[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]



 
                 DEPARTMENTS OF LABOR, HEALTH AND HUMAN
               SERVICES, EDUCATION, AND RELATED AGENCIES
                        APPROPRIATIONS FOR 2002

_______________________________________________________________________

                                HEARINGS

                                BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS
                              FIRST SESSION
                                ________
  SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
                    EDUCATION, AND RELATED AGENCIES
                      RALPH REGULA, Ohio, Chairman
 C. W. BILL YOUNG, Florida           DAVID R. OBEY, Wisconsin
 ERNEST J. ISTOOK, Jr., Oklahoma     STENY H. HOYER, Maryland
 DAN MILLER, Florida                 NANCY PELOSI, California
 ROGER F. WICKER, Mississippi        NITA M. LOWEY, New York
 ANNE M. NORTHUP, Kentucky           ROSA L. DeLAURO, Connecticut
 RANDY ``DUKE'' CUNNINGHAM,          JESSE L. JACKSON, Jr., Illinois
California                           PATRICK J. KENNEDY, Rhode Island
 KAY GRANGER, Texas
 JOHN E. PETERSON, Pennsylvania
 DON SHERWOOD, Pennsylvania         
                   
 NOTE: Under Committee Rules, Mr. Young, as Chairman of the Full 
Committee, and Mr. Obey, as Ranking Minority Member of the Full 
Committee, are authorized to sit as Members of all Subcommittees.
       Craig Higgins, Carol Murphy, Susan Ross Firth, Meg Snyder,
             and Francine Mack-Salvador, Subcommittee Staff
                                ________
                                 PART 3

                 DEPARTMENT OF HEALTH AND HUMAN SERVICES

                          PUBLIC HEALTH SERVICE

              (Excluding the National Institutes of Health)
                                                                   Page
 Centers for Disease Control......................................    1
 Substance Abuse and Mental Health Services Administration........  535
 Agency for Health Care Research and Quality......................  839
 Health Resources and Services Administration..................... 1175
                                ________
         Printed for the use of the Committee on Appropriations
                                ________
                     U.S. GOVERNMENT PRINTING OFFICE
 74-703                     WASHINGTON : 2001





                      COMMITTEE ON APPROPRIATIONS

                   C. W. BILL YOUNG, Florida, Chairman

 RALPH REGULA, Ohio                  DAVID R. OBEY, Wisconsin
 JERRY LEWIS, California             JOHN P. MURTHA, Pennsylvania
 HAROLD ROGERS, Kentucky             NORMAN D. DICKS, Washington
 JOE SKEEN, New Mexico               MARTIN OLAV SABO, Minnesota
 FRANK R. WOLF, Virginia             STENY H. HOYER, Maryland
 TOM DeLAY, Texas                    ALAN B. MOLLOHAN, West Virginia
 JIM KOLBE, Arizona                  MARCY KAPTUR, Ohio
 SONNY CALLAHAN, Alabama             NANCY PELOSI, California
 JAMES T. WALSH, New York            PETER J. VISCLOSKY, Indiana
 CHARLES H. TAYLOR, North Carolina   NITA M. LOWEY, New York
 DAVID L. HOBSON, Ohio               JOSE E. SERRANO, New York
 ERNEST J. ISTOOK, Jr., Oklahoma     ROSA L. DeLAURO, Connecticut
 HENRY BONILLA, Texas                JAMES P. MORAN, Virginia
 JOE KNOLLENBERG, Michigan           JOHN W. OLVER, Massachusetts
 DAN MILLER, Florida                 ED PASTOR, Arizona
 JACK KINGSTON, Georgia              CARRIE P. MEEK, Florida
 RODNEY P. FRELINGHUYSEN, New Jersey DAVID E. PRICE, North Carolina
 ROGER F. WICKER, Mississippi        CHET EDWARDS, Texas
 GEORGE R. NETHERCUTT, Jr.,          ROBERT E. ``BUD'' CRAMER, Jr., 
Washington                           Alabama
 RANDY ``DUKE'' CUNNINGHAM,          PATRICK J. KENNEDY, Rhode Island
California                           JAMES E. CLYBURN, South Carolina
 TODD TIAHRT, Kansas                 MAURICE D. HINCHEY, New York
 ZACH WAMP, Tennessee                LUCILLE ROYBAL-ALLARD, California
 TOM LATHAM, Iowa                    SAM FARR, California
 ANNE M. NORTHUP, Kentucky           JESSE L. JACKSON, Jr., Illinois
 ROBERT B. ADERHOLT, Alabama         CAROLYN C. KILPATRICK, Michigan
 JO ANN EMERSON, Missouri            ALLEN BOYD, Florida
 JOHN E. SUNUNU, New Hampshire       CHAKA FATTAH, Pennsylvania
 KAY GRANGER, Texas                  STEVEN R. ROTHMAN, New Jersey    
 JOHN E. PETERSON, Pennsylvania
 JOHN T. DOOLITTLE, California
 RAY LaHOOD, Illinois
 JOHN E. SWEENEY, New York
 DAVID VITTER, Louisiana
 DON SHERWOOD, Pennsylvania
   
