest rates of cancer mortality for selected cancers seen 
among different populations. And I'll elaborate briefly on each 
of those points.
    The first one about surveillance, a critical first step is 
to pinpoint exactly what differences exist among racial and 
ethnic groups, as well as socioeconomic groups. By legislation, 
the National Cancer Institute's Surveillance Epidemiology End 
Results program is charged with this responsibility as far as 
cancer is concerned, by monitoring incidence of mortality and 
survival rates. It's the closest thing we have to a national 
report, but it's severely limited in a few areas.
    Several groups are not covered in the SEER program. In 
order for it to be most effective, the committee recommended it 
should be expanded to include populations not covered, such as 
lower income or poverty level whites, especially those living 
in rural areas, for example Appalachia; Hispanics of all 
national origins; African Americans living in rural 
communities, particularly the south; and the American Indian 
population. Furthermore, the results should be correlated with 
the State cancer registries that are being developed under the 
CDC program of the National Program Cancer Registries.
    As far as disparities are concerned, we believe NCI should 
give consideration to the magnitude of the cancer problems in 
different ethnic groups. The research needs of these groups and 
of medically underserved groups could be identified primarily 
on the burden of disease which is found in each of these 
populations. Without setting boundaries to begin with of race 
and ethnicity, let's look at the burden of disease which is 
found by inadequate surveillance program. This was the gist of 
one of our recommendations.
    Third, while a disproportionately large share of African 
Americans and Hispanics live at or below the poverty level, 
poor whites, particularly the rural poor, constitute the 
largest group of poverty level individuals. According to the 
U.S. Bureau of the Census, in 1996, there were approximately 10 
million African Americans, approximately 7 million Hispanics, 
approximately 1.3 million Asians or Pacific Islanders, 714 
million American Indians and almost 22 million whites living 
below the poverty line. These individuals suffer from rates of 
disease and disability as high or in some cases higher than 
racial and ethnic minorities and should be a higher priority in 
NIH's research efforts.
    Insofar as the Office of Research on Minority Health is 
concerned, we believe NIH needs to formulate a blueprint or 
coordinated plan for addressing questions related to minorities 
and the medically underserved. Within NCI, the Office of 
Special Populations Research is charged to serve as the 
Director's eyes and ears on research needs of minority groups, 
the low income and low literacy populations, the blue collar 
workers and other populations considered to be at a higher risk 
for cancer. But this office lacks the authority and the 
resources to coordinate an extensive program of research among 
ethnic minorities.
    Similarly, the Office of Research on Minority Health, which 
is to coordinate the studies on ethnic minority health 
problems, but its impact also is limited by the size of its 
budget and its lack of authority over NIH research programs. It 
has no involvement, furthermore, with the medically underserved 
who are not recognizable by race or ethnicity. That office 
should more actively coordinate, plan and facilitate cancer 
research relevant to ethnic minorities and medically 
underserved populations across NIH centers and institutes.
    Insofar as reducing cancer mortality by achieving the 
lowest rates of cancer mortality for selected cancers, what we 
mean by this is that there are low rates of some cancers. For 
example, prostate cancer among Chinese, high rates among 
African Americans. We suggested that it would be important to 
look at those populations that have low rates of cancer as well 
as looking only at the populations that have high rates of 
cancer.
    My more extensive remarks have been submitted to the 
Committee. I would like to point out two particular things, 
though, that may be relevant. One of them is that there's been 
much discussion about various rates of diseases beyond cancer 
in minority populations. A few months ago, the Lexington Herald 
Leader produced a supplement which relates to health disorders 
in Appalachian or Eastern Kentucky, a 99 percent rural white 
population. You'll find on reading this that the rates for 
diabetes, hypertension, coronary heart disease and some cancers 
are almost as high, in some cases higher, than rates that have 
been reported for recognizable minorities. I think this may be 
an important thing for the group.
    In addition, there may be some reprints of specific issues 
which perhaps I could add to the Committee's files later. But 
the bulk of my testimony really relates to the IOM committee 
report. Thank you very much.
    [The prepared statement of Gilbert H. Friedell follows:]
  Prepared Statement of Gilbert H. Fridell, Director Emeritus, Markey 
                 Cancer Center, University of Kentucky
    Good morning Chairman Bilirakis and members of the Subcommittee. On 
behalf of the entire IOM Committee on Cancer Research Among Minorities 
and the Medically Underserved, I am pleased to be here today to present 
our report.
    One in four deaths in this country is attributable to cancer, which 
is expected to become the country's leading killer in the next century. 
Recent scientific gains have fueled the first overall reduction in 
deaths from cancer, but not all groups in the U.S. population have seen 
an improvement. Poor people and some ethnic minorities are more prone 
to certain types of cancer and are less likely to survive it than the 
rest of the population.
    African-American men, for example, are more likely to be diagnosed 
with prostate cancer than white men. Asian Americans are more likely 
develop stomach and liver cancer. Cervical cancer is higher among 
Hispanic- and Vietnamese-American women. African-American women, though 
less likely than others to develop breast cancer, are also less likely 
to survive it. Further, lower-income whites in rural areas such as 
Appalachia have some of the highest rates of specific types of cancer 
in the country. And Native Americans have the lowest cancer survival 
rates of all.
    A key question for researchers and public health officials is why 
these differences in cancer incidence, mortality, and survival rates 
persist.
    The 15-member Institute of Medicine committee that I served on 
examined these questions, and assessed how the National Institutes of 
Health (NIH) prioritizes research on cancer among minority and 
medically underserved populations and how it applies research findings 
to prevention and treatment programs. We also looked at the adequacy of 
procedures related to including minorities in clinical trials, as well 
as the communication of research results to these groups and other key 
issues to the public. In the report, published in January, 1999, we 
offered recommendations that we hope not only will help improve the 
health of minorities and the medically underserved, but everyone in our 
increasingly diverse society.
    A critical first step is to pinpoint exactly what differences exist 
among racial and ethnic groups, as well as socioeconomic groups. By 
legislation, the National Cancer Institute's (NCI) Surveillance, 
Epidemiology, and End Results (SEER) program is assigned the 
responsibility of assessing the burden of cancer in the population by 
continuously monitoring cancer incidence, mortality, and survival 
rates. It is the closest thing the country has to a longitudinal 
national cancer database, but its usefulness is diminished by 
limitations in the way data are collected.
    Unfortunately, several key groups are not adequately covered in the 
SEER program. In order for this program to be most effective, the 
committee recommended it should be expanded to include populations not 
covered, such as lower-income or poverty level whites, especially those 
living in rural areas such as Appalachia; Hispanics of all national 
origins; African Americans living in rural communities, particularly in 
the South; and American Indian populations. Further, this database 
should be coordinated with newer state databases to create a national 
registry with uniform methods of data collection and analysis.
    In accordance with the guidelines of the federal Office of 
Management and Budget, NIH classifies the population into one of four 
racial categories--White, Black, Asian or Pacific Islander, or Native 
American. This method of classification was not intended for 
epidemiological research and, in fact, is not consistent with current 
scientific thinking. There are no known biological boundaries that 
justify the division into races.
    We recommend that NCI place a greater emphasis on the differences 
in cancer among ethnic groups and those of low socioeconomic status, 
with a view to determining the roles that diet, lifestyle, and customs 
play in varying rates of cancer. We need to take advantage of the 
ethnic diversity of the American population to explore, for example, 
why Chinese American men have such low rates of prostate cancer 
compared with African American men.
    Overall, we believe that NIH needs to formulate a blueprint or a 
coordinated plan for addressing questions related to cancer among 
minorities and the medically underserved. NIH's Office of Research on 
Minority Health coordinates studies on ethnic minority health problems, 
but its impact is limited by the size of its budget and other 
constraints, and it has no involvement with the medically underserved 
who are not recognizable by race or ethnicity. That office should more 
actively coordinate, plan, and facilitate cancer research relevant to 
ethnic minorities and medically underserved populations across NIH 
centers and institutes. Within the National Cancer Institute, the 
Office of Special Populations Research lacks the authority and 
resources to coordinate an extensive program of research on cancer 
among ethnic minorities. This office should be given greater authority 
to expand NCI's research in these areas.
    NCI also should improve its estimates of the money it spends on the 
health needs of minorities and the medically underserved. NCI reported 
spending about $124 million in fiscal year 1997 for research and 
training programs addressing cancer in these populations. NCI's 
estimate is derived by calculating the percentage of minorities 
enrolled in research studies. We believe that NCI should base its 
estimate on the research questions involved rather than on the 
percentage of minorities in its studies. Such a coding procedure would 
allow NCI to accurately provide data on the number of studies that pose 
research questions specifically designed to better understand the 
burden of cancer among minority and medically underserved populations, 
and the amount of funds allocated to these studies. When one considers 
the greater burden of cancer among minorities and the increasing 
diversity of the U.S. population, NCI's current allocation is too low.
    In setting research priorities, NCI places strong emphasis on 
research that capitalizes on scientific opportunities, and rightly so. 
However, we believe that NCI should give consideration to the magnitude 
of the cancer problem in different ethnic groups. The research needs of 
ethnic minority and medically underserved groups should be identified 
on the basis of the burden of disease in these populations, with an 
assessment of the most appropriate areas of research. These areas of 
needed research may be stimulated by requests for applications or other 
targeted efforts from NIH institutes.
    Participation in clinical trials among minorities has improved in 
recent years, to the point where their participation in NCI-sponsored 
cancer treatment trials is proportionate to the burden of disease in 
these populations. However, participation in prevention trials remains 
low. The absence of minorities in some of these trials--for example the 
recently concluded tests of tamoxifen to prevent breast cancer in women 
at high risk for the disease--raises questions about how applicable the 
results are to minority populations.
    As NIH and NCI continue to review strategies for communicating with 
the public, they should give special attention to the needs of 
ethnically diverse and medically underserved communities. Among the key 
issues that remain is how to obtain truly informed consent from 
research subjects who experience language and literacy barriers.
    NIH should establish a formal system of reporting to Congress and 
the public on cancer studies for ethnic minorities and medically 
underserved groups. Reports should include details on the number and 
type of research programs specifically targeted to these groups, and 
the contributions of ethnic minority scientists and community groups 
representing minorities and the medically underserved to the research 
priority-setting process. At the same time, NCI should improve efforts 
to disseminate information about cancer to patients, clinicians, and 
others in ethnic minority and underserved populations, and create a 
system to assess effectiveness. Cancer survivors from these groups 
should be tapped as important resources for educating others in their 
communities about cancer.
    Finally, the committee concluded that the diversity of the American 
population offers a great opportunity for exploring all of the possible 
causes of cancer. For example, we asked what might happen if all 
Americans had the same rate of cancer at each site as the lowest rate 
of any ethnic group. For example, if all Americans had the low rate of 
lung cancer as Hispanics, mortality due to lung cancer would be reduced 
by 50 percent. This is not to suggest that those groups that experience 
low rates of some forms of cancer should not be the focus of our 
research and prevention efforts; rather, research on the dietary 
patterns, lifestyles, and health behaviors of lower-risk groups offers 
an opportunity to improve the health of higher-risk groups. It is a 
goal worth pursuing as long as there were not promises of quick 
results.
    Throughout our study, the National Cancer Institute was generous in 
providing the information that we requested, and it is clear to us that 
NCI is undergoing dynamic change. In fact, some of our suggestions for 
improvement today have already been suggested internally at NCI and are 
in the process of being implemented. We commend NCI's plans to increase 
its commitment to behavioral research, especially if some of that 
research is specifically targeted toward minorities and the medically 
underserved.
    The National Cancer Institute is a great national resource that is 
vigorously pursuing the goal of reducing cancer in America. From the 
beginning of the ``War on Cancer'' it has been forced to grapple with 
the continuous demand for quick results. There was even a strong notion 
that the problem of cancer would be solved by 1976. But we now know 
that there are no quick fixes in cancer research. A big breakthrough is 
often the result of years of patient and sometimes unrecognized effort. 
Cancer is not one but more than 100 diseases. We hope our 
recommendations will help NCI and all of NIH tackle this difficult 
health problem in order to further the health of all Americans.

    Mr. Greenwood. Thank you very much for your testimony, sir.
    Dr. Cohen.

  STATEMENT OF JORDAN J. COHEN, PRESIDENT AND CEO, ASSOCIATION 
                  OF AMERICAN MEDICAL COLLEGES

    Mr. Cohen. Thank you very much, Mr. Chairman, members of 
the Committee. My name is Jordan Cohen, and I'm President of 
the Association of American Medical Colleges, which represents 
U.S. medical schools and major teaching hospitals in our 
country, medical students, residents and faculty.
    The Association is pleased to endorse the Health Care 
Fairness Act, H.R. 3250, and we commend the Committee for 
holding this hearing. We must do more as a country to find 
solutions to the existing critical disparities in health status 
and access to quality health care among significant segments of 
our Nation's population.
    While it is important that everyone involved in providing 
health care to patients work to eliminate health disparities, 
medical schools and teaching hospitals have a unique 
responsibility both to integrate the knowledge of these 
disparities into the education of physicians and the delivery 
of health care, and to ensure that these problems are high on 
the research agenda, historically the AAMC has taken a 
leadership role in addressing issues related to inequalities 
and disparities in medicine. We have played an active role in 
enhancing the diversity of those providing health care and 
assisting our member institutions to advance the teaching and 
education and evaluation of cultural competence.
    AAMC supports the establishment of a center for research on 
minority health at the National Institutes of Health, and the 
development of a comprehensive research plan for all minority 
health research at the NIH in consultation with other NIH 
institutes and centers. The causes of health disparities are 
complex, and include a mix of socioeconomic, cultural and 
behavior factors, as we learned from Dr. Satcher earlier today.
    Few, if any, diseases are unique to particular racial or 
ethnic groups. But patterns of prevalence, as we've heard, and 
of severity, differ widely in various racial and ethnic 
populations. Research on minority health issues should be 
incorporated into the mission of each of the NIH institutes and 
centers, building on the scientific and clinical expertise that 
resides in their programs.
    The bill also authorizes the submission of the center's 
budget directly to the President and to Congress. 
Traditionally, the Association has not supported the creation 
of such a separate budget bypass for specific areas of 
research. However, the critical need to enhance the research 
efforts to address minority health disparities is sufficient, 
in our view, to justify making an exception in this case to our 
longstanding policy opposing bypass budgets.
    AAMC has consistently and strongly advocated additional 
funding for the NIH's effort to attract and retain more under-
represented minorities into careers in biomedical and 
behavioral research. AAMC supports the establishment of centers 
of excellence for research as another positive initiative to 
achieve a more diversified research work force. We also believe 
that any institution with a well documented and sustained 
commitment to addressing issues of minority health should be 
eligible for these awards.
    The Association is especially pleased with the provisions 
in Title IV on medical education, which will enable health 
professional schools to enhance and expand existing programs to 
address cultural competency. In particular, we note that the 
legislation would provide support for increased curricula and 
faculty development for cultural competency at all levels of 
health professions education, including continuing education.
    In conclusion, we believe that the disparities in health 
status as a function of race and ethnicity are among the most 
pressing challenges that confront our Nation. AAMC thanks the 
Subcommittee for holding this hearing to examine these issues, 
and urges Congress to move forward when considering and passing 
H.R. 3250.
    Thank you very much.
    [The prepared statement of Jordan J. Cohen follows:]
 Prepared Statement of Jordan J. Cohen, President and CEO, Association 
                      of American Medical Colleges
    The Association of American Medical Colleges (AAMC) is pleased to 
have this opportunity to testify in support of the Health Care Fairness 
Act, H.R. 3250. Representing the nation's 125 accredited allopathic 
medical schools, nearly 400 major teaching hospitals and health care 
systems, 91 academic and professional societies representing more than 
87,000 faculty members, and the nation's 167,000 medical students and 
residents, the AAMC commends the subcommittee for holding this hearing. 
Our country must do more to find solutions to the existing, critical 
disparities in health status and access to quality health care among 
significant segments of this nation's population.
    The AAMC, whose overarching mission is the improvement of the 
health of the nation, is deeply concerned about these disparities. 
While it is important that everyone involved in providing health care 
to patients work to eliminate health disparities, medical schools and 
teaching hospitals have a unique responsibility to integrate knowledge 
of these disparities into the education of physicians and the delivery 
of health care, and to ensure that these problems are high on the 
research agenda. Historically, the AAMC has taken a leadership role in 
addressing issues related to inequalities or disparities in medicine. 
We have played an active role in enhancing the diversity of those 
providing health care and in assisting our member institutions to 
advance the teaching and evaluation of cultural competence.
    For more than 30 years, the AAMC and its member medical schools and 
teaching hospitals have committed themselves to increase the racial and 
ethnic diversity in the medical profession, including establishing a 
division within the AAMC to address minority issues, sponsoring 
workshops highlighting the importance of noncognitive variables (e.g., 
leadership, determination, altruism, compassion, maturity, coping 
capabilities, communication skills) in the admissions process, 
promoting the development of a minority affairs infrastructure within 
medical schools, creating two AAMC Task Forces to identify problems and 
solutions related to increasing minority enrollment, launching in 1991 
Project 3000 by 2000, and most recently, organizing and staffing the 
Health Professionals for Diversity coalition.
    The AAMC is pleased to endorse the Health Care Fairness Act, H.R. 
3250, which identifies a series of pressing issues that affect the 
health of a significant portion of our nation's population. We believe 
that the disparities in health status and access to health care among 
various racial and ethnic groups result from multiple causes, and that 
the multiple solutions proposed in this legislation are needed to 
eradicate these inequities.
    The AAMC supports the establishment of a Center for Research on 
Minority Health at the National Institutes of Health (NIH) and the 
development of a comprehensive research plan for the conduct and 
support of all minority health research at the NIH in consultation with 
all other NIH institutes and centers, as called for in Title I of the 
bill. The causes of health disparities are complex and include a mix of 
socioeconomic, cultural, and behavioral factors. Few if any diseases 
are unique to particular racial and ethnic groups, but patterns of 
prevalence and severity differ widely in various racial or ethnic 
populations. Accordingly, the AAMC believes that research on minority 
health issues should be incorporated into the mission of each of the 
NIH institutes and centers, building upon the scientific and clinical 
expertise that resides in these programs. The NIH's success is based on 
its ability to marshal the full weight of all of its institutes to 
solve fundamental scientific questions and to address the most urgent 
challenges of disease.
    We note that Title I also authorizes the submission of the Center's 
budget directly to the President and Congress. Traditionally, the 
Association has not supported the creation of such a separate budget 
by-pass for specific areas of research. However, the critical need to 
enhance the research efforts to address minority health disparities is 
sufficiently to justify making an exception to our long-standing policy 
opposing by-pass budgets.
    The AAMC has long been concerned about the need to attract and 
retain more underrepresented minorities into careers in biomedical and 
behavioral research, and has consistently and strongly advocated 
additional funding for the NIH's efforts in this area. The AAMC 
supports the establishment of Centers of Excellence for Research as 
another positive initiative to achieve the goal of a more diversified 
research workforce. We also believe that any institution with a well-
documented commitment to addressing issues of minority health should be 
eligible for these awards. The bill states that eligible institutions 
must have significant numbers of minority students and faculty without 
defining what is meant by significant. We would suggest that this 
wording be modified so as not to leave the impression that research on 
minority health issues is, or should be, the concern only of minority 
researchers. We look forward to an opportunity to work with members of 
the subcommittee to assure that this program will be designed to 
encourage as many institutions as possible to develop substantive 
programs of research in these areas.
    The Association is especially pleased with the provisions in Title 
IV on medical education, which will enable health professions schools 
to enhance and expand existing programs to address cultural competency. 
In particular, we are pleased to note the legislation would provide 
support for increased curricula and faculty development for cultural 
competency at all levels of health professions education, including 
continuing education. These programs will complement and enhance the 
AAMC's education initiatives, including the dissemination of specific 
objectives for medical education, the recognition by accrediting bodies 
on the importance of requiring the inclusion of cultural issues in the 
curriculum, and the mounting of faculty development activities to 
enhance the teaching and evaluation of cultural awareness.
    The bill also authorizes an information clearinghouse for curricula 
to reduce racial and ethnic disparities in health care and health 
outcomes, and a national conference on continuing health professions 
education as a method to reduce such disparities. The AAMC believes 
that both of these initiatives will promote greater dissemination of 
successful efforts to reduce health disparities.
    In conclusion, the disparities in health status as a function of 
race and ethnicity are among the most pressing challenges that confront 
us as a nation. The AAMC thanks the subcommittee for holding this 
hearing to examine these issues and urges Congress to move forward in 
considering and passing H.R. 3250.

    Mr. Greenwood. Thank you, Dr. Cohen, very much, for your 
testimony.
    Dr. Schulman.

     STATEMENT OF KEVIN A. SCHULMAN, ASSOCIATE PROFESSOR OF 
 MEDICINE AND DIRECTOR OF THE CENTER FOR CLINICAL AND GENETIC 
           ECONOMICS, DUKE UNIVERSITY MEDICAL CENTER

    Mr. Schulman. Mr. Chairman, thank you, and Mr. Brown, and 
other members of the Committee.
    Thank you very much for inviting me to appear before the 
Committee today. I want to try and provide a framework and 
rationale for the medical education sections of the Health Care 
Fairness Act, especially Section 201, which refers to grants 
for medical education curriculum development.
    Medical literature has carefully documented racial and 
ethnic differences and the use of medical therapies for 
patients with many conditions. We've heard a lot on this today. 
One point to emphasize here is that these differences in 
treatments have been shown to result in differences in patient 
survival in and of themselves.
    One issue not addressed by this entire body of literature 
is whether physicians who are contributing to these differences 
are making different treatment recommendations based on patient 
race and sex. We explored this concept directly in a major 
study published last year in the New England Journal of 
Medicine.
    We assessed physicians' treatment recommendations for 
simulated patients who differed from each other only on the 
basis of race and sex. We include eight patient actors in the 
experiment, 4 black, 4 white, 4 male and 4 female. Their 
pictures are included in the testimony I submitted to the 
Committee.
    Overall, we found that for identical patients, physicians 
were less likely to refer blacks compared to whites, and women 
compared to men, for cardiac catheterization, and that the 
lowest referral rates were for black women. Further, we were 
able to show that these results were not influenced by patient 
personality.
    In addition, the physicians rated the black patient actors 
of being of lower socioeconomic status than the white patient 
actors, despite the fact that all patients had identical job 
descriptions, lived in the same location, were dressed in the 
same clothing and had the same health insurance.
    In this carefully controlled experiment, we were able to 
demonstrate that patients' characteristics influenced 
physician's recommendations for cardiac catheterization. The 
social psychology literature suggests that all of us 
characterize new individuals when we meet them using an 
automatic or subconscious process. These characterizations 
incorporate societal attitudes and stereotypes into a label 
that we attach to other people.
    The absence of bias indicates an ability to consciously 
override these automatic characterizations in relating to other 
people. Our experiment suggests that a brief interview with a 
new patient may not yield sufficient information to override 
these automatic characterizations. These subconscious 
characterizations may then contribute to physicians' treatment 
recommendations for identical patients observed in our study.
    The implication of this study is a disturbing one, that 
physicians are contributing to disparities in health care 
between blacks and whites in this country. This is not to say 
that physicians' actions are responsible for all or even a 
majority of the racial disparities in medical treatment that 
have been observed. In fact, we cannot assess the relative 
contributions of the many factors shown to affect differences 
in procedure utilization across patient race. In addition, we 
haven't looked at Hispanics or other races in our experiment.
    However, any contribution by physicians to these 
disparities cannot be tolerated, as Mr. Coburn said this 
morning.
    While disturbing, these results also offer us hope. As 
Thurgood Marshall said, what you have to do, white or black, 
you have to recognize that you have certain feelings about the 
other race, good or bad, and get rid of them. But you can't get 
rid of them until you recognize you have them.
    The medical education section of the Health Care Fairness 
Act offers an opportunity to directly address this issue. The 
legislation will allow us to develop new educational programs 
to target the subconscious biases that seem to explain a 
reversible component of the disparities in health care between 
blacks and whites. Finding the optimal method of implementing 
such a sensitive curriculum is an issue of major concern that 
would be addressed in the research effort called for in this 
legislation.
    The public will not be assured that the health care system 
is truly blind to race until we are able to show that these 
training programs are effective. Hence, the importance of the 
evaluation component of these grants. These evaluation efforts 
will allow us to understand what works in developing cultural 
competency curricula, and to rapidly disseminate effective 
programs to other sites, In this increasingly multicultural 
society, the issue of how to ensure that patient 
characteristics no longer influence clinical decisionmaking is 
of critical importance in designing medical school residency 
and continuing education curricula, and ensuring appropriate 
clinical practice.
    Thank you very much for asking me to present here with you 
today.
    [The prepared statement of Kevin A. Schulman follows:]
    Prepared Statement of Kevin A. Schulman, Associate Professor of 
  Medicine, Director, Center for Clinical and Genetic Economics, Duke 
                       University Medical Center
    Mr. Chairman and distinguished members of the Committee: Thank you 
very much for inviting me to appear before the Committee today. I want 
to try to provide a framework and rationale for Title II of the Health 
Care Fairness Act of 1999, specifically section 201, which refers to 
grants for medical education curriculum development.
    Large-scale epidemiologic studies have reported race and sex 
differences in management of patients with chronic diseases in the 
United States. In the vast majority of these studies, investigators 
have found that blacks are less likely than whites to undergo 
procedures in both inpatient and outpatient settings. Let me first 
review some of these data with you.
    In a recent article, we reviewed more than 30 major epidemiologic 
studies assessing differences in cardiac procedure utilization rates 
between blacks and whites. While these studies varied in the number of 
patients included, in the types of data analyzed, and in the specific 
clinical conditions under assessment, almost all found that blacks 
compared to whites were less likely to undergo cardiac catheterization, 
cardiac angioplasty, or coronary artery bypass surgery.
    While disturbing, these epidemiologic studies did not suggest 
either the reasons for differences in clinical practice or the 
implications of these differences for individual patients. Many of the 
authors felt that underlying structural factors within the health care 
system were responsible for the major portion of their findings, 
including differences in access to private health insurance. However, 
certain portions of this body of research suggest that insurance 
coverage is not the only reason for differences in access to 
procedures. In an important study of patients within a single health 
care system--the Veterans Health Administration--Dr. Eric Peterson 
found results similar to those reported in other epidemiologic studies; 
yet all patients at VA medical centers had the same insurance program, 
which eliminates insurance as an explanation for these differences. 
Similarly, Bruce Vladeck found, when he was Administrator of the Health 
Care Financing Administration, that black patients within the Medicare 
program were less likely than white patients to undergo cardiac 
procedures, again providing evidence that differences in insurance 
coverage do not fully explain the differential use of procedures in 
blacks compared to whites.
    Even with the important information that insurance may not be the 
only factor responsible for differences in access to procedures, 
controversy continued about whether differential access results in 
worse outcomes for minority patients. Dr. Peterson subsequently 
developed data that suggest that differences in mortality between 
blacks and whites exist even after adjustment for clinical factors, but 
are no longer apparent when differences in treatment between blacks and 
whites are included in statistical analysis. This was one of the first 
studies to demonstrate that differences in access to care result in 
differences in survival for a specific population of patients.
    Unfortunately, as we have looked beyond cardiovascular disease, we 
have found differences in access to other major medical procedures for 
blacks compared to whites, including the treatment of stroke patients 
and the use of bone marrow transplantation for patients with leukemia 
and lymphoma. In an important paper late last year, Dr. Peter Bach of 
Memorial Sloan-Kettering Cancer Center found that blacks compared to 
whites were less likely to undergo surgical resection for early-stage, 
non-small-cell lung cancer. Furthermore, Dr. Bach was able to 
demonstrate that differences in mortality between black and white 
patients were directly related to differences in surgical therapy 
received by those patients.
    Another significant study contributing to this field looked at 
patients with end-stage renal disease. The study examined whether 
patients with end-stage renal disease in the Medicare program were 
referred for evaluation for kidney transplantation. Once again, black 
patients compared with white patients were less likely to be referred 
for surgical procedures. In this study, however, the authors were also 
able to directly assess patients' desires for kidney transplantation. 
The authors reported that differences in patients' desires between 
blacks and whites did not explain differences in access to transplant 
evaluation.
    Dr. William Owen at Duke University Medical Center looked at 
patients undergoing dialysis at outpatient dialysis centers across the 
country. He found that blacks compared to whites were less likely to 
receive optimal doses of dialysis in 1993. However, through careful 
monitoring and feedback using clinical guidelines and clinical 
performance measures, this disparity in care was almost eliminated over 
a four-year period. Dr. Owen's study provides some evidence that 
physicians are contributing to disparities in care between blacks and 
whites.
    We explored this concept directly in a major study published last 
year in the New England Journal of Medicine. We were especially 
interested in exploring whether physicians contributed to differences 
in procedure rates among blacks and whites by assessing physicians' 
recommendations for simulated patients who differed from each other 
only on the basis of race and sex. Using a computer survey instrument, 
we presented groups of practicing physicians with clinical cases that 
varied from each other only on the basis of six patient variables, 
including patient age, race, sex, type of chest pain, cardiac history, 
and stress test results. Eight trained patient actors--four blacks, 
four whites; four men, four women; four 55-year-olds, four 70-year-
olds--were asked to record three identical interviews representing 
three distinct types of chest pain. We then asked 720 primary care 
physicians to interview one of the eight patient actors by reviewing 
one of 24 video segments. In this study, a total of 144 different cases 
were available for assessment by individual physicians.
    Overall, we found that for identical patients, physicians were less 
likely to refer blacks compared to whites and women compared to men for 
cardiac catheterization, and that the lowest referral rates were for 
black women. In an extensive series of analyses, we were able to show 
that these results were not influenced by patient personality. In 
addition, the physicians uniformly rated the black patient actors as 
being of lower socioeconomic status than the white patient actors, 
despite the fact that all patients had identical job descriptions, 
lived in the same locations, were dressed in the same clothing, and had 
the same health insurance.
    In this carefully controlled experiment, we were able to 
demonstrate that patients' characteristics influence physicians' 
recommendations for cardiac catheterization.
    The social psychology literature suggests that all of us 
characterize new individuals when we meet them using an automatic 
process. These characterizations occur subconsciously and incorporate 
societal attitudes and stereotypes. The absence of prejudice indicates 
an ability to consciously override these automatic characterizations.
    Our experiment suggests that a brief interview with a new patient 
may not yield sufficient information to override these automatic 
characterizations. These subconscious characterizations may then 
contribute to physicians' treatment recommendations for identical 
patients observed in our study.
    The implication of these studies is a disturbing one: that 
physicians are contributing to disparities in health care between 
blacks and whites in this country. This is not to say that physicians' 
actions are responsible for all or even the majority of the racial 
disparities in medical treatment. In fact, we cannot assess the 
relative contributions of the many factors shown to affect differences 
in procedure utilization across patient race. However, any contribution 
by physicians to these disparities can not be tolerated.
    The results of the studies I have reviewed suggest that 
physicians--though dedicated professionals--are similar to everyone 
else in society in that they may harbor subconscious attitudes and 
biases toward groups. These attitudes and biases, even at the 
subconscious level, may manifest themselves inadvertently when 
physicians make different treatment recommendations based solely on 
characteristics such as race. But these results also offer us hope and 
the opportunity to improve ourselves. As Thurgood Marshall said, ``What 
you have to do--white or black--you have to recognize that you have 
certain feelings about the other race, good or bad. And then get rid of 
'em. But you can't get rid of them until you recognize them.''
    How do we get rid of subconscious biases in the case of the 
individual physician? The potential for subconscious bias to influence 
clinical decision-making is a much more difficult topic to address from 
an educational and regulatory perspective than overt bias would be 
under civil rights law. There are currently no compelling studies that 
test and demonstrate the efficacy of particular approaches to this 
problem in medical education. While the American Medical Association 
has recently called for initiatives to increase awareness of racial 
disparities--in medical school curricula, medical journals, 
professional conferences, and peer review activities--only a small 
minority of U.S. medical schools reported that they had a cross-
cultural competency component to their curriculum. In a recent survey 
of U.S. medical schools, only 13 of the schools responding to the 
survey reported offering a course designed to explain the delivery of 
health care in ethnically diverse populations.
    Even in those medical schools that have implemented a ``cross-
cultural curriculum,'' there are no data regarding the effectiveness of 
current educational approaches. The need to explore the potential for 
cross-cultural education to reduce subconscious biases on the part of 
clinicians was recently highlighted in a study published in the 
American Journal of Medicine. In the study, when interviewing identical 
patients with identical complaints of chest pain, the participating 
medical students overall rated the quality of life lower for a 55-year-
old black woman than for a 55-year-old white man, despite the fact that 
the students thought the black woman had less severe heart disease. It 
seems that our medical students are entering medical school with 
subconscious biases about patients, the same biases we revealed in our 
1999 study of practicing physicians.
    The medical education section of the Health Care Fairness Act of 
1999 offers tremendous hope to the millions of Americans who have been 
deeply affected by these studies. The bill calls for the development of 
grants for medical education curriculum development and for research 
projects and demonstration projects to develop curricula designed to 
reduce disparities in health care outcomes, including faculty 
development and cultural competency programs for graduate and 
undergraduate medical education. These grants will allow us to develop 
new educational programs to target the subconscious biases that seem to 
explain a reversible component of disparities in health care.
    Adequately addressing this issue will require self-awareness on the 
part of individuals regarding their own perceptions and biases, and a 
willingness to find ways of overcoming these biases in both working 
with and treating patients. Finding the optimal method of implementing 
such a sensitive curriculum is an issue of major concern that would be 
addressed through the research effort called for in this legislation.
    Finally, the public will not be assured that the health care system 
is truly ``blind'' to race until we show that these training programs 
are effective; hence, the importance of the evaluation components of 
these grants. These evaluation efforts will allow us to understand what 
works in developing cultural competency curricula and to rapidly 
disseminate effective programs to other sites.
    In this increasingly multicultural society, the issue of how to 
ensure that patient characteristics no long influence clinical 
decision-making is of critical importance in designing medical school, 
residency, and continuing education curricula and in ensuring 
appropriate clinical practice. We have observed differences in 
treatment resulting in differences in survival for patients with 
cardiovascular disease and lung cancer. Our previous work suggests that 
physicians contribute to these differences by making different 
treatment recommendations based on patient race. Yet students in most 
medical schools today are not taught about issues of race or how their 
own subconscious biases may interfere with access to treatment. The 
Health Care Fairness Act of 1999 offers a first step to ensuring that 
all patients will be offered equal access to life-saving medical 
therapy, regardless of their race. The American public should expect no 
less from its health professionals.

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627.
[GRAPHIC] [TIFF OMITTED]66287.023

    Mr. Bilirakis. Thank you very much, Doctor.
    Dr. Anne Peterson, Health Commissioner for the Commonwealth 
of Virginia. Welcome, Dr. Peterson.

 STATEMENT OF ANNE PETERSON, HEALTH COMMISSIONER, COMMONWEALTH 
                          OF VIRGINIA

    Ms. Peterson. Thank you very much, Mr. Chairman and members 
of the Committee.
    I am the State Health Commissioner for Virginia, and 
perhaps in bringing a different perspective, some of which the 
questions came up earlier today that I hope to be able to 
address. Virginia is both recognizing many areas of racial 
disparities and beginning to address them in some very 
significant ways.
    We established an office of minority health in 1992, and we 
are developing partnerships between the private and public 
sector to establish goals to improve the health of all 
Virginians, with a focus on eliminating disparities. Dr. 
Satcher spoke about the Healthy People 2010. Virginia set 
eliminate disparities as part of our Healthy People 2000 goals. 
So we've been looking at that for quite a while already.
    We have a major initiative within that office on access to 
care. On June 20, 21 and 23 and have a forum on access to care 
for minority health this summer. One area, and this is the one 
I was asked to discuss today, where minorities have clearly 
been disproportionately affected, is HIV/AIDS. While African 
Americans comprise only 20 percent of Virginia's population, 
they account for almost two-thirds of the reported HIV cases in 
Virginia, and over half of the reported AIDS cases. Minority 
females have been particularly hard hit by this disease. 
Although African American women account for only 20 percent of 
the female population of Virginia, they represent over three 
quarters of the female HIV cases in Virginia and almost three 
quarters of all the female AIDS cases.
    While these statistics are alarming, we are making 
progress. By careful analysis of the HIV reporting data, 
Virginia was one of the first States to recognize that HIV and 
AIDS were disproportionately affecting the minority community. 
As a result of that early recognition of the minority disparity 
trend, Virginia has initiated efforts to directly address this 
disparity, and we are already beginning to see some results. 
Analysis of Virginia's surveillance data does not show that 
racial or gender disparity for the length of time between HIV 
diagnosis and AIDS.
    In other words, minority males and females are progressing 
from initial HIV diagnosis to sickness at a similar rate as 
whites. The number of AIDS deaths for minorities is also 
decreasing, after peaking in 1995, AIDS deaths have decreased 
substantially for both African Americans and whites. Initially 
the deaths decreased more markedly for whites than African 
Americans. With the addition of the 1999 data, the reduction of 
deaths among African Americans were comparable to those of 
whites. This may indicate that more minorities were able to 
access appropriate and timely care.
    Providing anti-retroviral treatment to pregnant women with 
HIV infection has also significantly decreased the transmission 
of HIV to their newborns. This is particularly important to 
minority health since of the perinatal HIV cases reported in 
Virginia for 1995 to 1999, 79 percent of the babies were 
African American. Since 1995, when Virginia law required that 
all physicians encourage pregnant women in their care to 
receive HIV testing, and if indicated, treatment, over 90 
percent of the HIV infected pregnant women have been tested. In 
1991, 91 percent of the infected mothers were treated with 
anti-retroviral medication and pre-natal transmission has 
decreased from 20 cases in 1992 to 2 so far this year.
    In closing, while Virginia has addressed disparities among 
minorities with HIV and AIDS, we are also focusing on primary 
prevention and other sexually transmitted diseases. An example 
is the syphilis elimination project, which uses a two-pronged 
approach of community involvement to assist prevention and 
education and train public health staff to identify and treat 
the disease. The National Centers for Disease Control and 
Prevention recently conducted a site visit to Danville, 
Virginia, and plans to use our efforts as a model for other 
States to follow.
    So I would just say, as you look at research and as we get 
data on health disparities and understand the risk factors, we 
then can, as this example shows, focus our resources and begin 
to make a difference in closing the disparity gap.
    Thank you for this opportunity.
    [The prepared statement of Anne Peterson follows:]
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    Mr. Bilirakis. Thank you very much, Dr. Peterson.
    Dr. John Harley, M.D., Ph.D., is a member and program head 
of the Oklahoma Medical Research Foundation out of Oklahoma 
City. Welcome, Dr. Harley, and please proceed, sir.