 VIRGIL H. GOODE, Jr., Virginia     
   
                 James W. Dyer, Clerk and Staff Director

                                  (ii)

 
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2002

                              ----------                              

                                             Thursday, May 3, 2001.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

                               WITNESSES

JEFFREY P. KOPLAN, M.D., DIRECTOR, CDC
DENNIS P. WILLIAMS, ACTING ASSISTANT SECRETARY FOR MANAGEMENT AND 
    BUDGET, DEPARTMENT OF HEALTH AND HUMAN SERVICES
WILLIAM GIMSON, DIRECTOR, FINANCIAL MANAGEMENT OFFICE, CENTERS FOR 
    DISEASE CONTROL AND PREVENTION
    Mr. Regula. The subcommittee will come to order.
    We have got a busy day and I am afraid we may get 
interrupted with a lot of votes today. So we will try to move 
ahead as quickly as possible.
    We are pleased to welcome you, Dr. Koplan, Mr. Gimson, Mr. 
Williams, and look forward to your testimony. I appreciated our 
visit down there. I hope we can get back sometime for the 
Members that missed the first trip. The Secretary was here 
yesterday, Secretary Thompson, and he mentioned his visit, too. 
I think some of the things that are happening around the world 
puts your agency in the spotlight. I always tell them back home 
you are in the front line trenches protecting their health.
    So with that, Dr. Koplan, we look forward to your 
testimony. Your full statement will be included in the record 
and we will appreciate your summarization of it.

                           Opening Statement

    Dr. Koplan. Thank you, Mr. Chairman. I am pleased to appear 
before you on behalf of the Centers for Disease Control and 
Prevention, CDC, an agency that protects the health and safety 
of the American people. Thank you very much for the recent trip 
you and several members of your subcommittee made to Atlanta. 
We enjoyed the visit and thought it was very helpful for us as 
well to engage in discussion with you.


                        PUBLIC HEALTH CHALLENGES


    As you indicated, CDC addresses the public health 
challenges of today and the future. We do it in three ways: 
protecting the health of the American people and taking action 
to protect their health; providing credible information to 
people to help them in making health decisions; and working 
with many partners throughout the health community and 
communities beyond the health community.


                          PREVENTION RESEARCH


    We do plenty of research at CDC. Indeed, you cannot pick up 
a medical journal any week without finding our authors on some 
of the lead articles, in the New England Journal, the Journal 
of the American Medical Association, et. cetera. But our unique 
role is in translating research into action. We see ourselves 
as a service agency and as an action oriented service agency.
    And the public health problems we face today present a wide 
array of challenges. Prevention research is able to identify 
ways in which we can dramatically change the health of 
Americans by improving their health through putting into 
practice many of the research discoveries we have made. An 
example would be immunization against infectious diseases, such 
as polio vaccine. Polio vaccine was discovered by Sabin and 
Salk, and if it had set on the shelf it would have been a great 
achievement to have discovered the vaccine, but it is putting 
into the arms and mouths of children that has made a difference 
in the world, and is making a difference today as we eradicate 
polio from the world.
    It is similar with many others of our prevention public 
health activities. And I will give you just a few quick 
examples.


                              SMOKE ALARMS


    We got involved in funded research that developed a 10-year 
lithium battery-powered smoke alarm, and then made sure that 
there were programs in place to see that these smoke alarms got 
installed and used. And so we did some pilot projects with 
these, and during an 18-month period we were able to 
demonstrate that we could save 100 lives from fire by the use 
of these community-involved smoke alarm installation programs, 
which we did with partners in fire departments in the 14 States 
in which we did these programs. They involved canvassing over 
100,000 homes, installing over 80,000 smoke alarms. And just as 
an example, one such smoke alarm was placed in a mobile home in 
Mississippi. A week later, two small boys, age 4 and 5 years 
old, were playing with matches in a bedroom and set the carpet 
on fire. They unsuccessfully tried to cover the fire with a 
rug. The smoke alarm activated, alerting the mother who was 
elsewhere, and she credits that alarm with saving her and the 
family.


                                DIABETES


    Another example, I think a telling one given the cost to 
our health care system, is the prevalence of diabetes in 
American adults. Between the short eight years of 1990 and 
1998, diabetes among adults increased 33 percent nationally. In 
the chart you see before you, the darkening of the colors on 
that chart indicates a higher rate of diabetes in this country, 
and from a very short time period in 1990, moving up to 1998, 
you would see a continuing darkening of the States in America 
representing an increased prevalence of diabetes in this 
country. We have seen this before for obesity. Here is the 
outcome of some of our behavioral patterns in terms of an 
actual disease outcome, and that disease pattern and the 
disease you see will make itself manifest when you speak to the 
folks from the Health Care Financing Administration, any health 
insurer, any health practitioner in the country. That is the 
toll on the American population.
    Results from several research studies, however, show that 
improving nutrition, increasing physical activity, controlling 
blood glucose levels, and improving access to proper preventive 
care can prevent or delay the progressionof complications from 
diabetes. Diabetes is the number one cause of blindness in this 
country, the number one cause of lower extremity amputations, and 
kidney failure.
    The CDC-funded New York Diabetes Control Program 
collaborates with 14 regional community coalitions and 3 
university-based Centers of Excellence to improve diabetes 
care. In two years the interventions this group have done have 
reduced hospitalization rates by 35 percent--that is a 35 
percent reduction in cost, a 35 percent reduction in beds used, 
and a 35 percent reduction in the toll that diabetes takes on 
people. Lower extremity amputations, amputations of the legs, 
have decreased by 40 percent in this trial period. If we had a 
pill that did that or a vaccine that did that, you would want 
to buy it fast and put it into play across the country. And we 
have that pill and vaccine in this diabetes prevention program.

                           CHANGING BEHAVIOR

    There are cynics around and people unaware of the triumphs 
of public health who regularly say you cannot change human 
behavior. That is plain incorrect. In our own lifetime we find 
ourselves using seatbelts that we did not use when we took our 
drivers education classes, if we took them, when we were 16. We 
go to parties now where no one is smoking, where in our 
parents' homes people smoked all the time. And if you look at 
the contents in our refrigerators, they are different than when 
we grew up in our parents' homes.

                              TOBACCO USE

    Similarly, tobacco use has changed in this country 
considerably. Yet today, nearly 3,000 young people across the 
country will begin smoking regularly each day. To reverse this 
trend, some States, with support from us and others, have 
implemented very effective tobacco prevention programs. Florida 
is a good example. Florida's program, based on CDC's 
guidelines, results in 29,000 fewer youth smokers in a year. 
Other States have done similar programs. California began a 
comprehensive tobacco prevention program in 1989, and over the 
past 10 years per capita consumption of cigarettes in 
California has declined by more than half. As a result, now we 
are reaping the health benefits of this. Again, it is not just 
the behavior. In California, now we see a reduction in rates of 
lung and bronchial cancer.

                                SYPHILIS

    Another triumph that we hope to make in the next couple of 
years involves a disease that really is a 17th century 
disease--syphilis. It should not exist in the United States in 
the year 2001. It is preventable and curable. We know how it is 
spread and we know how to stop it. But we are in a unique 
position now. It is at the lowest rate it has ever been. We 
have the fewest number of cases we have ever had, in the fewest 
number of counties in the United States.
    So a couple of years ago, we decided to say what if we can 
show if you deploy extra resources in a couple of places, can 
you make a bigger difference than if we do things as business 
as usual. So we took three counties, high rates of syphilis 
counties--Marion County, Indiana, Indianapolis; Davidson 
County, Tennessee; and Wake County, North Carolina--put some 
extra resources into those counties, and now two years later 
look to see has that made a difference. And what you see is 
almost twice the rate of decline in those counties where we 
have invested more than where we have not. Showing again that 
investment in public health makes a big difference and has a 
big pay-off in terms of outcomes, and in this case, progress 
towards syphilis eradication.