     STATEMENT OF JOHN B. HARLEY, OKLAHOMA MEDICAL RESEARCH 
                           FOUNDATION

    Mr. Harley. Thank you, Mr. Chairman and ranking member, and 
committee members.
    I have two initiatives that I'll mention that are going on 
in my laboratory. First is the Lupus Multiplex Registry and 
Repository, as a national collection of pedigrees with multiple 
members of lupus. We facilitate the work of many scientists by 
providing them with data and materials from these families. And 
second, I act as principal investigator on a study of genetic 
linkage of lupus in African Americans. We understand this is 
the only study funded by the NIH that specifically concentrates 
on genetic linkage in African Americans.
    The OMRF was chartered in 1946 as a private, non-profit 
biomedical research institution which employs over 400 
scientists, physicians, technicians and administrative support 
personnel. The OMRF focuses on several critical areas of 
research, cancer, heart disease, diabetes, Alzheimer's and 
Parkinson's disease, as well as lupus and other autoimmune 
diseases. I am pleased to discuss a subject that's vital to 
Oklahoma, the Health Care Fairness Act, H.R. 3250, because 
Oklahoma, which means land of the red man in Choctaw language, 
is home to 263,000 Native Americans, the second highest number 
of Native Americans of any State in the U.S.
    We have instituted a biomedical research center unique to 
Oklahoma, the Native American Biomedical Research Center. This 
center will address many of the same issues the Health Care 
Fairness Act addresses, including the dramatic disparity in the 
incidence of many diseases in our Native American population.
    Oklahoma is blessed with the rich and ancient traditions 
that spring from our Native American heritage. In fact, we not 
only have one of the largest populations of Native Americans in 
the country, but also among the most diverse, with over 100 
separate tribal groups represented. Unfortunately, we also have 
particularly serious problems from the numerous and severe 
medical conditions that affect this population.
    For example, it is especially true that the high incidence 
of autoimmune diseases in Native Americans, these are diseases 
where the immune system turns on itself and attacks one's own 
body, diseases and disorders thought to have an autoimmune 
origin include rheumatoid arthritis, lupus, type 1 diabetes or 
juvenile diabetes, multiple sclerosis, scleroderma and others. 
In some groups of Native Americans, these diseases are 
especially common.
    There is great scientific interest at the present time in 
the genetics of autoimmune diseases, in spite of the fact that 
research in this area is one of the most traditionally 
underfunded in the U.S. Oklahoma's medical investigators have 
special opportunities to contribute to the solution of these 
seemingly overwhelming problems through research and genetics. 
Indeed, scientists at OMRF have done some of the most 
significant work in the field of autoimmunity and appreciate 
the opportunity for discovery and helping solve the serious 
problems that these disease pose in selected groups of Native 
Americans.
    In my personal experience in the rheumatic disease clinic 
in one of the State's Indian Health Service hospitals, the 
spectrum of autoimmune diseases and their clinical 
presentations are very different in Native Americans compared 
to what we know from Americans of European extraction. I am 
concerned that the very definitions of what the diseases are 
must be changed to accommodate how differently they find 
expression in Native Americans. Accordingly, this also implies 
that different therapeutic management is likely to be warranted 
among the affected Native Americans.
    Autoimmune diseases affect different populations in 
different ways. In Native Americans, for example, rheumatoid 
arthritis is found in as many as 7 percent of some groups, 
which is more than five times more frequent than that found in 
European Americans. Lupus is another example of high incidence 
of autoimmune diseases in certain Native American populations.
    In the Oklahoma Sioux, lupus appears to have an incidence 
of about fivefold greater than that found in European 
Americans. Other smaller groups, such as the Apache Tribe, also 
have a dramatically high incidence.
    Working on the genetic problems of Native Americans has a 
number of advantages. First, the gene pool is different from 
that found in European Americans or in African Americans. There 
are also, of course, major differences between Native American 
groups. Second, Native Americans offer the opportunity to apply 
newer genetic approaches using an isolated population strategy 
or genetic add mixture. These approaches have a much greater 
prospect of success than do the much larger and more expansive 
studies performed in the out-bred American population.
    For example, scleroderma is found at a rate of about 1 in 
200 of the Oklahoma Choctaw, about 50 times the rate found in 
both non-Choctaw Native Americans in Oklahoma and in European 
Americans. One of these new genetic approaches was used to 
identify two regions of the human genome which contains genes 
that appear to dramatically increase the risk of scleroderma in 
the Oklahoma Choctaw.
    The advances in scientific technology have been 
revolutionary in the area of genetics. This technology is being 
joined with the research excellence of numerous biomedical 
sciences at the OMRF, University of Oklahoma Health Sciences 
Center and other research facilities in the State to address in 
a major way the genetics of autoimmune disease in our Native 
American populations. Our opportunities, then, are not only to 
advance medical knowledge, but also to help provide a solution 
to these serious, life-long, often debilitating diseases in 
particularly affected tribal groups.
    The Oklahoma Medical Research Foundation proposes to build 
a unique genetic unit focusing upon disease processes in Native 
Americans with an initial and special emphasis on autoimmune 
disorders. We propose to bring together all the necessary 
ingredients that will result in important progress and 
contribute to solving these problems for affected Native 
Americans in Oklahoma as well as for all of mankind.
    An NIH center for research on minority health would 
facilitate funding of OMRF's Native American Research Center. 
In addition, the new NIH center would accelerate studies into 
dramatic disparities among incidence of many diseases among all 
of our minority peoples. Medical breakthroughs and scientific 
advances that originate from studies focusing on minority 
populations would likely be very beneficial to all Americans. 
OMRF's mission statement is that more may live longer, 
healthier lives. With an NIH center focus on minority health, 
we can better do our best to ensure that OMRF's goals of 
longer, healthier lives are achieved for all.
    [The prepared statement of John B. Harley follows:]
   Prepared Statement of John B. Harley, Program Head, Arthritis and 
            Immunology, Oklahoma Medical Research Foundation
    Thank you for the opportunity to speak with the subcommittee. My 
name is Dr. John Harley and I am the Head of the Arthritis and 
Immunology Program at the Oklahoma Medical Research Foundation (OMRF). 
Chartered in 1946, OMRF is a private, non-profit biomedical research 
institution which employs over 400 scientists, physicians, technicians, 
and administrative and support personnel. OMRF focuses on several 
critical areas of research: Cancer, heart disease, diabetes, 
Alzheimer's and Parkinson's diseases, as well as lupus and other 
autoimmune diseases.
    Today, I am honored to discuss a subject that is vital to Oklahoma, 
the Health Care Fairness Act. Because Oklahoma is home to 263,000 
Native Americans, the second highest number of Native Americans in any 
state in the U.S., we have instituted a biomedical research center 
unique to Oklahoma--the Native American Biomedical Research Center. 
This Center will address many of the same issues that the Health Care 
Fairness Act addresses, including the dramatic disparity in the 
incidences of many diseases in our Native American population.
    Oklahoma is blessed with the ancient and rich traditions that 
spring from our Native American heritage; in fact, our state has one of 
the largest populations of Native Americans in the country. 
Unfortunately, we also have particularly serious problems from the 
numerous and severe medical conditions that affect this population. 
This is especially true in the high incidence of autoimmune diseases--
where the immune system ``turns on itself'' and attacks one's own 
body--among the more than 100 separate tribal groups in Oklahoma. 
Diseases and disorders thought to have an autoimmune origin include 
rheumatoid arthritis, lupus, diabetes (Type 1, or ``juvenile''), 
multiple sclerosis, scleroderma and others. In some groups of Native 
Americans, these diseases are especially common.
    There is great scientific interest at the present time in the 
genetics of autoimmune diseases, in spite of the fact that research in 
this area is one of the most underfunded in the U.S. Oklahoma's medical 
researchers have special opportunities to contribute to the solution of 
these seemingly overwhelming problems through research in genetics. 
Indeed, scientists at OMRF have done some of the most significant work 
in the field of autoimmunity and appreciate the opportunity for 
discovery and for helping solve the serious problems that these 
diseases pose in selected groups of Native Americans. Indeed, in my 
personal experience the spectrum of autoimmune diseases and their 
clinical presentations are so different than what is seen in Americans 
of European extraction, that I am suspicious that different methods of 
description and, possibly, therapeutic management may be warranted 
among Native Americans.
    Autoimmune diseases affect different populations in different ways. 
In Native Americans, for example:

 Rheumatoid arthritis is found in as many as 7% of some groups, 
        which is more than five times more frequent than in European-
        Americans. Lupus is another example of the high incidence of 
        autoimmune diseases in certain Native American populations.
 In the Oklahoma Sioux, lupus appears to have an incidence of 
        about five-fold greater than that found in European-Americans.
    Working on the genetic problems in Native Americans has a number of 
advantages. First, the gene ``pool'' is different from that found in 
European-Americans or African-Americans. There are also, of course, 
major differences between Native American groups. Second, Native 
Americans offer the opportunity to apply newer genetic approaches using 
``admixture,'' a method of determining racial mix between ethnic groups 
and isolated populations which cannot be applied with the same 
expectation of success in the ``outbred'' American population. For 
example, scleroderma is found at a rate of about one in 200 among the 
Oklahoma Choctaw, about 50 times the rate found in both non-Choctaw 
Native Americans in Oklahoma and European-Americans. One of these new 
genetic approaches was used to identify two regions of the human 
genome, which appear to dramatically increase the risk of scleroderma 
in the Oklahoma Choctaw.
    The advances in scientific technology have been revolutionary in 
the area of genetics. This technology is being joined with the research 
excellence of numerous biomedical scientists at OMRF, the University of 
Oklahoma Health Sciences Center, and at other research facilities in 
the state to address in a major way the genetics of autoimmune disease 
in our Native American populations. Our opportunities, then, are not 
only to advance medical knowledge but also to help provide a solution 
to these serious, lifelong, often debilitating and sometimes fatal 
diseases in particularly affected tribal groups.
    The Oklahoma Medical Research Foundation proposes to build a unique 
genetic unit focusing upon disease processes in Native Americans, with 
an initial and special emphasis on autoimmune disorders. We propose to 
bring together all the necessary ingredients that will result in 
important progress and contribute to solving these problems for 
affected Native Americans in Oklahoma, as well as for all of mankind.
    An NIH Center for Research on Minority Health would facilitate 
funding of OMRF's Native American Research Center. Additionally, the 
new NIH Center would accelerate studies into the dramatic disparities 
among the incident of many diseases among all our minority peoples.
    Medical breakthroughs and scientific advances that originate from 
studies focusing on minority populations will likely be very beneficial 
to all Americans. OMRF's mission statement is ``. . . that more can 
live longer, healthier lives.'' With a NIH center focusing on minority 
health, we can better do our best to ensure that OMRF's goals of 
longer, healthier lives are achieved for all.

    Mr. Bilirakis. Thank you, Doctor.
    Dr. Elena Rios is President of the National Hispanic 
Medical Association, located here in Washington, DC. Doctor, 
please proceed.

 STATEMENT OF ELENA RIOS, PRESIDENT, NATIONAL HISPANIC MEDICAL 
                          ASSOCIATION

    Ms. Rios. Thank you, Congressman and guests. I am deeply 
honored to join you today in support of the Health Care 
Fairness Act, H.R. 3250, which has the strong potential to 
create knowledge and innovation. Medical and health services 
research, cultural competence training for health professions 
and civil rights monitoring, which I believe will tremendously 
decrease the disparities that face all the minorities 
represented today in the United States.
    I'm representing two critical national Washington, DC based 
organizations, the National Hispanic Medical Association, which 
represents 30,000 licensed Hispanic physicians in the United 
States, and the Hispanic Serving Health Professions Schools, 
Inc., which was established in 1996 by the Department of Health 
and Human Services in response to the White House's Educational 
Excellence for Hispanic Education Initiative, which represents 
20 medical schools from across the United States, with 9 
percent Hispanic student enrollment.
    We also work closely with the Hispanic Health Coalition, 
which represents 30 national organizations. I'm here today to 
urge you to take up the challenge to pass H.R. 3250 and make 
America healthier.
    During my brief presentation, I just want to focus on three 
issues: the current health status of Hispanics, the need for 
research and cultural competence in medical services for 
Hispanics and all Americans, and to provide you with our 
recommendations to improve the bill. In terms of the Hispanic 
health status, let me just start by saying that Hispanics 
really are the largest population in the United States right 
now, the current U.S. census estimates of 30 million do not 
include the 4 million from Puerto Rico or the 3.5 million that 
the INS estimates as current residents from Hispanic 
backgrounds. I know by the year 2050 the projections say that 1 
in every 4 Americans will be Hispanic. Indeed, the United 
States is soon to become the second largest Spanish speaking 
country in the world.
    Hispanics are a heterogenous group from 20 countries. 
There's a lot of different cultures to deal with, even among 
the Hispanics. The socioeconomic factors, as we know, determine 
the lifestyle of people in this country, and Hispanics are one 
of three, below the poverty level. The median income of $23,000 
versus the $41,000 for non-Hispanic whites. In 1998, Hispanics 
continued to have the lowest educational attainment, with 
Mexican Americans having 50 percent high school dropouts.
    In terms of access to health care, Hispanics have very, 
very poor socioeconomic status and very poor access to health 
care. The numbers of uninsured in the United States has 
increased to 44 million and are increasing at a faster rate as 
we heard earlier, due to a myriad of factors. But Hispanics are 
the largest group of uninsured in the United States, 2 out of 5 
Hispanics, according to a recent commonwealth fund, introduced 
data at our National Hispanic Medical Association annual 
conference, and there will be more work in this area as several 
different organizations look at strategies to eliminate this 
disparity in the insurance rates of Hispanics.
    Hispanics are also the least likely to be linked to regular 
sources of care, as we heard earlier.
    What I'd like to just focus on now is the need for medical 
research. We heard a lot about this earlier, but I think in 
order to understand the disease pattern that affects Hispanics, 
factors that lead to decreasing barriers for Hispanics to 
access care, factors that increase outreach to Hispanics for 
health promotion programs and treatment services and physical 
and mental health and research programs that can train Hispanic 
health profession students to become researchers, we critically 
need to increase biomedical and health services research that 
targets all the major population groups fairly and equitably. 
This bill should promote support for research, not only in 
biomedical institutions, but by community based agencies and 
non-profit entities that target all the minority communities in 
the country.
    There has been minimal Federal support for Hispanics to be 
included in research, and we urge you to encourage research 
with passage of this bill.
    In terms of the need for cultural competence curriculum, 
cultural competence has been defined as a set of academic and 
interpersonal skills that allow individuals to increase their 
understanding and appreciation of cultural differences and 
similarities within, among and between groups. This requires a 
willingness and an ability to draw on community based values, 
traditions and customs and to work with knowledgeable persons 
of and from the community in developing focused interventions, 
communications, and other supports.
    There is an urgent need to adopt legislation like H.R. 3250 
that promotes health professions cultural competence 
curriculum, given the growing diversity in the United States 
population. We believe that successful strategies for 
increasing access to health insurance include cultural 
competence standards for health professions education, as well 
as for the whole health system, the facilities, the standard 
services, language services, etc.
    There is definitely a critical need for cultural competence 
training for the future health work force of the country, as 
well as the current work force to eliminate health disparities, 
as we heard earlier.
    We believe there are important principles that enhance the 
cultural competence of the physician in the physician patient 
relationship, including respect for values, respect for health 
and illness beliefs, respect for family dynamics and 
decisionmaking, cultural awareness, assimilation, acculturation 
levels, role of traditional healers, role of the pharmacists in 
our community, Spanish, using the language Spanish, elimination 
of biases, awareness of Hispanic sub-groups, nuances, languages 
and diet. We believe that more patients from the Hispanic 
community and other ethnic communities would access services if 
they were provided in a culturally competent manner.
    In terms of recommendations, for research we just really 
thought that the research endowment program is only one program 
that could be developed by this bill. Another important aspect 
is actual development of consortia among biomedical 
institutions and partnerships development with community based 
organizations and health professional organizations to enhance 
minority research.
    In terms of the centers of excellence for research 
training, we just thought it was important to commend the bill 
for having the Health Resources and Services Administration 
centers of excellence mentioned. But these are separate from 
the new NIH centers of excellence which wish to be created.
    Mr. Bilirakis. Doctor, please summarize.
    Ms. Rios. In terms of the cultural competence curriculum, 
as I said earlier, we really should understand the importance 
of the Hispanic physicians and other physicians from our 
communities and being able to share their expertise in 
developing curriculum for developing a center for cultural and 
linguistic competence in health care that could coordinate all 
the curriculum mentioned in the bill.
    In summary, I'd just like to say that we commend the 
efforts of the Committee and we look forward to working with 
you all in developing more of the bill.
    Thank you.
    [The prepared statement of Elena Rios follows:]
  Prepared Statement of Elena Rios, Director, Hispanic-Serving Health 
    Professions Schools, Inc., President, National Hispanic Medical 
                              Association
                              introduction
    Honorable Congressmen and Congresswomen and guests, I am deeply 
honored to join you today in support of the Health Care Fairness Act, 
H.R. 3250 which has the strong potential to create knowledge and 
innovation--medical and health services research, cultural competence 
training for health professions, and civil rights monitoring--which I 
believe will tremendously decrease the disparities in health that face 
Hispanics, African Americans, Asian Americans/Pacific Islanders, and 
Native Americans in the United States today.
    I am representing two critical national Washington DC based 
organizations: a) National Hispanic Medical Association, which 
represents 30,000 licensed Hispanic physicians in the United States; 
and b) Hispanic-Serving Health Professions Schools, Inc., (established 
in 1996 by the Department of Health and Human Services in response to 
the White House Educational Excellence for Hispanic Americans 
Initiative), which represents 20 medical schools from across the nation 
with 9% Hispanic student enrollment. The missions of both organizations 
are to improve the health of Hispanics. We work closely with the 
Hispanic Health Coalition, representing 30 national and local 
organizations, and with minority coalitions to continue to challenge 
policy-makers to address the economic, social, environmental and 
cultural factors responsible for the poor health status and the poor 
access and utilization of health and mental health services of our 
communities. I am here today to urge you to take up the challenge to 
pass HR 3250 and make America healthier.
    During my brief presentation, I will focus on three major issues--
1) the current health status of the Hispanic population in the United 
States, 2) the need for research and cultural competence in medical 
services for Hispanics and all Americans, and 3) to provide you with 
our recommendations to improve the Health Care Fairness Act, H.R. 3250.
                         hispanic health status
Population Growth, Poor Health and Access to Care
    The Hispanic population has become the largest minority group in 
the United States. According to the U.S. Census estimate for 1999, 
there are 32 million Hispanics or nearly 12% of the population. If you 
include the Immigration and Naturalization Service estimates of 
Hispanic residents who lack legal status ( 3.5 million) and the Puerto 
Rico Commonwealth population (4 million), the Hispanic population in 
2000 numbers about 40 million. By the year 2050, 1 in every 4 Americans 
will be Hispanic. Indeed, the U.S. is soon to become the second largest 
Spanish speaking country in the world, second to Mexico.
    Hispanics are a heterogeneous group representing more than 20 
countries. The 1999 population statistics released by the U.S. Census 
reported that Hispanic's county of origin were 66% Mexico, 14% Central/
South America, 10% Puerto Rico, 7% Caribbean and other countries, and 
4% Cuba.
    Nearly 87% of all Hispanics live in ten states: California, Texas, 
New York, Florida, Illinois, New Jersey, Arizona, New Mexico, Colorado, 
and Nevada. Major Hispanic metropolitan areas include: Los Angeles-
Orange-San Bernardino Counties, California; New York-Northern New 
Jersey-Long Island-Connecticut, New York; Miami-Fort Lauderdale, 
Florida; Chicago-Gary-Lake County, Illinois, Indiana, Wisconsin; San 
Francisco-Oakland-San Jose, California; Houston-Galveston-Brazbria, 
Texas; Dallas-Fort Worth, Texas; and San Antonio, Texas.
    The following areas were home to 58% of Hispanics in 1994:

 Los Angeles County--nearly 7 million or 1 in 4 persons
 New York--nearly 3 million
 San Francisco, Miami, Chicago--nearly 1 million
 Houston and Dallas--800,000
 San Antonio--600,000
    In 1994, the Census estimated that 39% of Latinos were born outside 
of U.S. Median Age = 26 years old, 10 years younger than non-Hispanic 
whites
    Socioeconomic factors determine the lifestyle of people in the U.S. 
One out of three Hispanics in 1998 were below the Federal poverty 
level. The 1993 median income was $23,700 for Hispanics vs. $41,100 for 
non-Hispanic whites. In 1998, Hispanics continued to have the lowest 
education levels of attainment with 54.7% having attained high school 
graduation and 10% BA degrees. For Mexican Americans, 50% of those 25 
years old and above have 8 years of education or less.
    Hispanics and Disease Mortality Rates (age adjusted, in order of 
frequency): Heart Disease; Cancer; Unintentional Injuries; 
Cerebrovascular Disease; Diabete; sand HIV/AIDS
    Immigrant health issues are very important for te Hispanic 
community, since the majority of immigrants to the U.S. are from 
Mexico. There continues to be an emphasis on isues of access to health 
care services with Spanish language translators and information and 
restoring benefits such as food stamps that impact on health.
    Spanish language use is a major factor for communicating with 
Hispanics in the U.S. 68% are monolingual in Spanish, 86% of Hispanics 
report Spanish as their first language, 64% feel more comfortable with 
Spanish, and 69% report Spanish spoken at home. It is no wonder that 
Spanish media that has loyal viewers, listeners, and readers, including 
TV and radio and newspapers have been extremely successful in the U.S.
    To add to the poor socioeconomic status of the Hispanic population, 
in general, they do not have adequate access to the health care 
delivery system. The numbers of uninsured in the United States has 
increased to 44 million and are increasing at a faster rate due to a 
myriad of factors. Hispanics are the largest group of uninsured in the 
United States. 2 out of 5 Hispanics are uninsured according to a 
February 2000 Commonwealth Fund Report, introduced at the National 
Hispanic Medical Association Annual Conference, the so called ``working 
poor.'' The lack of health insurance coverage varies depending if they 
are children or adults, if they are poor, if they work in the service 
or farming industries, or if they are immigrants or undocumented 
workers.
    Hispanics are least likely to be linked to a regular source of 
care. Over 30% do not have a family doctor, or clinic to go when they 
need care and the Hispanics, 25 years and older, have the least number 
of dental visits compared to Whites or Blacks. For children, Hispanics 
had the highest rates without a physician visit in the past year and 
Hispanics had 3 times the rate of Whites and 2 times the rate of Blacks 
for no regular source of care. Most non-citizens who have become legal 
residents since 1996 are barred from Medicaid for five years, 
regardless of need.
    This situation is more severe among Spanish-speaking populations 
due to the shortage of bilingual and bi-cultural physicians and other 
health and mental health professionals. The United States medical 
schools have been able to produce only about 5% Hispanic physicians and 
with the demise of affirmative action, we recognize the worsening 
numbers of underrepresented minority medical students. Furthermore, due 
to health care providers' lack of familiarity with the culture and 
language of patients, and with the limited medical education about 
cultural competence, Hispanics do not receive the state-of the art 
treatment that the American health care system is so proud to provide. 
With the trend toward managed-care systems of care the access and the 
quality of medical care has become worse for Hispanics and is expected 
to become even more disastrous.
    Other major factors that need to be addressed to improve access to 
health care in this country include:

 Health Care Facilities (hospitals, clinics, private medical 
        offices)
 Transportation
 Child Care
 Language Services Access
    Hispanics have one of the worst health status in this country. To 
begin with, diabetes type 2 is three times higher among Hispanics, 
compared to non-Hispanics; cervical cancer is the highest among 
Hispanic women (followed by Vietnamese women); mortality for breast 
cancer is one of the highest among Hispanic and African American women 
due to the fact that minority women do not have access to health care 
for early cancer prevention and screening, and they come at a later 
stage for diagnosis and treatment; prostate cancer is killing our men, 
and due to the heavy marketing of the tobacco and alcohol industries, 
lung cancer (due to smoking) and alcoholism are very serious health 
problems in our community; HIV/AIDS and other sexually transmitted 
diseases, combined with tuberculosis, continue to be devastating for 
the health of our youth and adults. For example, HIV is the third cause 
of death among Hispanics, in the U.S., and Puerto Rico has the second 
highest HIV rate in the country. Furthermore, Hispanics tend to live in 
neighborhoods with high environmental pollution; exposed to violence in 
the street, in their homes and in their workplace; and they are most 
likely to work in occupations where they are exposed to dangerous 
chemicals (e.g., pesticides) and poor working conditions. This is 
particularly true among janitors, landscapers, agricultural workers, 
etc. I could go on and on documenting the seriousness of our problems. 
However, it is important for policy-makers like yourselves to keep in 
mind that the health status of Hispanics vary by age, nationality, 
gender, socioeconomic status, immigration status and by levels of 
acculturation and assimilation to the mainstream society.
Need for Better Medical Research about Hispanics
    We know that medical and health services research can lead to 
information that will improve the health of our nation.
    In order to better understand the disease patterns that affect 
Hispanics, factors that lead to decreasing barriers for Hispanics to 
access to care, and factors that can increase outreach to Hispanics for 
health promotion programs and treatment services in physical and mental 
health, and research programs that can train Hispanic health 
professions students to become researchers, we critically need to 
increase biomedical and health services research that targets all the 
major population groups fairly and equitably. This bill should promote 
support for research by biomedical institutions, community based 
agencies, non-profit entities that target all minority communities in 
the U.S. There has been minimal Federal support for Hispanics to be 
included in medical and health services research, and we urge you to 
encourage increased Hispanic research and Hispanics entering research 
careers with this bill.
    One of the most serious problems impacting the health of Hispanics 
is the lack of data on their health and medical needs and the lack of 
biomedical research on the diseases with the greatest prevalence in 
this population. Until 1990, we did not even know how many Hispanics 
die in this country or the mortality rates of certain diseases. As a 
member of the National CDC HIV Strategic Planning Committee and the 
Medicare Education Advisory Committee, we find that we can not develop 
many measurable objectives for Hispanics because the data is not 
available. This situation is more severe at the local level where 
departments of healths in smaller communities do not have the 
infrastructures to collect data. Some states, especially in the South, 
with recent great influxes of Mexican immigrants have databases that 
only recognize Black, White and Other.
    Another very important research finding has been the disparities in 
health, including access, utilization of health services, health 
status, medical treatment and disease patterns for minorities.A recent 
report on the from the Agency for Health Care Research and Quality 
found that Hispanics were more likely than whites to be in fair or poor 
perceived health status but less likely to be reported as having 
functional limitations. Indeed, the DHHS has challenged the U.S. to 
develop partnerships for outreach and research through its Racial and 
Ethnic Disparities in Health Initiative.
    A major focus of the Department of Health and Human Services 
``Hispanic Agenda for Health'' and the Health Care Fairness Act is to 
meet the challenge of little research on Hispanics. DHHS, through this 
initiative established the Hispanic-Serving Health Professions Schools, 
Inc., in response to President Clinton's Executive Order 12900, 
``Educational Excelence for Hispanic Americans'' to develop 
comprehensive, coordinated faculty development Fellowships to increase 
research on Hispanic health at member institutions--20 medical schools. 
In the future, HSHPS plans to expand to public health schools, nursing 
schools, dental schools and other health professional schools. HSHPS 
has developed collaborative efforts for the first time among medical 
schools to develop Hispanic research and Hispanic health researchers. 
HSHPS also represents all the HRSA Centers of Excellence. We urge your 
support that can continue these efforts.
    The National Hispanic Medical Association has also encouraged 
research careers at our national conference, and has developed a 
Research Network to identify physicians who are Hispanic researchers 
and to encourage grant applications to the Federal government. NHMA 
physicians have a tremendous base of patients who are Hispanic for 
research in our community that could prove valuable for efforts to 
eliminate disparities in health in our country. We urge you to support 
the research efforts of other Hispanic organizations with expertise in 
working with the Hispanic community.
Need for Health Professions Cultural Competence Curriculum
    Cultural competence has been defined as a set of academic and 
interpersonal skills that allow individuals to increase their 
understanding and appreciation of cultural differences and similarities 
within, among, and between groups. This requires a willingness and 
ability to draw on community-based values, traditions, and customs and 
to work with knowledgeable persons of and from the community in 
developing focused interventions, communications and other supports.
    There is an urgent need to adopt legislation that promotes health 
professions cultural competence curriculum, given the growing diversity 
in the U.S. population and especially, given the tremendous increase in 
Hispanics across the nation, and given the critical levels of uninsured 
Hispanics.
    We believe that successful strategies for increasing access to 
health insurance must include cultural competence standards for health 
professions education as well as for the health system facilities and 
services and standards for language services.
    There is a critical need for cultural competence training for the 
future health workforce and the current workforce to eliminate the 
health disparities for Hispanics and others with cultural backgrounds, 
to increase quality care, to decrease the likelihood of liability/
malpractice claims, and to encourage utilization to services. By 
supporting this legislation, we can support all these outcomes which 
will decrease costs and improve the health of the nation.
    We find that once Hispanics enter the medical care system, they 
find that the health care system in this country is not user friendly, 
it has no capacity to deal with populations who have different cultural 
backgrounds or different illnesses; and that classicism, racism and 
social discrimination impact negatively the quality of the services 
provided. On the other hand, the literature shows that, in general, 
Hispanic physicians provide services to a predominant Hispanic 
clientele. There is a growing demand for Hispanic physicians. Why is 
this?
    We believe that there are important principles that enhance the 
cultural competence of the physician in a physician-patient 
relationship: respect for values, health and illness beliefs, respect 
for family dynamics and decision-making, cultural awareness, 
assimilation and acculturation levels and health behaviors, role of 
traditional healers, role of pharmacists, Spanish use, elimination of 
biases, awareness of Hispanic sub-group nuances, language, and diet. We 
believe that more patients from the Hispanic community and other ethnic 
communities would access services if they were provided in a culturally 
competent manner.
    The NHMA and HSHPS are dedicated to sharing our expertise of 
Hispanic physicians who have served numerous Hispanic patients and 
their families with the development of curriculum for future 
generations of health professionals. We all benefit by this bill that 
provides support for the collection of this unique knowledge and the 
development of formal training programs in medical schools, nursing 
schools, public health schools, dental schools, mental health 
professional training programs, etc.
    There has been an acceptance of cultural competence over the past 
decade by the Federal government, state governments, undergraduate and 
graduate medical education, nursing education and mental health 
education focused on service delivery and curriculum development for 
health professions and health staff in public clinics. The following 
are important milestones:

 1992--State of California Cultural Competency Task Force for 
        Medicaid
 1995--U.S. Department of Health and Human Services Office on 
        Women's Health and Office of Minority Health National 
        Conference on Cultural Competence and Women's Health Medical 
        Education Curricula; Curricula Collection Distributed
 1996--DHHS Hispanic Agenda for Action establishes a Cultural 
        Competence Workgroup
 to stimulate activities across the Department
 1997--Substance Abuse and Mental Health Services 
        Administration develops Cultural Competence Principles for 
        Mental Health and Substance Abuse Treatment
 1998--Council on Graduate Medical Education Minority Workforce 
        Report
 1998--DHHS OWH and OMH Review of the United States Medical 
        Licensing Examination for Cultural Competence
 1998--Health Care Financing Administration Regulations on 
        Cultural Competence for all Medicaid and Medicare contractors 
        published
 1999--Liaison Committee on Medical Education Standard on 
        Cultural Competence Approved (accreditation for all medical 
        schools)
 2000--Accreditation Council for Graduate Medical Education 
        Standard for Cultural Competence in process (accreditation for 
        residency programs)
 2000--OMH publishes Recommendations for Standards for 
        Culturally and Linguistically Appropriate Health Services for 
        Public Comment
    In addition, over the past decade, private sector organizations 
including HMOs, pharmaceutical companies, hospitals, and national 
health professions organizations have sponsored conferences and 
training programs for staff in order to develop cultural competence for 
more effective medical delivery for Hispanic and other ethnic groups in 
their target areas.
    Centers of Excellence--statement about their importance to Hispanic 
health
    HSHPS same type of statement--need for coordinating programs under 
this legislation
    NHMA--cultural competence projects
Recommendations to Improve HR 3250
    1. Research--The $100 million appropriation for minority research 
should be distributed to research efforts focused on all four of the 
major minority groups--Hispanic, African American Asian American and 
Pacific Islander and Native American. There should be a fair and 
equitable distribution plan.
    The research endowment program is only one program mentioned in the 
bill. The Hispanic-Serving Health Professions Schools, Inc. conducts 
the HSHPS Research Fellowship Program to develop faculty for its 20 
member medical schools. Some research funding in this bill could be 
used to develop faculty through fellowships, who would become leaders 
in the health arena for Hispanic research.
    Another important aspect for minority research is consortium 
development among biomedical institutions and partnership development 
with community based agencies and health professional associations to 
enhance minority research. In the case of Hispanics, we could better 
understand regional and sub-group variations related to disease 
pathophysiology, medical treatment issues if the HSHPS organization, 
for example, could develop consortiums and partnerships with the 20 
medical schools in our membership that have a demonstrated commitment 
to Hispanic health.
    Lastly, research skills development and training for medical 
students and residents is needed to encourage them to consider research 
careers. The bill could support these efforts through grants to 
organizations other than biomedical institutions such as the National 
Hispanic Medical Association and other Hispanic organizations that 
provide training programs to younger students interested in health 
careers.
    2. Centers of Excellence for Research Training--The Health 
Resources and Services Administration funds Black, Hispanic, Native 
American and All Minority Centers of Excellence that are granted to 
health professions schools that have the track record and commitment to 
recruiting minority students and faculty and developing curriculum and 
research that focuses on minority populations. The Centers of 
Excellence have created several innovative accomplishments to enhance 
diversity training and research for better health system. We applaud 
the vision behind HR 3250 for challenging the National Institutes of 
Health to develop a similar program that can only be as successful. We 
hope that you would support this bill to continue to develop Centers of 
Excellence programs that encourage research on minority populations.
    3. Medical Education and Health Professions Curriculum--The 
eligibility for awards to develop innovative curriculum should not be 
limited to health professions schools. Residency programs, community 
based organizations, the health professions associations such as the 
National Hispanic Medical Association should be allowed to compete for 
NIH funds and to provide their expertise to the advancement of cultural 
competence. Indeed the NHMA and the Association of American Indian 
Physicians wrote a grant to develop cultural competence training of 
physicians in Orange County, California about heart disease risk 
factors to the CDC REACH Program. We see our role as sharing expertise 
in dealing with our communities because we know that there is such a 
disastrous shortage of minority physicians and other health 
professionals in the country.
    4. National Cultural Competence Conference--The national conference 
by the Office of Minority Health on cultural competence curriculum 
should not be limited to continuing medical education courses, but 
should include undergraduate and graduate medical education as well as 
the other health professions curriculum that are innovative. The 
Department of Health and Human Services convened a major national 
conference that brought together the major players in the medical 
education (licensing, accreditation, medical schools, residency 
programs, foundations, state government and Federal government) who 
were encouraged to build innovative curriculum in cultural competence. 
This leadership needs to be continued at all levels of health 
professions education. Faculty who teach future providers for the 
health system need to be educated about successful curricula and to be 
encouraged by Federal leadership. Hispanic physicians and other 
minority health providers need to be encouraged to share their vast 
knowledge base, the ``art of medicine'' that has not been part of the 
Western medicine institutionalized information sources--publications, 
curriculum, mainstream medical specialty and academic conferences. This 
knowledge is needed especially for the future health providers who will 
face increasing challenges of diversity in their patients.
    5. Coordination and Dissemination of Cultural Competence 
Curriculum--Although we agree that the dissemination function would 
best be served by the OMH Resource Center, we strongly urge you to 
support that the coordination function be under the responsibility of 
the OMH Center for Cultural and Linguistic Competence in Health Care 
(CCLCHC). The CCLCHC was established by the Office of Minority Health 
in 1995, upon Congressional mandate. The mission of this CCLCHC is to 
promote the removal of health care service barriers and increase access 
to health care for limited English-speaking (LEP), racially and 
ethnically diverse populations. The CCLCHC should be the focal point 
for the cultural competence efforts outlined in this legislation and we 
urge funding for it.
    6. Office of Civil Rights--Recently, the U.S. Commission on Civil 
Rights focused attention on Federal health care programs and called for 
the enhancement of the Office of Civil Rights in order to decrease 
disparities in health for minorities in the health system. We support 
the efforts in the bill to expand the efforts of the OCR.
                               conclusion
    We have mutual goals with everyone in this room-- to increase 
access to health care services for the most vulnerable and to 
simultaneously decrease health care costs to our society. After all, 
creating legislation is an exercise for the public good.
    I would argue if we don't pass this legislation, we are asking for 
greater health care costs to Americans. One cost is the major decrease 
in individual productivity and a decreased productive workforce. 
Another cost we would face is drastically reduced public health of all 
sectors of the population. After all, take a look around at any 
restaurant, hotel, airport, office buildings, hospitals--the workers 
are from many countries from around the world with different cultural 
backgrounds. If they cannot understand our health system because they 
are not provided appropriate information, or are not comfortable or 
respected by our physicians and health providers, why would they 
attempt to obtain medical treatment for TB, Hepatitis, AIDS or 
debilitating conditions like hypertension, heart disease, asthma, 
diabetes, cancer,etc.?
    HR 3250 is an opportunity to develop strategies to increase 
knowledge that will improve the quality of life for all minorities in 
the United States.
    We applaud Secretary Donna Shalala and the Department of Health and 
Human Services under the Clinton administration for laying the 
foundation for addressing Hispanic health care research and cultural 
competence through the ``Hispanic Agenda for Action.'' Much more needs 
to be done by the Department to meet the needs of the growing Hispanic 
population.
    We commend the Chairman of the Subcommittee on Health and 
Environment, Congressman Bilirakus, and the efforts of Congressman 
Thompson and the supporters of HR3250 to provide yet another great 
opportunity for research and cultural competence on Hispanics, African 
Americans, Asian Americans/Pacific Islanders, and Native Americans to 
advance knowledge about disease unique to each group, to increase 
researchers from each group and to develop quality health services with 
cultural competence training of providers.
    The health of all Americans will be enhanced by this bill. We 
strongly urge all of you to vote for passage of the bill into law.

                               References

    National Center for Health Statistics. Health, United States, 1999, 
Hyattsville, MD, 1999.
    U.S. Census Bureau Population Estimates Program, Population 
Division, Washington, DC.(Internet Release Date April 11, 2000)
    U.S. Department of Commerce, Economics and Statistics Association, 
Bureau of the Census. We the American Hispanics, 1993.
    The Commonwealth Fund. Hispanics and Insurance. February 2000.
    U.S. Department of Health and Human Services and Grantmakers in 
Health. Call to Action: Eliminating Racial and Ethnic Disparities in 
Health Conference Proceedings. September 1998.
    U.S. Department of Health and Human Services. Hispanic Agenda for 
Action. September 1996.
    Rios, E. and Simpson, C. Summary of National Conference. Cultural 
Competence and Women's Health in Medical Education. JAMWA. Vol 53, No. 
3, Supplement 1998.
    Komaromy, et all. The Role of Black and Hispanic Physicians in 
Providing Health Care for Underserved Populations. NEJM. Vol 334. No. 
20, Mar 16, 1996.
    U.S. Department of Health and Human Services. Public Health 
Service. Agency for Health Care Policy and Research. Health Status and 
Limitations: A Comparison of Hispanics, Blacks, and Whites, 1996. AHCPR 
Pub. No. 00-0001, October 1999.
    U.S. Commission on Civil Rights. The Health Care Challenges: 
Acknowledging Disparity, Confronting Discrimination, and Ensuring 
Equality. September 1999.

    Mr. Bilirakis. Thank you, Doctor.
    Mr. Ignatius Bau, Director of Health Policy, Asian Pacific-
Islander American Health Forum, located out of San Francisco, 
California. Welcome, Mr. Bau. Please proceed, sir.

   STATEMENT OF IGNATIUS BAU, DIRECTOR, HEALTH POLICY, ASIAN 
             PACIFIC-ISLANDER AMERICAN HEALTH FORUM

    Mr. Bau. Thank you and good afternoon. Thank you for the 
opportunity to testify here in support of H.R. 3250. I want to 
underscore the remarks made by Congressman Underwood earlier 
this morning, which highlighted many of the points that I'm 
going to make and which I will not repeat.
    We are a national organization that focuses on improving 
the health of Asian Americans and Pacific Islanders. We work 
with health providers, community health centers and community 
based organizations in the diverse Asian American and Pacific-
Islander communities on both health care as well as health 
promotion and health prevention programs.
    We, as Congressman Underwood said this morning, are a very 
diverse community. We're not a single community, but many, many 
communities, coming from over 50 countries and speaking over 
100 different languages and dialects. As a diverse community, 
we have very diverse health needs and diverse health statuses. 
The heterogeneity in our community is reflected in the fact 
that on the one hand we have stereotypes and images of very 
successful Asian American doctors and business people.
    But on the other hand, we know that southeast Asian women 
have the highest rates of cervical cancer among all Americans 
and at the same time have the lowest rates of screening for 
both breast and cervical cancer. We know that Native Hawaiians 
consistently suffer much, much worse health than their 
counterparts in the State of Hawaii. We know that hepatitis B 
and tuberculosis hit Asian Americans and Pacific-Islanders 
harder than any other racial and ethnic group. And we know that 
although one quarter of Asian Americans and Pacific-Islanders 
in the aggregate are uninsured, over 40 percent of Korean 
Americans are uninsured mainly because they're in small 
business and unable to afford health insurance on their own.
    Therefore, we wholeheartedly support this bill, H.R. 3250, 
including the elevation of the Office of Research on Minority 
Health to a national center on research for minority health and 
health disparities. Our organization and others have worked 
with the Office of Research on Minority Health and we know as 
much as they have done with us and in our community, they need 
the grant making and the direct authority in order to make sure 
that the research that we need in our communities to document 
these health disparities and more importantly, to document 
interventions that will be effective in addressing these health 
disparities, are in fact funded and placed in the community 
where they belong.
    We also applaud and very much want to focus on the bill's 
efforts to collect more complete race and ethnicity data when 
it comes to health status. This is one of the top priorities 
for Asian Americans and Pacific-Islanders. Without this data, 
it's difficult to talk about the diversity of our communities 
and the diversity of health status in our communities. Because 
when we're asked, how do you design your program, we need to 
know which languages and cultures to tailor those programs so 
that they can reach communities that are most effective. 
Therefore we very much support the efforts that have been made 
in the bill and would urge even more efforts to clarify and to 
even mandate more complete race and ethnicity data regarding 
health.
    Like others on this panel, we support the bill's support 
for training curricula, particularly for cultural competency, 
and we also support, along with Dr. Satcher's highlighting it, 
the media campaign for the Office of Civil Rights. We think 
that it's very important that the office continue to be 
supported in its efforts to ensure that the health of all 
Americans are protected by our civil rights laws.
    So in summary, this is long overdue legislation that would 
go a long way to address many of the health disparities in the 
Asian American and Pacific-Islander, as well as the other 
minority communities in this country, which will go a long way 
to advancing the health of all Americans.
    Thank you.
    [The prepared statement of Ignatius Bau follows:]
Prepared Statement of Ignatius Bau, Policy Director, Asian and Pacific 
                     Islander American Health Forum
    Thank you for the opportunity to testify this morning in support of 
H.R. 3250. The Asian and Pacific Islander American Health Forum is a 
national advocacy organization dedicated to promoting policy, program, 
and research efforts to improve the health and well-being of Asian 
Americans and Pacific Islanders. Since our inception in 1986, we have 
worked together with other communities of color to improve the health 
status of all Americans. In recent years, we have redoubled our 
collaborative efforts to find common solutions to the difficult 
challenges in health facing our communities and the nation as a whole.
    Before I comment on the Health Care Fairness Act, I would like to 
provide a brief overview of our Asian American and Pacific Islander 
communities. We include many diverse peoples, originating from Palau to 
Pakistan, from American Samoa to Singapore, from Hong Kong to Hawaii. 
We come from over fifty countries and speak over a hundred different 
languages and dialects. We are composed of fifth generation Americans, 
recent immigrants and refugees, and indigenous peoples of the Pacific. 
According to the U.S. Census Bureau, we are the fastest growing racial/
ethnic population in the U.S., expected to increase nearly 40% from 
1990 to this year's census.
    We also are an incredibly heterogeneous population. As a group, 
Asian Americans and Pacific Islanders have the highest percentage of 
college graduates but we also have the highest percentage of those who 
have less than five years of education.

 Behind the images of immigrant success stories, there are 
        indigenous Pacific Islanders and Southeast Asian refugees that 
        continue to face long-term poverty
 Behind the images of dot-com South Asian American 
        millionaires, there are Thai Americans who work long hours 
        under extreme conditions in garment factory sweatshops
 Behind the images of successful Chinese American doctors, 
        there are Korean American grocery store owners who cannot 
        afford any health care
    This great heterogeneity also applies in our health status. For 
example,

 Native Hawaiian men and women have some of the highest rates 
        of lung cancer incidence and death among all Americans
 Southeast Asian women have highest rates of cervical cancer 
        among all Americans but at the same time have the lowest rates 
        of breast and cervical cancer screening
 Asian Americans and Pacific Islanders have the highest rates 
        of tuberculosis and Hepatitis B among all Americans
 Nearly one quarter of Asian American and Pacific Islanders do 
        not have health insurance
    Our organization was established by Asian American and Pacific 
Islander providers and advocates who came together to address these and 
other health disparities among Asian American and Pacific Islander 
populations. We believe that the elimination of health disparities and 
the improvement of the health of all Americans has to be a united 
effort. Therefore, we enthusiastically support the Health Care Fairness 
Act (H.R. 3250).
    Specifically, we support the elevation of the Office of Research on 
Minority Health at the National Institutes of Health (NIH) to a 
National Center for Research on Minority Health and Health Disparities. 
We believe that the NIH needs a strong and effective coordinating body 
to comprehensively plan and implement a health disparities research 
agenda at the NIH. Moreover, as a member of a population with diverse 
cultures and languages, we applaud the emphasis on research on the 
cultural and linguistic aspects of outreach, prevention, and treatment.
    We applaud the bill's focus on collecting more complete race and 
ethnic information regarding health status. This is one of the top 
priorities for our Asian American and Pacific Islander communities. For 
too long, the challenges facing many segments of our Asian American and 
Pacific Islander communities have been ignored because there is no 
national or local data to document our needs. Moreover, most of the 
available data do not fully represent the experiences of the diversity 
in the Asian American and Pacific Islander communities. Without more 
complete data collection, many Asian American and Pacific Islander 
communities will not have the tools to highlight and address the 
challenges that we face in eliminating health disparities.
    We also support the bill's support for training curricula and 
continuing medical education programs to reduce disparities in health 
care outcomes, including development of curricula for cultural 
competency in graduate medical education. It is vital that our current 
and future health care providers are well-equipped to serve all 
Americans.
    Finally, we strongly support the bill's national media campaign, 
including the use of ethnic media, to inform the public of the programs 
and activities of Office of Civil Rights at the Department of Health 
and Human Services. The Office of Civil Rights already has been working 
constructively with providers and health care institutions to ensure 
the civil rights of all Americans in health care settings and its 
efforts would be enhanced with such additional community awareness and 
outreach.
    This is long overdue legislation that will go a long way in 
ensuring equal access, quality and outcomes in health care for all 
Americans. We applaud the co-sponsors of this legislation for coming 
together to address these challenges collectively. We pledge our 
cooperation in working with this Committee to secure passage of this 
bill. Thank you.

    Mr. Bilirakis. Thank you very much, Mr. Bau.
    The Chair recognizes Dr. Coburn to start the questioning.
    Mr. Coburn. Thank you, Mr. Chairman.
    I just want to touch on one thing with Dr. Rios. Did I hear 
you say that, maybe it was an implication, that the Federal 
Government ought to be setting the curricula for the cultural 
competency? I understand what the bill says, but what did you 
say?
    Ms. Rios. No, we are supportive of the way the bill is 
written that the Government should encourage cultural 
competency curricula, that there is a need for mainstream 
society to learn more about how to deal with our cultures. What 
I mentioned was the definition of cultural competency.
    Mr. Coburn. I just wanted to clarify that it's not your 
testimony that the Government ought to be establishing it. The 
health care professionals who are minorities and know those 
cultural characteristics ought to be the ones.
    Ms. Rios. Yes. I think the community organizations and the 
schools need to develop the curricula.
    Mr. Coburn. Dr. Peterson, I want to ask you some questions, 
and I'm very interested in your testimony on HIV. Is it your 
thought that the disparity is now declining in Virginia because 
you have a program of HIV and AIDS notification, partner 
notification and reporting?
    Ms. Peterson. I think it makes a difference. Virginia was 
one of the first States to have named HIV reporting, so that in 
the packet of data that you have, if you look at pages 9 and 10 
and compare them, you can see that in 1990, we could recognize 
there was a trend to a racial disparity in the HIV population. 
We couldn't see that in our AIDS data until, actually it was 
1990, for HIV and 1993-94 for AIDS.
    That meant that as we used our Ryan White dollars, we could 
begin to focus resources in our minority population years 
earlier than other States. So having the data, knowing for all 
of your different sub-populations, and I would agree with many 
others on the panel that we need to have that data, did allow 
us to focus. It has not taken care of all of the disparity in 
the HIV-AIDS situation. But I think what we try and tease out 
is access to care, the kinds of things that system wide we can 
address. It looks like we're doing pretty well because we've 
been able to focus early.
    Mr. Coburn. So basically Virginia is refocusing their 
dollars where the disease is and in Virginia it happens to be 
moving into minority populations. But wherever it moved, that 
you would be able to focus the dollars that way.
    Ms. Peterson. Right. And working in collaboration with 
consortiums and local groups who then, in that close 
partnership, can deal with cultural competency as well.
    But yes, we have, and one of the maps shows the AIDS cases 
in the graph for hot spots. We have our resources focused 
there.
    Mr. Coburn. And you do have partner notification law in 
Virginia?
    Ms. Peterson. Yes.
    Mr. Coburn. Did you recall hearing the testimony of Dr. 
Satcher that he believes, and it's the CDC's position, the name 
based reporting and partner notification?
    Ms. Peterson. Yes, and I would agree completely. On partner 
notification, that is how we do all of our sexually transmitted 
disease. It makes sense for communicable disease control. We've 
been doing it for a very long time with our HIV name reporting. 
And we have had no objections to it. We safeguard 
confidentiality very, very carefully.
    Mr. Coburn. Has there ever been a break in confidentiality?
    Ms. Peterson. No, there has not been.
    Mr. Coburn. When you report to the CDC on HIV-infected, and 
somebody contracts it heterosexually, do you report that as a 
heterosexual transmission?
    Ms. Peterson. We do. Virginia has a slightly different 
reporting scheme than CDC.
    Mr. Coburn. Then let me ask you the question, when the data 
is received by CDC how do they classify it?
    Ms. Peterson. They probably put it in their other.
    Mr. Coburn. Other meaning no identifiable risk?
    Ms. Peterson. Right.
    Mr. Coburn. Does that make sense to you as a commissioner 
of public health?
    Ms. Peterson. What we are trying to do, and made a decision 
a number of years ago, is to identify for each person what is 
the mode that they contracted the disease, and therefore, if 
it's heterosexual transmission, since it's now in the 
heterosexual population, we wanted to be able to track that.
    So we do it a little differently. We know that this is a 
debate that they are going back to see whether they don't want 
to go the same direction as Virginia.
    Mr. Coburn. Dr. Friedell, a couple questions. We had a 
little private discussion when I was introduced to you an hour 
or so ago in terms of human papilloma virus. The House passed 
yesterday a bill which requires the CDC to now track and 
develop tools and educational information for the American 
public on human papilloma virus. I know as you related to me 
the significant increase you're seeing in cervical cancer in 
the community that you serve.
    One of the things that concerns me, as you talked about 
cervical cancer and prostate cancer and these other things, is 
the reports that are out there now that there is a positive 
correlation between HPV exposure and prostate cancer. When we 
see the prostate cancer, what it is in this country, and we see 
a sexually transmitted disease that now has a correlation with 
it, what's your experience now in how we handle HPV in terms of 
a communicable disease and what we should be doing? Do you have 
any comments for this Committee in regard to that?
    Mr. Friedell. I don't really have any experience as far as 
prostate cancer and HPV, but I have a fair amount of experience 
with the idea of human papilloma virus infection when it comes 
to cancer of the cervix. Cancer of the cervix is at a higher 
rate in the Appalachian population of Eastern Kentucky. In 
fact, our own data show that recently, I'm also the director of 
the State cancer registry, that the incidence of invasive 
cervical cancer in Eastern Kentucky and Appalachian Kentucky, 
our rural poor population, is exactly the same as in our 
African American population.
    In terms of HPV and its function, I don't know that we have 
any reporting mechanism for definition of HPV itself. Until we 
get a more reliable test, I think in a longer range, most 
people believe that recognizing human papilloma virus of 
certain strains, I think it's 16, 18, 31 particularly, that 
perhaps developing a vaccine is the most effective way to deal 
with that particular problem as part of the cervical cancer 
problem.
    Mr. Bilirakis. I know this is a subject that Dr. Coburn is 
very knowledgeable in and wants to continue on. But our trouble 
is, we have probably an hour's worth of votes starting now. I 
really don't want to make you good people wait until we return.
    So possibly if we can maybe hustle right on through.
    Mr. Brown.
    Mr. Brown. Thank you.
    Mr. Bau, tell me a little bit about tuberculosis, why it's 
more common among Asian Americans, what nationalities 
especially does it hit, just the poor who are here, and is 
there much multi-drug resistant TB among Asian Americans that 
have contracted it?
    Mr. Bau. From what I know, a lot of the tuberculosis is 
from folks who are coming from other countries where 
tuberculosis is much more prevalent. So even though we do 
immigration screening for that, a lot of that, and Dr. Peterson 
could probably speak to it as well, it means that we then need 
both culturally appropriate as well as linguistically 
appropriate programs to follow up to make sure people continue 
to stay on their medications.
    And also the conditions where tuberculosis continues to 
spread, where there's overcrowding, where there's not good 
ventilation. When you've got new immigrant populations coming 
in, housing situations in which those kinds of situations do 
exist, then that also leads to the spread, even again to the 
best efforts.
    So again, a lot of it is targeting the efforts. I think Dr. 
Peterson could also speak to the fact that our funding for 
tuberculosis control was at a really good level and then it 
fell dramatically several years ago. So again, part of the 
resurgence that we see is directly correlated to the amount of 
funding that goes into those programs.
    Mr. Brown. Dr. Peterson, comment if you would, and also, 
are we doing directly observed treatment well in Virginia?
    Ms. Peterson. We are doing directly observed treatment for 
cases that are infectious. The resource funding issue is a 
limiting factor for skin test positive, but non-infectious 
cases, and doing directly observed therapy. I would reiterate 
that in Virginia, our cases are foreign borne at this point. 
One of our measures of success is finding them, treating them 
early and making sure that we don't have any cases that are 
transmission within the U.S. Virginia has been very successful 
with that. It's getting harder to do.
    Mr. Brown. Thank you, Mr. Chairman.
    Mr. Bilirakis. Dr. Cohen, your organization, AAMC, has 
traditionally opposed set-aside programs for research that is 
not reviewable by research management. We've had a policy here 
in the Congress, of not directing NIH on how they should spend 
those research dollars, even though we sometimes are unhappy 
about some of the decisions they make, and we let them know 
that. But we still hesitate to direct that.
    Yet this legislation, as you know, allocates funds directly 
to the proposed center. Comment quickly?
    Mr. Cohen. Well, I think the decision we came to was that 
the urgency of this matter was such that we were willing to 
forego that traditional objection to bypass budgets, which we 
continue to have a strong policy against. But we feel that the 
balance here has shifted because of the urgency of this issue.
    Mr. Bilirakis. The urgency, then. I see.
    Well, I have so much more, but the Chair is going to 
recognize Mr. Whitfield.
    Mr. Whitfield. Mr. Chairman, thank you, and I understand 
you're going to relieve this panel.
    Mr. Bilirakis. Yes, we're going to finish up.
    Mr. Whitfield. I would first of all ask unanimous consent 
that Dr. Friedell be able to admit into the record an article 
from the Lexington Herald relating to incidence of cancer 
within the State of Kentucky.
    Mr. Bilirakis. Without objection. And to add to that, there 
is a package here which has been cleared through the Minority 
National Alliance of State Territorial AIDS Directors, the data 
and testimony of Thomas Liberti, Chief, Bureau of HIV-AIDS in 
Florida. I would ask unanimous consent that that be made a part 
of the record. It has been cleared.
    Mr. Whitfield. Mr. Chairman, I'm just going to make one 
statement. I read Dr. Friedell's testimony, and I think 
everyone on this panel would agree that we are very much 
concerned about the programs for research and health, 
prevention of disease in minorities. I think it's also 
important, and Dr. Friedell pointed this out very well, that we 
be concerned about all underserved populations, whatever their 
ethnicity might be.
    There are, as a matter of fact, more poor white people 
underserved in the country than there are blacks, Hispanics, 
Native Americans put together. And this bill focuses entirely 
on minorities, which is important. But I think we also, as we 
move forward in this legislation, must focus on the medically 
underserved as well.
    Mr. Bilirakis. Mr. Strickland.
    Mr. Strickland. I just want to make one quick statement. We 
only have a couple of minutes left. But I'm going to echo my 
colleague's comments. I believe we need to focus on minority 
health. I believe the statistics are alarming and unacceptable 
that you have talked about.
    I also believe, talking to Dr. Friedell and others, that 
correlation is not necessarily causation, and race and 
ethnicity may not be the primary causative factor. It may be 
medically underserved populations and poverty related 
conditions. So I hope this bill is not so limited that it 
leaves out a whole mass of citizens who rightfully should be 
considered as being underserved.
    Mr. Bilirakis. I appreciate that, Mr. Strickland.
    Very quickly, and I don't know how much time we have, we 
don't have very much, but if the elevation of the office to 
center is a potential stumbling block because of the fact that 
dollars bypass the director, etc., and unless we get the 
administration's approval, I don't know really how much hope 
there will be.
    So I would ask you about the other provisions of this bill, 
Title II, Title III, Title IV, and Title V. Do you feel there's 
a lot to be gained by those titles and can be gained from a 
constructive basis, whether or not at this time the office is 
elevated to center?
    [All witnesses respond in the affirmative.]
    Mr. Bilirakis. You all do, then. Thank you.
    Well, ladies and gentlemen, we really appreciate it. We 
apologize for your waiting so long. Some of you have had this 
experience before and know what it's like up here.
    Also, we do ask that you be willing to answer any written 
requests to you. You've been an awful lot of help. Thank you so 
much. The hearing is adjourned.
    [Whereupon, at 3:07 p.m., the subcommittee was adjourned.]
    [Additional material submitted for the record follows:]
  Coordination of Minority Health Activities Within the Department of 
                       Health and Human Services
    The Department of Health and Human Services (DHHS) utilizes both 
formal and informal strategies to accomplish the coordination of 
minority health activities in a timely, efficient, and effective 
manner.
    In 1998, the Secretary established an infrastructure to 
institutionalize the White House minority initiatives within each 
operating division of the Department. This included the initiatives 
for: Historically Black Colleges and Universities (HBCU), the Hispanic 
Agenda for Action (HAA), the White House Initiative on Tribal Colleges 
and Universities, and the Asian American and Pacific Islander Action 
Agenda. This formal structure was also established to improve 
coordination of issues and activities that crossed all four 
initiatives.
    To fulfill the above goals, a Departmental Minority Initiatives 
Steering Committee was established to provide direction and guidance 
for the initiatives. This Committee is composed of the Heads or 
Deputies of the DHHS Operating Divisions; the Assistant Secretaries for 
Management and Budget, Planning and Evaluation, and Health/Surgeon 
General; and senior staff members from the Executive Secretariat, 
Office for Civil Rights, Office of the General Counsel, and the Office 
of Intergovernmental Affairs. The Deputy Secretary chairs the 
Committee, and the Deputy Assistant Secretary for Minority Health 
serves as its Executive Director. This Committee meets on a quarterly 
basis.
    Supporting this Steering Committee is the Departmental Minority 
Initiatives Coordinating Committee (DMICC) which acts as the 
coordinating body and meets monthly. The Department's Office of 
Minority Health (OMH) is responsible for providing staff support to 
both the DMICC and the Steering Committee, and plays a lead role in the 
ongoing management of all minority initiatives. The body of this 
committee is made up of senior level staff members who are responsible 
for the management of minority health activities within the DHHS 
Operating Divisions. In addition, on an as needed basis, subcommittees 
or work groups are created to better address issues that intersect the 
four initiatives, and allows for additional input from the targeted 
racial/ethnic groups.
    The Operating Divisions also coordinate activities among themselves 
in instances where a Department-wide plan is not involved. Again, these 
coordination activities may occur informally or through more formal 
means such as an interagency agreement for cofunding a program or 
project. OMH has also established cooperative agreements with minority 
organizations, which allows offices and agencies to collaborate in the 
conduct of mutually inclusive initiatives for improving the health 
status and quality of life for racial/ethnic populations. In addition, 
the Operating Divisions often utilize the DMICC meeting as an avenue 
for sharing information regarding minority health activities within 
their respective agencies.
    All of these formal and informal procedures have been instituted to 
ensure that greater coordination exists throughout DHHS. These 
activities also ensure that those individuals within each agency with 
the appropriate knowledge and experience are involved in developing, 
coordinating, and reporting on the Department's efforts to address the 
health needs of minority communities.