                    FUTURE PUBLIC HEALTH CHALLENGES

    There are lots of future public health challenges we have 
got to deal with. We have had a successful 55 year history, but 
more to come. Our national security is threatened by infectious 
disease threats. Our lifestyle is challenged by behavioral 
changes that affect many chronic diseases. And we need to 
strengthen our public health infrastructure so that every 
State, every county and city has the capability to deal 
effectively with public health challenges.
    The President's fiscal year 2002 budget allows us to 
address these public health challenges by increases in 
programmatic areas such as birth defects and disability; 
environmental health; epidemic services; health statistics; 
HIV/AIDS, STDs, and TB prevention; immunization; injury 
prevention; and other areas.
    Mr. Regula. Excuse me. How much time do you need to finish 
your statement? We have got a vote.
    Dr. Koplan. You tell me how long you want, and I will do it 
in that time.
    Mr. Regula. I was going to say if you could wrap up in a 
minute, we can go vote, and then I will go to the questions.
    Dr. Koplan. Absolutely. You visited us before. You know 
that while we are internationally recognized, our conditions 
and our workplace belie our global reputation. Laboratory 
facilities 30 to 60 years old. This is an ongoing problem in 
the workplace that is the site of our national capability for 
biomonitoring and toxicology today. The President's 2002 budget 
includes $150 million to improve key components of our physical 
plant.
    The details of our budget are in the written materials and 
we would refer you to those. I would just say in a rapid 
conclusion, one, as you indicated, when there is a problem in 
this country or around the world, we stand ready to be called 
and our staff will go out. We have our Epidemic Intelligence 
Service ``disease detectives'' ready to go out in a moment's 
notice. There has been news in recent days of their work, and 
here is an example from an ebola outbreak in Zaire.
    As you know, Benjamin Franklin was right about a lot of 
things--the need for democracy, the importance of science, and 
that ``an ounce of prevention is worth a pound of cure.'' We 
are here to help support that concept. Thank you.
    [The prepared statement of Dr. Koplan follows:]

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    
    Mr. Regula. Very well. We will recess for the vote. Mrs. 
Lowey will have the first questions when we come back.
    The subcommittee will come to order.
    Mrs. Lowey

                       CHRONIC DISEASE PREVENTION

    Mrs. Lowey. Well, thank you very much my gracious Chairman. 
It is a pleasure.
    Welcome, Dr. Koplan. It is always an honor and a privilege 
for us to have you come before this committee. As you know, 
many of us have been strong fans of the CDC for a very long 
time and feel that unless we are translating all the research, 
all the information in a way so that it really affects people's 
lives we are not doing our job. And that is really what CDC is 
all about.
    I was particularly delighted to hear your comments about 
prevention. When you look at the numbers on diabetes, and when 
you see the numbers, and I want to make sure again that you 
were talking about adult diabetes directly connected to obesity 
and behavior patterns, it is clear to me that we have a lot of 
work to do. We have been talking about this at several 
hearings. I have always been concerned about chronic disease 
prevention. And we know that regular exercise, good nutrition, 
and other behavioral changes can prevent the onset of many 
chronic diseases. How we help people make these changes in 
their lives and how we can do more of that is very important to 
me.
    If you can discuss with us how the cuts in the 
Administration's budget affect your ability to carry out 
prevention programs, I would be most appreciative. In the other 
hearings, we were talking about working closely with Secretary 
Thompson but that the budget may need fine tuning in some ways. 
I think in this area, in my judgement, it certainly needs some 
fine tuning. Can you discuss that, please.
    Dr. Koplan. As you indicated, chronic diseases are the 
major causes of death and disability in this country today and 
will continue to be. And whether that is heart disease and 
stroke, diabetes, or cancer, those are crucial areas. They are 
also areas that we have invested a considerable sum for 
research. In heart disease, the National Heart, Lung, and Blood 
Institute has conducted over the last 15 years major studies 
that have identified what the risk factors are for these 
conditions and that interventions can markedly reduce those 
rates. And we have made progress in that nationally. We have 
more to go. It is likely that in the current budget, however, 
we would have some curtailment of some of these programs State 
by State and some small reduction in the amounts given in our 
State-by-State programs.
    Mrs. Lowey. Given those graphs, and I know the Chairman's 
commitment, I hope this will be an area that we can fine tune 
to make sure we continue your very important work.

                            SAFE MOTHERHOOD

    Another area, Dr. Koplan, that I have been very much 
involved with and am a great supporter of is the Safe 
Motherhood Initiative at CDC. Last year, I worked with Chairman 
Porter and Ranking Member Obey to increase funding for this 
program. As you know, the number of women who die from 
complications of childbirth has been essentially flat for the 
last 20 years. In fact, the maternal mortality rate in the 
United States is higher than in the majority of industrial 
nations, which is simply unacceptable with the health care 
system we have. This problem is particularly severe, as you 
know, in the African-American community where mothers are as 
much as four times more likely to die in childbirth than 
whites. This is absolutely unacceptable.
    I would be appreciative if you could please tell us about 
the progress of the Safe Motherhood program. Could you also 
outline the effect that the cuts in this program included in 
the Administration's budget would have. This is another area, 
in my judgement, where we could have some fine tuning.
    Dr. Koplan. Safe Motherhood has been a terrific program and 
provides us with both important information and important 
opportunities to intervene. As you indicated, two to three 
women a day die during childbirth in this country still, and 
3,000 women a day have serious complications due to pregnancy.