                                DHHS MINORITY HEALTH DIRECTORS AND ADMINISTRATORS
----------------------------------------------------------------------------------------------------------------
                                             Location Of Minority                                    Telephone
                 Agency                        Health Activities             Contact Person           Number
----------------------------------------------------------------------------------------------------------------
DHHS/OS.................................  Office of Minority Health,  Nathan Stinson Ph.D.,         301-443-5084
                                           Office of Public Health     M.D., M.P.H.,
                                           and Science                  Deputy Assistant
                                                                       Secretary for Minority
                                                                       Health
FDA.....................................  Office of Consumer Affairs  Mary Wallace,                 301-827-4406
                                                                        Director of Consumer
                                                                       Programs
NIH.....................................  Office of Research on       John Ruffin, Ph.D.,           301-402-1366
                                           Minority Health,             Director
                                            Office of the Director
IHS.....................................  External Affairs, Office    Leo Nolan, Senior Policy      301-443-7261
                                           of the Director             Analyst
                                                                        (contact is usually
                                                                       issue specific)
ATSDR...................................  Office of Urban Affairs     Vincent Nathan, Ph.D.,        404-639-5064
                                                                       M.P.H.,
                                                                        Minority Health Program
                                                                       Manager
AHRQ....................................  Center for Cost and         Morgan Jackson, M.D.,         301-594-0147
                                           Financing Studies            Minority Health Program
                                                                       Director
HRSA....................................  Office of Minority Health,  M. June Horner,               301-443-2964
                                           Office of the                Director
                                           Administrator
AoA.....................................  Office of the Assistant     Sunday Mezurashi, Special     202-401-4541
                                           Secretary                   Assistant
                                                                        to the Assistant
                                                                       Secretary
HCFA....................................  Beneficiary Services        Kevin Nash, Program           41O-786-5781
                                           Group,                      Executive for
                                            Center for Beneficial       Minority Health
                                           Services                    Initiatives
CDC.....................................  Office of Minority Health,  Wilma Johnson, MSPH,          404-639-7210
                                            Office of the Director      Acting Associate
                                                                       Director
SAMHSA..................................  Office of Minority Health,  Deloris Hunter, Ph.D.,        301-443-7265
                                            Office of the               Director
                                           Administrator
----------------------------------------------------------------------------------------------------------------

                                 ______
                                 
                                    Academic Health Centers
                                                       May 10, 2000
The Honorable Michael Bilirakis
Subcommittee on Health and Environment
Committee on Commerce
2125 Rayburn House Office Building
United States House of Representatives
Washington, D.C. 20515
    Dear Mr. Chairman: The Association of Academic Health Centers is 
writing to express out support for H.R. 2391 and H.R. 3250, bills that 
would elevate the Office of Research on Minority Health at the National 
Institutes of Health to a National Center.
    Health status disparities in the United States among minority, 
disadvantaged, and underserved communities continue to persist, even 
though improvements have been made in the general population.
    By elevating the existing NIH office to a center, research on 
health disparities will be a higher priority, and the community will be 
empowered to take responsibility to achieve the national goal of 
improving the health status of all Americans. As you know, the goal of 
Healthy People 2010 is to eliminate disparities in health.
    AAHC requests that you make this letter a part of the record for 
your subcommittee's May 11th hearing on health status disparities.
    Thank you for the opportunity to present our views.
            Sincerely,
                                        Roger J. Bulger, MD
                                                          President
                                 ______
                                 
  Prepared Statement of Loretta Davis-Satterla, Director, Division of 
         HIV/AIDS-STD, Michigan Department of Community Health
    AIDS case reporting has been the cornerstone of national efforts to 
monitor the spread and impact of the HIV/AIDS epidemic. In the past, 
monitoring AIDS-defining conditions provided population-based data that 
reflected changes in the incidence of HIV infection. However, recent 
advances in HIV treatment have slowed the progression of HIV disease 
and has contributed to a decline in AIDS incidence. Thus, AIDS case 
reporting provides information on an epidemic which is a decade or more 
old. Advances in treatment have diminished the ability of AIDS 
surveillance data to represent trends in the incidence of HIV infection 
and as a consequence, the capacity of local, state, and federal public 
health agencies to monitor the HIV epidemic has been compromised.
    Surveillance activities are a key element of a comprehensive public 
health response to this epidemic. Surveillance data assists public 
health in monitoring the epidemic including the number of people 
infected, the number of newly acquired infections and the modes of 
transmission. In addition, the data is used to target and evaluate 
prevention and care efforts, and in the allocation of resources.
    In Michigan, confidential HIV reporting has been required by 
statute since 1989. Confidential HIV reporting has greatly enhanced 
Michigan's ability to rapidly and effectively respond to the dynamics 
of this epidemic. It is estimated that there are currently 13,000 
individuals residing in Michigan who are infected with HIV. The HIV/
AIDS Reporting System (HARS) reveals that there are 4,433 currently 
living with AIDS and an additional 4,830 individuals living with HIV 
and not AIDS. In contrast to AIDS case surveillance, HIV case 
surveillance provides data to better characterize populations in which 
HIV infection has been newly diagnosed, including persons with evidence 
of recent HIV infection. Compared with persons living with AIDS, those 
reported living with HIV infection in Michigan are more likely to be 
women (18% for AIDS vs 26% for HIV) and African Americans (55% for AIDS 
and 62% for HIV). Approximately, 1% of AIDS cases occurred in both 
persons aged 13-19 years and 20-24 years. In comparison, 4% of HIV 
cases occurred in persons aged 13-19 years and 13% of HIV cases 
occurred in persons 2024 years. Thus, AIDS case surveillance alone does 
not accurately reflect the extent of the HIV epidemic among African 
Americans, women, adolescents and young adults.
    Having knowledge about those more recently infected with HIV, with 
respect to risk as well as sociocultural characteristics, is 
exceedingly important in targeting prevention efforts. HIV case data 
facilitate identification of trends in the epidemic. As a direct result 
of having HIV case data available for planning efforts, current 
prevention efforts supported by the Michigan Department of Community 
Health emphasize racial/ethnic minorities, women and at-risk youth. 
Having a snap-shot of an emerging epidemic has also facilitated 
development of prevention interventions which are responsive to 
community needs, as well as being culturally and linguistically 
competent. HIV case data, combined with other types of data, has guided 
allocation of prevention resources to address priority needs and 
communities. Confidential HIV case data have also been critical in 
planning and evaluating continuum of care efforts.
    Michigan is fortunate to have a statewide client-level data 
collection system (the Uniform Reporting System or URS) which documents 
the service utilization patterns of persons living with HIV/AIDS (PLWH/
A) who access service programs funded through the Ryan White CARE Act. 
The URS data, when used in conjunction with HIV/AIDS surveillance data, 
allow us to evaluate whether the HIV/AIDS Continuum of Care system is 
reaching the population known to be living with the disease. Because 
client descriptive information is linked to service data, the URS 
allows us to review how intensively different subsets of the population 
are utilizing different components of the care system, and it can also 
be used to identify gaps in service to specific groups or in specific 
areas.
    The URS and HIV/AIDS Reporting System (HARS) case report data are 
compared at least annually to ascertain whether the population 
receiving services is consistent demographically with the cases 
reported in each region and the state, and to verify whether minority 
and historically underserved populations have been served in proportion 
to their representation in the community of persons living with HIV 
infection and/or AIDS. Over the last several years this comparison has 
revealed that clients served by RWCA-funded agencies were 
representative of the HIV epidemic in Michigan.
    As the proportions of women and African Americans have increased in 
the epidemic, they have also increased in URS data, indicating a 
growing need for services among these populations. For example, the 
percent of African Americans served went from 56.6% of the total in 
1995 to 63% of the total served in 1999, and the number served 
increased by 35% (3,066 to 4,143). The proportion of Hispanic clients 
served has also increased slightly, going from 3.1% (1995) to 3.6% of 
the total served (1999), with the number served increasing by 43% (166 
to 238). The number of women (of all races) served in 1999 was 40.6% 
more than the number reported in 1995 (1,176 to 1,653). Females made up 
26% of the total served during 1999 while they were only 21.7% of the 
total served during 1995.
    The fact that URS data and HARS data report similar demographic 
proportions for the known infected population and the population 
reported to be ``in care'' indicates that the continuum of care system 
in Michigan has been successful at reaching and serving people who are 
representative of the epidemic in the state. Without client-level data 
and HIV case reporting this type of evaluation would not be possible.
    African Americans and women of all races have been described as 
``traditionally under served populations'' and this designation has 
considerable basis in fact, especially for those who are also living 
with HIV disease. Effectively treating HIV and all its physical 
symptoms is difficult, but when exacerbating co-morbidities or 
socioeconomic conditions (such as poverty, homelessness, or lack of 
insurance) are also present, the range of available treatment options 
becomes significantly more limited and the challenge of providing 
quality care is compounded exponentially. Simply put, co-morbidities 
and other co-factors increase the complexity and the cost of care for 
persons living with HIV. A significant proportion of PLWH/A, effected 
by one or more of these co-morbidities or socioeconomic factors, are 
African Americans and women.
    The URS data over the past five years have documented that poverty, 
lack of health insurance, the presence of mental health and/or 
substance abuse problems, and homelessness/inadequate housing are 
factors which effect a higher proportion of African Americans living 
with HIV and women living with HIV than the general HIV/AIDS affected 
population who use Ryan White funded services.
    Poverty is the co-factor which effects the largest percentage of 
persons living with HIV. Poverty creates significant barriers to care 
because it effects every aspect of life, beginning with lack of health 
insurance, and transportation to medical care, and extending to poor 
nutrition, inadequate housing and generally poor health practices due 
to lack of resources.
    Substance abuse, and/or mental illness also have a serious impact 
on the complexity of care for people with HIV. Substance abuse or 
mental health issues are difficult to treat individually and often have 
a negative impact on an individual's health since either co-morbitity 
can effect a person's ability to adhere to treatment and remain in 
care. In addition, substance abusers or the mentally ill often have 
unstable living conditions, which makes follow-up difficult.
    When seeking to address these issues, with the goal of achieving 
100% access and 0% disparity, it is essential that systems are utilized 
that allow identification of emerging trends relative to race/
ethnicity, gender and behavioral risk factors. Planning based on trends 
in HIV infection provides a more accurate assessment of the 
distribution of the infected population, the number of individuals in 
need of access to treatment, and the type of medical and support 
services required to meet client needs. In Michigan, HIV case reporting 
and the Uniform Reporting System have been effective tools in 
addressing the current epidemic by facilitating planning of appropriate 
prevention, early intervention and care services. Michigan has 
documented that the combined prevalence of those living with a 
diagnosis of HIV infection and those living with AIDS provides a more 
realistic and useful estimate of the resources needed for prevention 
and care services than does AIDS prevalence alone.
                                 ______
                                 
  National Alliance of State and Territorial AIDS Directors
                                                       May 11, 2000
The Honorable Thomas Bliley
Chairman
House Commerce Committee
U.S. House of Representatives
Washington, DC 20515

The Honorable Michael Bilirakis
 Chairman
Health and Environment Subcommittee
U.S. House of Representatives
Washington, DC 20515

    Dear Chairman Bliley and Chairman Bilirakis: On behalf of the 
National Alliance of State and Territorial Directors, I am requesting 
submission for the record HIV/AIDS surveillance information that 
illustrates disparities among racial/ethnic minorities in terms of HIV/
AIDS in the U.S. The attached tables provide data on the percentage 
comparison of individuals living with AIDS, and the percentage of 
individuals diagnosed with HIV (not AIDS) based on race and sex for the 
25 States that had initiated HIV reporting before 1995.
    Confidential HIV reporting enhances the ability of public health 
programs to rapidly and effectively respond to the dynamics of the HIV/
AIDS epidemic. HIV case surveillance provides data to better 
characterize and deliver services to populations in which HIV infection 
has been newly diagnosed, including persons with evidence of recent HIV 
infection. The data compiled in these tables generally indicate that 
compared with persons living with AIDS, those reported living with HIV 
infection are more likely to be people of color and women. The data 
suggest that AIDS case surveillance alone does not accurately reflect 
the extent of the HIV epidemic among African Americans, Hispanics and 
women in the United States.
    Having knowledge about those more recently infected with HIV in 
terms of risk factors and socio-cultural characteristics is important 
in targeting prevention and treatment programs. Planning based on 
trends in HIV infection provides a more accurate assessment of the 
distribution of infected populations, the number of individuals in need 
of access to treatment, and the type of medical and support services 
required to meet client needs through programs such as those funded by 
the Ryan White CARE Act.
    Thank you for the opportunity to submit this information for the 
committee consideration.
            Sincerely,
                                          Julie M. Scofield
                                                 Executive Director

                                                 Alabama Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       37.6%    White..................................       35.2%
Black.......................................       60.9%    Black..................................       62.2%
Hispanic....................................        1.2%    Hispanic...............................        0.8%
Asian.......................................        0.2%    Asian..................................        0.1%
Indian......................................        0.1%    Indian.................................        0.1%
Unknown.....................................        0.0%    Unknown................................        1.5%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       81.4%   Male....................................       74.2%
Female......................................       18.6%    Female.................................       25.8%
----------------------------------------------------------------------------------------------------------------


                                                Arkansas Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       61.4%   White...................................       53.0%
Black.......................................       36.2%   Black...................................       43.7%
Hispanic....................................        1.4%   Hispanic................................        0.9%
Asian.......................................        0.1%   Asian...................................        0.1%
Indian......................................        0.5%   Indian..................................        0.2%
Unknown.....................................        0.3%   Unknown.................................        2.2%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       82.5%   Male....................................       75.2%
Female......................................       17.5%   Female..................................       24.8%
----------------------------------------------------------------------------------------------------------------


                                                 Arizona Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       69.5%   White...................................       66.1%
Black.......................................        8.0%   Black...................................       10.5%
Hispanic....................................       19.5%   Hispanic................................       16.4%
Asian.......................................        0.7%   Asian...................................        0.5%
Indian......................................        2.2%   Indian..................................        2.9%
Unknown.....................................        0.1%   Unknown.................................        3.5%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       89.8%   Male....................................       86.2%
Female......................................       10.2%   Female..................................       13.8%
----------------------------------------------------------------------------------------------------------------


                                                Colorado Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       70.5%   White...................................       71.2%
Black.......................................       13.2%   Black...................................       13.4%
Hispanic....................................       15.3%   Hispanic................................       12.1%
Asian.......................................        0.4%   Asian...................................        0.4%
Indian......................................        0.6%   Indian..................................        0.7%
Unknown.....................................        0.0%   Unknown.................................        2.2%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       91.5%   Male....................................       91.3%
Female......................................        8.5%   Female..................................        8.7%
----------------------------------------------------------------------------------------------------------------


                                                  Idaho Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       83.6%   White...................................       85.1%
Black.......................................        2.6%   Black...................................        5.5%
Hispanic....................................       11.8%   Hispanic................................        8.4%
Asian.......................................        1.0%   Asian...................................        0.0%
Indian......................................        1.0%   Indian..................................        0.7%
Unknown.....................................        0.0%   Unknown.................................        0.4%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       85.2%   Male....................................       83.6%
Female......................................       14.8%   Female..................................       16.4%
----------------------------------------------------------------------------------------------------------------


                                                 Indiana Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       69.3%   White...................................       60.7%
Black.......................................       26.5%   Black...................................       35.2%
Hispanic....................................        3.9%   Hispanic................................        3.6%
Asian.......................................        0.1%   Asian...................................        0.3%
Indian......................................        0.2%   Indian..................................        0.1%
Unknown.....................................        0.0%   Unknown.................................        0.1%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       88.2%   Male....................................       82.4%
Female......................................       11.8%   Female..................................       17.6%
----------------------------------------------------------------------------------------------------------------


                                                Louisiana Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       40.4%   White...................................       29.2%
Black.......................................       56.3%   Black...................................       67.7%
Hispanic....................................        2.8%   Hispanic................................        2.4%
Asian.......................................        0.2%   Asian...................................        0.2%
Indian......................................        0.1%   Indian..................................        0.1%
Unknown.....................................        0.2%   Unknown.................................        0.3%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       81.4%   Male....................................       68.3%
Female......................................       18.6%   Female..................................       31.7%
----------------------------------------------------------------------------------------------------------------


                                                Michigan Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       41.3%   White...................................       33.6%
Black.......................................       55.0%   Black...................................       61.3%
Hispanic....................................        3.4%   Hispanic................................        3.0%
Asian.......................................        0.3%   Asian...................................        0.1%
Indian......................................        0.1%   Indian..................................        0.6%
Unknown.....................................        0.0%   Unknown.................................        1.4%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       81.9%   Male....................................       74.6%
Female......................................       18.1%   Female..................................       25.4%
----------------------------------------------------------------------------------------------------------------


                                                Minnesota Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       66.8%   White...................................       61.0%
Black.......................................       23.8%   Black...................................       28.7%
Hispanic....................................        6.5%   Hispanic................................        6.3%
Asian.......................................        0.8%   Asian...................................        0.9%
Indian......................................        2.1%   Indian..................................        2.2%
Unknown.....................................        0.0%   Unknown.................................        0.9%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       86.5%   Male....................................       82.8%
Female......................................       13.5%   Female..................................       17.2%
----------------------------------------------------------------------------------------------------------------


                                                Missouri Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       60.9%   White...................................       53.1%
Black.......................................       35.4%   Black...................................       43.0%
Hispanic....................................        3.1%   Hispanic................................        2.6%
Asian.......................................        0.3%   Asian...................................        0.4%
Indian......................................        0.4%   Indian..................................        0.2%
Unknown.....................................        0.1%   Unknown.................................        0.7%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       88.9%   Male....................................       84.4%
Female......................................       11.1%   Female..................................       15.6%
----------------------------------------------------------------------------------------------------------------


                                               Mississippi Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       31.6%   White...................................       23.7%
Black.......................................       66.8%   Black...................................       73.7%
Hispanic....................................        1.2%   Hispanic................................        1.1%
Asian.......................................        0.1%   Asian...................................        0.2%
Indian......................................        0.2%   Indian..................................        0.1%
Unknown.....................................        0.2%   Unknown.................................        1.1%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       75.7%   Male....................................       68.4%
Female......................................       24.3%   Female..................................       31.6%
----------------------------------------------------------------------------------------------------------------


                                             North Carolina Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       28.8%   White...................................       22.3%
Black.......................................       67.1%   Black...................................       74.8%
Hispanic....................................        2.9%   Hispanic................................        1.0%
Asian.......................................        0.2%   Asian...................................        0.3%
Indian......................................        0.7%   Indian..................................        0.9%
Unknown.....................................        0.3%   Unknown.................................        0.7%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       77.6%   Male....................................       65.0%
Female......................................       22.4%   Female..................................       35.0%
----------------------------------------------------------------------------------------------------------------


                                              North Dakota Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       73.2%   White...................................       81.7%
Black.......................................        7.3%   Black...................................        6.7%
Hispanic....................................        4.9%   Hispanic................................        3.3%
Asian.......................................        2.4%   Asian...................................        0.0%
Indian......................................       12.2%   Indian..................................        6.7%
Unknown.....................................        0.0%   Unknown.................................        1.7%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       87.8%   Male....................................       81.7%
Female......................................       12.2%   Female..................................       18.3%
----------------------------------------------------------------------------------------------------------------


                                               New Jersey Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       25.8%   White...................................       19.1%
Black.......................................       54.2%   Black...................................       58.3%
Hispanic....................................       19.2%   Hispanic................................       20.4%
Asian.......................................        0.4%   Asian...................................        0.5%
Indian......................................        0.1%   Indian..................................        0.1%
Unknown.....................................        0.3%   Unknown.................................        1.6%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       68.5%   Male....................................       59.8%
Female......................................       31.5%   Female..................................       40.2%
----------------------------------------------------------------------------------------------------------------


                                                 Nevada Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       63.3%   White...................................       64.0%
Black.......................................       20.8%   Black...................................       22.7%
Hispanic....................................       13.8%   Hispanic................................       11.3%
Asian.......................................        1.3%   Asian...................................        1.0%
Indian......................................        0.8%   Indian..................................        0.8%
Unknown.....................................        0.0%   Unknown.................................        0.2%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       86.9%   Male....................................       81.7%
Female......................................       13.1%   Female..................................       18.3%
----------------------------------------------------------------------------------------------------------------


                                                  Ohio Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       56.6%   White...................................       43.2%
Black.......................................       38.2%   Black...................................       46.3%
Hispanic....................................        4.7%   Hispanic................................        4.2%
Asian.......................................        0.3%   Asian...................................        0.2%
Indian......................................        0.1%   Indian..................................        0.2%
Unknown.....................................        0.0%   Unknown.................................        5.9%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       85.8%   Male....................................       77.4%
Female......................................       14.2%   Female..................................       22.6%
----------------------------------------------------------------------------------------------------------------


                                                Oklahoma Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       69.7%   White...................................       65.7%
Black.......................................       17.8%   Black...................................       23.7%
Hispanic....................................        4.6%   Hispanic................................        3.8%
Asian.......................................        0.7%   Asian...................................        0.4%
Indian......................................        7.0%   Indian..................................        5.8%
Unknown.....................................        0.2%   Unknown.................................        0.6%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       88.2%   Male....................................       84.1%
Female......................................       11.8%   Female..................................       15.9%
----------------------------------------------------------------------------------------------------------------


                                             South Carolina Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       28.6%   White...................................       25.6%
Black.......................................       69.9%   Black...................................       73.0%
Hispanic....................................        1.3%   Hispanic................................        1.0%
Asian.......................................        0.1%   Asian...................................        0.2%
Indian......................................        0.1%   Indian..................................        0.1%
Unknown.....................................        0.0%   Unknown.................................        0.3%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       75.4%   Male....................................       68.7%
Female......................................       24.6%   Female..................................       31.3%
----------------------------------------------------------------------------------------------------------------


                                              South Dakota Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       82.5%   White...................................       79.5%
Black.......................................        4.8%   Black...................................        8.1%
Hispanic....................................        3.2%   Hispanic................................        3.7%
Asian.......................................        0.0%   Asian...................................        0.0%
Indian......................................        9.5%   Indian..................................        8.7%
Unknown.....................................        0.0%   Unknown.................................        0.0%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       85.7%   Male....................................       82.0%
Female......................................       14.3%   Female..................................       18.0%
----------------------------------------------------------------------------------------------------------------


                                                Tennessee Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       49.8%   White...................................       39.1%
Black.......................................       48.3%   Black...................................       59.6%
Hispanic....................................        1.5%   Hispanic................................        1.1%
Asian.......................................        0.2%   Asian...................................        0.2%
Indian......................................        0.1%   Indian..................................        0.0%
Unknown.....................................        0.0%   Unknown.................................        0.0%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       83.6%   Male....................................       72.6%
Female......................................       16.4%   Female..................................       27.4%
----------------------------------------------------------------------------------------------------------------


                                                  Utah Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       79.6%   White...................................       77.3%
Black.......................................        6.6%   Black...................................        9.1%
Hispanic....................................       11.7%   Hispanic................................       11.2%
Asian.......................................        0.8%   Asian...................................        0.3%
Indian......................................        1.3%   Indian..................................        1.8%
Unknown.....................................        0.0%   Unknown.................................        0.4%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       91.4%   Male....................................       85.6%
Female......................................        8.6%   Female..................................       14.4%
----------------------------------------------------------------------------------------------------------------


                                                Virginia Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       38.1%   White...................................       29.6%
Black.......................................       57.3%   Black...................................       65.8%
Hispanic....................................        3.8%   Hispanic................................        3.0%
Asian.......................................        0.6%   Asian...................................        0.5%
Indian......................................        0.1%   Indian..................................        0.1%
Unknown.....................................        0.1%   Unknown.................................        0.9%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       80.7%   Male....................................       72.4%
Female......................................       19.3%   Female..................................       27.6%
----------------------------------------------------------------------------------------------------------------


                                                Wisconsin Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       54.8%   White...................................       48.3%
Black.......................................       34.4%   Black...................................       41.9%
Hispanic....................................        9.4%   Hispanic................................        7.7%
Asian.......................................        0.4%   Asian...................................        0.8%
Indian......................................        0.8%   Indian..................................        1.1%
Unknown.....................................        0.1%   Unknown.................................        0.3%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       86.8%   Male....................................       79.4%
Female......................................       13.2%   Female..................................       20.6%
----------------------------------------------------------------------------------------------------------------


                                              West Virginia Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       79.3%   White...................................       58.4%
Black.......................................       19.3%   Black...................................       37.2%
Hispanic....................................        1.1%   Hispanic................................        2.3%
Asian.......................................        0.0%   Asian...................................        0.4%
Indian......................................        0.0%   Indian..................................        0.2%
Unknown.....................................        0.2%   Unknown.................................        1.5%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       86.0%   Male....................................       71.3%
Female......................................       14.0%   Female..................................       28.7%
----------------------------------------------------------------------------------------------------------------


                                                 Wyoming Profile
----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Race                                  HIV Prevalence by Race
----------------------------------------------------------------------------------------------------------------
White.......................................       88.9%   White...................................       76.3%
Black.......................................        4.8%   Black...................................        6.8%
Hispanic....................................        6.3%   Hispanic................................       13.6%
Asian.......................................        0.0%   Asian...................................        1.7%
Indian......................................        0.0%   Indian..................................        1.7%
Unknown.....................................        0.0%   Unknown.................................        0.0%
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
           AIDS Prevalence by Sex                                    HIV Prevalence by Sex
----------------------------------------------------------------------------------------------------------------
Male........................................       92.1%   Male....................................       79.7%
Female......................................        7.9%   Female..................................       20.3%
----------------------------------------------------------------------------------------------------------------
AIDS prevalence as of 12/1998; prevalence of diagnosed HIV (not AIDS) as of 12/1998.
Source: Centers for Disease Control and Prevention (CDC)

                                 ______
                                 
         National Association of Community Health Centers, 
                                           Inc.'
                                                       May 11, 2000
The Honorable Mike Bilirakis, Chair
The Honorable Sherrod Brown, Ranking Member
Subcommittee on Health and Environment
House Commerce Committee
2125 Rayburn House Office Building
Washington, DC 20515
    Dear Chairman Bilirakis, Ranking Member Brown, and members of the 
Subcommittee: Thank you for providing an opportunity for us to submit a 
statement on behalf of the National Association of Community Health 
Centers regarding H.R. 3250, the ``Health Care Fairness Act of 1999.'' 
We appreciate your consideration of our views.
    We strongly support the goal of this legislation: to reduce and 
eventually eliminate the health disparities that currently exist 
between white Americans and those who are members of a racial or ethnic 
minority. For more than thirty years, community, migrant and homeless 
health centers have been working toward that goal. The goal of the 
national health center program is to provide, ``100% Access'' to health 
care with ``Zero health disparities.''
    Health centers provide high quality primary care to people of all 
ages, from all cultures, and with all incomes. Health centers are the 
health care home for nearly 4.5 million children 7 million people of 
color, over 600,000 farmworkers, and more than a half-million homeless 
men, women, and children each year--11 million patients in all, 4.5 
million of whom are uninsured.
    We take pride in the successes we have had thus far in developing 
and implementing service delivery models that are notable for helping 
to reduce some of the gaps that exist in health outcomes for minorities 
today. Some of our accomplishments include: dramatic reductions in 
infant mortality rates; successful management of diabetes, 
hypertension, and asthma that afflicts many of our patients from racial 
and ethnic minority groups; childhood immunization rates that shame the 
industry standard; and increased usage of prenatal care and preventive 
health strategies by health center patients.
    However, we claim only to have been consistent warriors in this 
battle, with some successful fighting techniques to share. Our nation 
is far away from winning the war against health disparities. Therefore, 
we applaud the Subcommittee for its bold vision and its willingness to 
take a stand on these issues by convening today's hearing on H.R. 3250.
    Without question, more research in this field needs to be done. We 
applaud the sponsors of this legislation for proposing the creation of 
the National Center for Research on Minority Health and Health 
Disparities. We believe such a Center is long overdue. However, NACHC 
strongly urges the Committee to clearly convey its intent to 
appropriators that funding for this Center should, to the extent 
possible, be dedicated out of the existing budget for the National 
institutes of Health so as not to undermine funding for other important 
programs funded under the Labor, Health and Human Services, and 
Education Appropriations bill.
    There are several important sections in the legislation that 
provide for the support and conduct of research and demonstration 
programs to test and evaluate strategies for eliminating health 
disparities and for promoting effective interventions. We believe 
health centers are well situated to be given priority consideration as 
demonstration test sites for the research models funded under this 
bill.
    We also support adding a new requirement to the bill that would 
call for the collection of data and information on best practice models 
of service delivery where disparities in health outcomes are currently 
being addressed, such as at federally qualified health centers.
    We appreciate the inclusion of health centers among the provider 
groups named as eligible entities to receive incentives under a new 
program that would encourage health care professionals to participate 
in continuing medical education programs designed to decrease 
disparities in minority health.
    And finally, we would encourage changes to the legislation that 
would include participation from health center experts on the new 
advisory committee to the Secretary of Health and Human Services, as 
well as in the development of and participation in the national 
conference on continuing medical education on cultural competency that 
is mandated under the bill. Health center clinicians and directors have 
years of valuable, field-tested experience in providing culturally 
competent care. Failure to include their expertise in these endeavors 
would be an unfortunate oversight.
    In sum, the National Association of Community Health Centers would 
encourage the Subcommittee to move forward with favorable consideration 
of this legislation, including any of the suggested changes we have 
outlined in this statement. We believe H.R. 3250 is a good bill and 
deserves to become law.
    This Congress has an opportunity to right many of the wrongs that 
exist in today's healthcare system. Taking action to reduce and 
eliminate racial disparities in health outcomes is a good step in the 
right direction.
    Again, thank you for this opportunity to share our thoughts with 
you.
            Sincerely,
                            Carolyn Emanuel-McClain        
                  Chair, National Board of Directors, NACHC        
          Executive Director, Family Health Centers, Inc. NACHC    
                                         Orangeburg, South Carolina
                                           Tom Van Coverden
                                           President and CEO, NACHC
                                 ______
                                 
                       National Medical Association
                                           Washington, D.C.
                                                       May 11, 1999
The Honorable Michael Bilirakis
Chairman,
House Committee on Commerce,
Subcommittee on Health and the Environment
2125 Rayburn House Office Building
Washington, D.C. 20515
    Dear Mr. Chairman: The National Medical Association (NMA) is very 
pleased to support H.R. 2391 and H.R. 3250, bills which would elevate 
the Office of Research on Minority Health (ORMH) at the National 
Institutes of Health (NIH) to a National Center.
    In spite of the fact that the nation has experienced tremendous 
advances in biomedical research, the benefits of these advances have 
not fully translated into better health status or health care for 
African Americans and other racial and ethnic minorities. Communities 
of color continue to be unduly plagued with disproportionate rates of 
death and disease. As the changing demographics of the nation yield an 
increasingly diverse U.S. population, it is absolutely essential that 
the nation become increasingly proactive in addressing the critical 
health and biomedical research needs of communities of color.
    By elevating the existing NIH office to a center, research on 
health disparities will be a higher priority, and communities of color 
will be empowered to take responsibility to achieve the national goal 
of closing the health disparity gap.
    In reference to today's hearing on H.R. 3250, the NMA supports the 
critical provisions of this critical legislation, which include:

 The establishment of the Center for Research on Minority 
        Health and Health Disparities at the National Institutes of 
        Health (NIH);
 The provision of funds to support programs of excellence in 
        biomedical research and for peer-reviewed minority health-
        focused research grants;
 The requirement to establish a comprehensive plan and budget 
        for the conduct and support of all minority research activities 
        of the NIH agencies; and
 The establishment of a grant program to support the 
        development of culturally competent curricula in health care 
        education.
    The NMA strongly supports both legislative measures and believes 
that they will create important opportunities for the nation to make 
concrete advances in it's effort to close the health disparity gap. NMA 
would appreciate it if you would include this letter in the record for 
your subcommittee's May 11th hearing on H.R. 3250, the Health Care 
Fairness Act. We look forward to working with you to ensure passage and 
enactment of this important bill.
            Sincerely,
                                       Javette Orgain, M.D.
                                                          President
                                 ______
                                 
                                           Research!America
                                                       May 10, 2000
The Honorable Michael Bilirakis
Subcommittee on Health and Environment
Committee on Commerce
2125 Rayburn House Office Building
United States House of Representatives
Washington, D.C. 20515
    Dear Mr. Chairman: Research!America is writing to stress the 
importance of consideration of H.R. 2391 and H.R. 3250, bills which 
would elevate the Office of Research on Minority Health (ORME) at the 
National Institutes of Health (NIH) to a National Center.
    Health status disparities in the United States among minority, 
disadvantaged, and under served communities continue to persist, even 
though improvements have been made in the general population. According 
to our polls, the top health concerns of American citizens are the very 
diseases which disproportionately affect minority and under served 
populations such as cancer and AIDS.
    It is time this nation makes research on health disparities a 
higher priority so the community will be empowered to achieve the goal 
of improving the health status of all Americans.
    Research!America would appreciate it if you would make this letter 
a part of the record for your subcommittee's May 11 hearing on health 
disparities.
    Thank you for the opportunity to present our views.
            Sincerely,
                                                     Paul G. Rogers
                                 ______
                                 
Prepared Statement of Gloria M. Rodriguez, Assistant Commissioner, New 
   Jersey Department of Health and Senior Services, Division of AIDS 
                         Prevention and Control
    I welcome the opportunity to comment on H.R. 3250, the Health Care 
Fairness Act of 1999. It has long been an ``accepted'' fact that many 
diseases disproportionately affect minorities. I use the term 
``accepted'' purposefully, as it reflects society's lack of concern at 
the results of these disparities. Therefore, I commend the Committee 
for recognizing the importance of this issue and holding a hearing on 
this legislation.
    The establishment of a National Center for Research on Minority 
Health and Health Disparities may assist in the coordination of 
minority health research and the delivery of health services in a 
culturally appropriate manner. A vital aspect of this bill is the 
comprehensive review and study of all data collection and reporting 
systems and practices relating to the collection of data on race or 
ethnicity. It is imperative in examining the effects of race and 
ethnicity on health care access and outcomes to collect information on 
subgroups within specific minority populations. When targeting 
prevention as well as treatment efforts, different methods and 
approaches may be needed to address the distinct needs of certain 
subpopulations. I can best describe this through example.
    In New Jersey, we have had a very successful HIV surveillance 
system in place since 1992. Prior to November 1991, only persons 
diagnosed with full-blown AIDS were reported to the State Health 
Department. As you know, an AIDS diagnosis and the concomitant damage 
to an individual's immune system may reflect an infection that occurred 
10 to 15 years earlier. AIDS is truly the end stage of what we refer to 
as HIV disease. Since we began collecting information on persons 
diagnosed with HIV infection, we have been able to obtain data on 
persons more recently infected with HIV. We have been looking at the 
``front end'' of the epidemic for over eight years. This has enabled 
us, in collaboration with the New Jersey HIV Prevention Community 
Planning Group, to better prioritize and target our prevention efforts 
throughout the State. We have been able to fund programs that may not 
have received prevention funds without the kind of data analysis 
conducted on HIV disease. We have found that among teens and young 
adults, aged 1324, more than one-half of the persons living with HIV 
disease are females--the only age group where females outnumber males. 
Additionally, 84% of this population are Hispanic or African American. 
If we were just looking at AIDS case data, we would not be aware of 
this fact, and would only see that 61% of all people ever diagnosed 
with AIDS in that age group were males. The HIV information has shown 
us that teenage girls and young women, especially those who are African 
American or Hispanic, are being infected and living with HIV in larger 
numbers than males. This is a significant change from the first decade 
of the epidemic, and is critical information for targeting our 
prevention efforts to young people.
    HIV surveillance has also given us the opportunity to determine the 
implementation and effectiveness of public health service 
recommendations for preventing perinatal HIV transmission, 
opportunistic infections, and AIDS defining illnesses. The HIV disease 
data can also be used to assess potential short-term and long-term 
adverse outcomes related to perinatal exposure to antiretroviral 
agents. These effects include birth defects, toxic reactions, and tumor 
development. When we know a great deal of information about people 
living with HIV infection, we can allocate prevention, counseling, 
treatment and other resources where the need is greatest. This 
information has also enabled us to determine that the decline in deaths 
among those with HIV/AIDS has not been uniform across all racial and 
ethnic groups. For example, there has been a 73% decline in deaths 
among AIDS patients in New Jersey between 1995 and 1999. However, the 
decline among whites was 83%, among Hispanics was 72%, and among 
African Americans was 68%.
    Even with this HIV/AIDS surveillance system, which is a model 
program nationally, our efforts would be greatly enhanced if we could 
include more information on minority subgroups. When an epidemic 
affects minorities as disproportionately as the HIV epidemic has done, 
it is too easy to simply say we need to have certain programs for 
Hispanics and certain programs for African Americans, and leave it at 
that level. If we want to make a significant impact, we need to target 
subgroups that may differ on critical characteristics or cultural 
norms. If we could look at more specific subpopulation data, we would 
be better able to determine and evaluate prevention efforts within 
specific communities. We would also have more information regarding 
treatment/support system needs within subgroups. Using methods and 
approaches that are appropriate to different subgroup populations will 
recognize the cultural differences that exist in the larger community.
    Because of the data systems in place in most hospitals and provider 
offices, we are limited to the general category of Hispanic if we want 
to look at data specifically for Latinos. Institutionalized data 
collection systems need to systematically collect information on 
minority subpopulations. Federal standards for the uniform collection 
of race and ethnic information must lead the way for the reporting of 
this data. Currently, we can only obtain this level of detail by 
directly interviewing patients or clients. Since it would be impossible 
for us to conduct interviews with all persons reported with HIV 
infection, we are limited in our ability to obtain this data except for 
certain special studies.
    I would like to reiterate our support for this legislation and the 
establishment of a National Center for Research on Minority Health and 
Health Disparities. I also urge as a priority the examination of all 
collection and reporting systems relating to data on race and 
ethnicity. Our efforts, as we enter the third decade of our battle 
against HIV disease, would be greatly enhanced with more thorough 
information on minority subpopulations.
                                 ______
                                 
   Prepared Statement of Thomas Liberti, Chief, Bureau of HIV/AIDS, 
                      Florida Department of Health
    My name is Thomas Liberti. I am Chief of the Bureau of HIV/AIDS, 
Florida Department of Health. I would like to thank the Chairman and 
the members of the Subcommittee on Health and Environment for inviting 
me to submit written testimony on the impact of HIV/AIDS on the health 
status of racial and ethnicminorities in Florida and Florida's response 
to this challenge.
    Florida has 5.5% of the U.S. population, but 10.2% of the 724,656 
cumulative AIDS cases reported in the U.S. through 1999. Florida's 
population of more than 15 million people is racially and ethnically 
diverse: 73% are white, 13% are black, 12% are Hispanic, 1% are Asian/
Pacific Islander and less than 1% are American Indian. Minority 
populations in Florida, particularly blacks, have been 
disproportionately affected by HIV/AIDS, and the numbers of HIV/AIDS 
cases in their ranks have been exacerbated by special issues and 
barriers associated with HIV prevention, early intervention and patient 
care. With regard to HIV/AIDS, the racial and ethnic disparities are 
quite alarming.
    In Florida, blacks have historically had relatively poor access to 
quality health care. They tend to have problems associated with 
poverty, poor schools, inadequate social services, limited housing, few 
job opportunities and lack of insurance that impede HIV/AIDS prevention 
initiatives and access to HIV/AIDS health care. These issues are 
further complicated by patterns of substance abuse and sexually 
transmitted diseases in the black community. In addition, many blacks 
have a basic lack of trust in the health care system. The stigma 
associated with HIV/AIDS continues to affect the black community, and 
blacks often seek help only when they are acutely ill. Prevention and 
treatment programs in the black community must be built around sound, 
culturally appropriate, working relationships that establish and foster 
trust. The most effective programs for blacks will be those that are 
driven by members of the black community. Such programs must address 
critical issues of late access to HIV diagnostic and treatment 
services, which are consistently reflected in HIV/AIDS trends:

 Compared with the U.S., Florida's AIDS cases are more likely 
        to be black (46% versus 37% of total cases), female (21% versus 
        16%) and heterosexual (16% versus 10%).
 While blacks comprise 13% of Florida's population, they 
        account for 46% of the 75,694 AIDS cases and 60% of the 14,765 
        HIV cases reported in the state through 1999. (HIV infection 
        reporting was implemented in July 1997.)
 In 1999, blacks accounted for 47% of AIDS cases in men and 73% 
        of those in women.
 In 1999, the AIDS incidence rate per 100,000 among blacks was 
        238.3, almost 12 times higher than that for whites (20.4).
 In 1999, blacks accounted for 51% of HIV cases in men and 75% 
        of those in women.
 It is estimated that more than 35,000 blacks in Florida are 
        currently living with HIV infection.
 An estimated 1 in 50 blacks are HIV-infected, compared to 1 in 
        127 Hispanics and 1 in 286 whites.
 Through 1999, among blacks with a reported risk factor for 
        AIDS, 22% were men who have sex with men, 33% were injection 
        drug users, 5% were both men who have sex with men and 
        injection drug users, and 38% were those who acquired HIV 
        through heterosexual contact.
 Among childbearing women in Florida, blacks are at least 10 
        times more likely than whites to be HIV-infected.
 81% of Florida's 1,374 pediatric AIDS cases and 81% of 
        Florida's 142 pediatric HIV cases are black.
 Black women who are heterosexually infected with HIV are the 
        fastest growing group of infected persons.
 HIV/AIDS is the leading cause of death for both male and 
        female blacks aged 25 to 44 years.
 In 1999, blacks accounted for 58% of all HIV/AIDS deaths.
 The HIV/AIDS death rate per 100,000 population in 1994 was 5.5 
        times higher for blacks than for whites; in 1999, the rate 
        increased to 10.9 times higher for blacks than for whites.
    In Florida, Hispanic communities are extremely diverse.
    Members of these communities include any persons whose ancestry can 
be traced to Cuba, Puerto Rico, Mexico, Central or South America, or 
other Spanish cultures or countries of origin regardless of race. 
During the past 20 years, the Hispanic population has emerged as one of 
the fastest growing segments of Florida's population. Many Hispanics 
are faced with problems of unemployment, inadequate housing, poor 
access to health care, and language barriers.

 Hispanics account for 12% of Florida's population, but 15% of 
        the cumulative AIDS cases and 14% of the cumulative HIV cases 
        reported through 1999.
 In 1999, the AIDS incidence rate per 100,000 population among 
        Hispanics was 63.8, three times higher than that for 
        whites(20.4).
 It is estimated that more than 12,000 Hispanics in Florida are 
        currently living with HIV infection.
 Through 1999, among Hispanics with a reported risk factor for 
        AIDS, 61% were men who have sex with men, 18% were injection 
        drug users, 5% were both men who have sex with men and 
        injection drug users, and 14% were those who acquired HIV 
        through heterosexual contact.
 Male-to-male sexual contact is the predominant mode of HIV 
        transmission among Cubans, while injection drug use 
        predominates among Puerto Ricans.
 HIV/AIDS is the third leading cause of death among Hispanics 
        aged 25-44 years.
 In 1999, Hispanics accounted for 12% of all HIV/AIDS deaths.
 From 1994 through 1999, the HIV/AIDS death rate per 100,000 
        population has consistently been more than two times higher 
        than that for whites.
    Asian/Pacific Islanders and American Indians comprise 1.4% of 
Florida's population. Members of these communities differ widely in 
language used, cultures and times of immigration to Florida. Combined, 
they account for less than 1% of the cumulative AIDS cases reported 
through 1999. In 1999, their AIDS incidence rate per 100,000 population 
was 26.0; however, this rate is based on a total of only 17 cases 
reported in 1999. These low numbers may reflect under-counting and data 
collection issues.
    (Supplemental, supporting data concerning HIV/AIDS and minorities 
in Florida are respectfully attached to this testimony for the 
Committee's consideration.)
    Eliminating disparities in health outcomes is a major priority for 
the Florida Department of Health and Governor Jeb Bush. Under the 
leadership of Department of Health Secretary Robert G. Brooks, M.D., 
the department has identified the following six major areas of health 
disparities in culturally and ethnically diverse communities in the 
state: maternal/ infant mortality, vaccinations, HIV/AIDS, diabetes, 
chronic cardiovascular diseases, and cancer. In response to this 
crisis, the 2000 Legislature passed and funded an act entitled, 
``Reducing Racial and Ethnic Health Disparities: Closing the Gap,'' to 
improve racial and ethnic health outcomes.
    In addition, the Florida Department of Health has made numerous 
efforts to address the racial and ethnic disparities in HIV/AIDS health 
outcomes through community-based, culturally sensitive approaches. 
These efforts include working with minority, community-based 
organizations to implement culturally sensitive HIV prevention and 
treatment programs; facilitating efforts of black clergy and their 
congregations to mobilize risk-reduction education and supportive 
attitudes from within the community; and continuing to work with 
legislative and other community leaders to assure enhanced resources in 
areas of greatest unmet need.
    In September 1999, Secretary Brooks appointed 23 members to 
Florida's Minority HIV/AIDS Task Force. The task force is composed of 
representatives from various groups, including persons infected with 
HIV or AIDS, minority community-based support organizations, minority 
treatment providers, the religious community, and the Department of 
Health. The creation of the task force was mandated by HB 2125, which 
was passed during the 1999 Legislative Session, largely due to the 
efforts of the Legislative Black Caucus.
    The Department of Health strongly encouraged the creation of the 
task force as a means of addressing the disproportionate impact of HIV/
AIDS on minorities. The task force has been compiling testimony at 
public meetings throughout the state to submit a report of its findings 
and recommendations to the Governor, the President of the Senate, and 
the Speaker of the House of Representatives by February 1, 2001. This 
report will include:

 specific strategies for reducing the risk of HIV and AIDS in 
        the state's minority communities;
 a plan for establishing mentor programs and exchanging 
        information and ideas among minority community-based 
        organizations that provide HIV and AIDS prevention services;
 the needs of prevention and treatment programs within 
        communities and the resources that are available within 
        minority communities;
 specific strategies for ensuring that minority persons who are 
        at risk of HIV and AIDS infection seek testing;
 specific strategies for ensuring that persons who test 
        positive for HIV or AIDS are provided with access to treatment 
        and secondary prevention services;
 specific strategies to help reduce or eliminate high-risk 
        behaviors in persons who test negative but continue to practice 
        high-risk behaviors; and
 a plan to evaluate the implementation of the recommendations 
        of the task force.
    In November 1999, the Department of Health's Office of Equal 
Opportunity and Minority Health hosted state and national leaders from 
government, health care and the minority community at the Inaugural 
Interagency Minority Health Symposium in Orlando. The symposium, 
entitled ``Joining Hands, Gathering Solutions,'' focused on the 
collaborative roles state agencies can play in eliminating HIV/AIDS 
disparities and other health disparities among the state's minority 
communities. During the symposium, presenters provided compelling data 
and information concerning these issues and discussed access and 
operational challenges and solutions. Panels composed of state agency 
representatives convened to discuss existing and natural organizational 
partnerships and to explore ways to maximize the influence of those 
partnerships in advancing the health of all Floridians.
    In January 2000, the Department of Health, Bureau of HIV/AIDS 
conducted the Florida Black Leadership Conference on HIV/AIDS in Fort 
Lauderdale. This two-day conference brought together community leaders; 
representatives of faith communities and community based organizations; 
business leaders; people living with HIV or AIDS; political leaders; 
and other partners in the black community. The goal of the conference 
was to develop innovative ways to reinforce the black community's 
primary and secondary HIV prevention efforts through educational 
plenary sessions and interactive workshops. The diversity of the 
participants and unique structure of the conference provided 
opportunities for the Department of Health to compile recommendations 
to help guide future HIV/AIDS programs and policies.
    Other initiatives include the following:

 Establishing the Florida HIV/AIDS Minority Network, a venue 
        for minority community-based organizations and faith-based 
        organizations throughout the state to share information, ideas, 
        provide peer mentoring and receive expert technical assistance 
        on infrastructure development and capacity building.
 Conducting ``Church as a Change Agent Workshops,'' one-day 
        workshops held with pastors and other leaders in the faith 
        communities, inviting the black church to partner with the 
        Florida Department of Health on HIV/AIDS prevention 
        initiatives.
 Creating regional minority HIV/AIDS coordinator positions to 
        spearhead local minority initiatives and work cooperatively 
        with existing establishments to strengthen minority HIV 
        prevention and care organizations.
 Targeting HIV/AIDS funding to minority communities through 40 
        prevention contracts.
 Implementing the Targeted Outreach to Pregnant Women Act to 
        link at-risk women to services.
 Providing intensive outreach to bring more minorities into 
        programs such as the AIDS Drug Assistance Program, the AIDS 
        Insurance Continuation Program and Housing Opportunities for 
        Persons with AIDS.
 Ensuring that minority HIV/AIDS patients have expanded access 
        to outpatient medical care, pharmaceuticals, dental services, 
        and case management.
 Partnering with alcohol, drug abuse and mental health programs 
        to develop and implement HIV/AIDS prevention projects 
        statewide.
 Collaborating with the Department of Corrections to conduct 
        peer education projects at three large correctional facilities.
    The Florida Department of Health recognizes and appreciates the 
efforts of the Subcommittee on Health and Environment, the 
Congressional Black Caucus and the President's race initiative to 
address the root causes of racial/ethnic disparities concerning HIV/
AIDS. We are encouraged that our nation's leaders have entered into 
such meaningful partnerships with the states, through which culturally 
sensitive HIV/AIDS prevention and patient care programs can be further 
developed and implemented to close the racial/ethnic gap.
    I would like to thank you, once again, for the opportunity to 
provide testimony on the impact of HIV/AIDS on minorities in Florida, 
and our response to the challenges of this devastating epidemic.
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                                                      June 16, 2000
Michael Bilirakis, Chairman
Subcommittee on Health and Environment
U.S. House of Representatives
Committee on Commerce
Room 2125, Rayburn House Office Building
Washington, DC 20515-6115
    Dear Mr. Bilirakis: As requested in your letter of June 2, 2000, I 
am providing supplemental information to my testimony of May 11. I have 
restated each question, and followed it with my response.
    Question: The Commonwealth of Virginia reports both cases of HIV 
and AIDS. Does reporting the full scope of HIV infection and not just 
the end stage, AIDS, provide better opportunities to address prevention 
and care and any disparities that may exist?
    Response: HIV reporting provides data for identifying populations 
in which HIV has been newly diagnosed, whereas AIDS reporting usually 
identifies individuals infected years ago. In 1999 in Virginia, women 
comprised 31% of reported HIV cases, but just 23% of reported AIDS 
cases. While the 1999 racial breakdown for reported African-American 
HIV cases (69%) compared to AIDS cases (66%) does not now show a large 
difference, the trend to increasing proportions in minority populations 
was identified several years earlier because Virginia had HIV 
reporting.
    Age differences are also seen between AIDS and HIV cases. Of 52,690 
HIV infections diagnosed from January 1994 through June 1997 in 25 
states that conducted name-based surveillance, 14% of the cases 
occurred in persons aged 13-24 years. In comparison, only 3% of AIDS 
cases occurred within this age group in the same time period. Thus, 
AIDS case surveillance alone does not accurately reflect the extent of 
the HIV epidemic among adolescents and young adults.
    Required HIV reporting therefore catches changing demographics of 
cases far earlier than AIDS reporting alone can do. This allows earlier 
determination of populations at risk and behavioral risk factors, and 
earlier targeted resource allocation to address recognized changes.
    Since 1996, HIV treatment utilizing a combination of anti-
retroviral medications has prevented many individuals with HIV 
infection from progressing to AIDS. AIDS reporting alone would never 
capture these individuals. Therefore, states that have documented cases 
of both AIDS and HIV infection provide a more reliable and useful 
estimate of the resources needed for patient care and services than 
AIDS prevalence alone.
    Question: Surgeon General Satcher testified that he supports the 
CDC recommendations made last December to move states to HIV name 
reporting, while the Commonwealth of Virginia has conducted HIV name 
reporting and partner notification for over a decade. Has the minority 
community (or any community) voiced objections to these practices? Has 
there ever been a breach of patient confidentiality that has resulted 
from either of these practices?
    Response: There has never been a breach of confidentiality, and I 
am confident in the ability of staff of the Division of HIV/STD to 
handle information professionally. Periodically, the minority community 
has raised questions in public meetings, forums, and presentations 
addressing minority health and AIDS issues. Concerns have typically 
focused upon misconceptions regarding both the name-based reporting and 
partner notification processes. These questions have been addressed by 
providing information about the Division of HIV/STD's policies 
regarding confidentiality. All employees are required to review and 
sign confidentiality statements outlining the procedures to be followed 
when processing all HIV/STD epidemiological documents.
    Presentations describing the Virginia Department of Health's (VDH) 
commitment to confidential partner notification, along with an 
explanation of methods used to notify individuals, have been helpful in 
alleviating the public's concerns and clearing up misconceptions. In 
addition, VDH speakers review HIV-related legislation that outlines 
confidentiality requirements and penalties for non-adherence, in order 
to stress the legal protections provided by existing policies and 
procedures. The Assistant Attorney General assigned to VDH provides 
legal guidance and interpretation of policy to localities, further 
enhancing a consistent approach to these issues.
    Question: As you know, women and minorities are represented in 
higher proportions in HIV case reports than in AIDS case reports. Do 
you believe that changing Ryan White CARE Act funding formulas to take 
into account HIV cases, rather than just AIDS cases, would be an 
effective way to better target funding and address some of the health 
disparities that exist for minorities?
    Response: HIV reports present a more accurate picture of the 
current epidemic than do AIDS reports alone. By monitoring HIV as well 
as AIDS, Virginia has been able to track the increased percentages of 
cases that have occurred among minorities and women. If all states 
reported HIV, then HIV cases could be included in the formula for 
determining Ryan White funding, and the funds could be more accurately 
targeted to current needs, earlier intervention and hopefully decreased 
transmission. More accurate targeting and program planning could assist 
with addressing some of the health disparities that exist for 
minorities.
    Question: Is partner notification a worthwhile prevention tool for 
HIV? Is it an effective intervention to identifying at-risk individuals 
and getting them into prevention and care programs?
    Response: Partner notification is a very worthwhile tool for HIV 
and comparable to how pubic health treats other communicable sexually 
transmitted diseases. HIV counseling and testing data for Virginia STD 
clinics for 1986-1998 indicate that 3,658 individuals received HIV 
testing as a result of being referred as partners of someone with HIV. 
Of those, 338 (9.2%) tested positive. Cumulatively, about 1% of STD 
patients has tested positive for HIV; therefore, partner notification 
clearly assists in identifying higher risk populations and therefore 
increases the testing and educating of individuals at increased risk. 
The 338 partners testing positive were also assisted in accessing 
medical and support care, including the AIDS Drug Assistance Program 
(ADAP) and other Ryan White services.
    Question: Is there any evidence to substantiate claims that name-
based HIV case reporting discourages individuals from seeking HIV 
testing or care?
    Response: Contrary to the claim that name-based case reporting 
discourages individuals from seeking HIV testing and care, several 
studies have shown that name-based reporting does not hinder 
individuals from seeking testing. Virginia's confidential testing 
numbers have remained relatively level over the last few years, while 
anonymous testing has decreased from 10,393 (12% of total tests) in 
1992 to 5,518 (7% of total tests) in 1998.
    Question: Intravenous drug use is a factor for the spread of HIV. 
Would you say that it should be a priority to develop programs for the 
treatment of heroin addicts by a new class of heroin-blocking drugs?
    Response: Evidence indicates that the new heroin-blocking drugs 
offer effective alternatives to the current medications available for 
treating heroin addiction. The Department of Mental Health, Mental 
Retardation, and Substance Abuse Services (DMHMRSAS) is the agency in 
Virginia that has responsibility for substance abuse treatment, and has 
indicated that developing programs for heroin addicts with the new 
heroin-blocking drugs is a priority. DMHMRSAS is currently developing a 
research protocol to address this issue. I look forward to hearing 
follow up reports from DMHRSAS on their efforts and results.
    Question: The Administration stated in their testimony that 
``Vietnamese women suffer from cervical cancer at nearly five times the 
rate of white women.'' Why is that? Is it a cultural factor linked to 
the willingness to get screened? Are you doing anything to reach out to 
this community?Response: Those who work with the Vietnamese community 
believe that the high incidence of cervical cancer among Vietnamese 
women is because many have no insurance and are impoverished. They 
generally do not have an orientation to preventive care. They will seek 
help for their children, but not for themselves. Since they have not 
received screening, they are diagnosed at a later stage of the disease. 
Even when they are symptomatic, they are reluctant to seek help for 
themselves. For illegal aliens, immigration issues may also present a 
barrier to seeking care.
    The VDH Breast and Cervical Cancer Early Detection Program (BCCEDP) 
is working with the National Asian Women's Health Organization (NAWHO) 
to sponsor a pilot training program later in the year entitled 
``Communicating Across Boundaries.'' The purpose of this training is to 
improve the skills and capacity of local and state breast and cervical 
cancer health care programs and providers in the provision of 
culturally competent screening services to Asian American women.
    The Centers for Disease Control and Prevention, through the BCCEDP, 
provides funding for screening for breast and cervical cancer 
throughout the state of Virginia for women 50-64 years of age who are 
uninsured or underinsured, and at 200% of poverty level or less. 
Recipients must be legal residents of the United States. The Vietnamese 
Resettlement Association in Northern Virginia is an administrative 
provider site for the BCCEDP. Asian women represent one of the minority 
populations targeted by the BCCEDP for screening services for breast 
and cervical cancer.
    Please let me know if you need any additional information.
            Sincerely,
                                  E. Anne Peterson, MD, MPH
                                          State Health Commissioner
                                 ______
                                 
                                                      June 13, 2000
The Honorable Michael Bilirakis
Chairman
Subcommittee on Health and Environment
U.S. House of Representatives
Committee on Commerce
Room 2125, Rayburn House Office Building
Washington, D.C. 20515-6115
    Dear Congressman Bilirakis: Thank you for your letter of June 2 
regarding my testimony before the Subcommittee on Health and 
Environment on May 11, 2000 on H.R. 3250, the Health Care Fairness Act 
of 1999. I have addressed the members questions below.
    Our study carefully assessed the influence of six patient 
characteristics or study variables on physician decision making: race, 
sex, age, type of chest pain, medical history and exercise stress test 
results. These were the only variables that differed across the 144 
cases we presented to the participating physicians (our study 
subjects). All patients in the study had the same address, the same job 
description (active or retired), and the same type of insurance 
(Private or combined private/Medicare). Thus, we did not vary 
geographic characteristics of the patients in our study.
    We recruited our physician sample at two national meetings of 
physician specialty societies. Thus, participating physicians were 
drawn from across the country. However, we did not collect information 
on physician practice location as one of our physician demographic 
variables.
    In comparison to the Wennberg work cited in the letter, we found 
variation in physician decision making based on patient characteristics 
in identical settings. The study was not designed to test whether 
geographical factors have an additional interaction with patient 
characteristics in physician decision making.
        Sincerely,
                      Kevin A. Schulman, M.D., Director    
                      Center for Clinical and Genetic Economics    
   Duke Clinical Research Institute, Duke University Medical Center
                                 ______

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