          PREGNANCY RISK ASSESSMENT MONITORING SYSTEM (PRAMS)

    What the Safe Motherhood program does, in part, is have a 
monitoring and data collection system called the Pregnancy Risk 
Assessment Monitoring System, PRAMS, which brings us 
information on what are the risk factors for these women, why 
are these women having these complications and dying. It is 
conducted in 33 States. Each State is so different one to 
another that it really is important to collect different pieces 
of information on this. We then use that information and target 
the interventions that, hopefully, will eliminate, and if not 
eliminate, certainly reduce the rates of maternal mortality you 
have described and complications. We may be forced to curtail 
some of these State-based programs depending on our resources.
    Mrs. Lowey. Are there any arguments for curtailing it? Is 
there any history there that I am missing? It seems to me this 
is a bipartisan initiative, and we have made progress in that 
direction. I cannot possibly imagine it. Maybe it was an 
oversight.
    Dr. Koplan. I think we and our State partners and other 
people in public health in the maternal and child health 
community find this to be an extraordinarily useful system.
    Mrs. Lowey. Thank you very much, Mr. Chairman. You have 
been generous with the time. I look forward to working with you 
again.
    And I apologize, Dr. Koplan, but, unfortunately, there are 
conflicts this morning. But I appreciated the opportunity to 
listen to you, and I look forward to working with you.
    Dr. Koplan. It was great to have you here. Thank you.
    Mrs. Lowey. Thank you so much.
    Mr. Regula. Mrs. Granger?
    Ms. Granger. I would like to follow up on the last 
question. Can you tell me what those risk factors are?
    Dr. Koplan. One major risk factor is racial. The African-
American community has higher rates of maternal mortality and 
complications. Other risk factors are smoking during pregnancy, 
alcohol use during pregnancy, and other substance abuse during 
pregnancy.
    Ms. Granger. Age, would that be?
    Dr. Koplan. Age is probably a risk factor, a significant 
one.
    Ms. Granger. Youth?
    Dr. Koplan. Extreme youth, yes.

                        BUILDINGS AND FACILITIES

    Ms. Granger. And one other question. I pressed you 
yesterday when you came by to say hello to my office and you 
talked about the difficult working situation you had. I think 
you said you are spread out in 22 separate buildings and talked 
about the age of the buildings. Can you just share a little bit 
of that today.
    Dr. Koplan. We would love to have you come visit us. We 
will not bring you to all 22 different sites, though, when you 
come.
    Ms. Granger. Please not.
    Dr. Koplan. Over the course of time, we have spread out in 
Atlanta and we are in 22 different sites involving rental 
space. That has meant that it is inefficient, security issues 
are important, particularly for our scientists. Facilities have 
deteriorated such that it has the potential of interfering with 
their work. So we are very pleased to have both a 10 year plan 
that permits us to get this on track. We are into the second 
year of this and, with the support of this subcommittee, we are 
on the way towards trying to improve those facilities 
significantly.
    Ms. Granger. Good. Thank you very much.
    Mr. Regula. Just as an add-on to that. Mr. Young talked to 
me yesterday, apparently his initiative put some money in for 
buildings last year.
    Dr. Koplan. Mr. Young has been very supportive of this 
overall building program. Last year's mark of $175,000,000 I 
think Mr. Young played a significant role in that.
    Mr. Regula. Right. He asked me how that was moving along 
because he knew we had been down there.
    Dr. Koplan. Moving along well. We have had terrific support 
from the Department and from OMB in permitting us to move along 
in this process, both in the design, the engineering, getting 
the infrastructure laid for the buildings to go in. And so we 
are looking, indeed, at an initial groundbreaking of an 
important laboratory structure which will include important 
bioterrorism laboratory activities. That should be started this 
fall.
    Mr. Regula. Okay. I will report that to him.
    Mr. Jackson, Ms. Pelosi was here when we recessed, so I 
will move to her.
    Mr. Jackson. Not a problem, Mr. Chairman.
    Mr. Regula. Go ahead, Ms. Pelosi.
    Ms. Pelosi. Thank you, Mr. Chairman. I would be delighted 
to have my colleague go ahead of me. But I will listen to his 
questions after then.
    Dr. Koplan, welcome. Good luck to you in your work. It is 
probably as important work as we have in the health field, 
prevention, prevention, prevention. We hear it over and over 
again. In your opening remarks, you say some people say people 
cannot change their behavior. Well, that is the most despairing 
comment. Certainly, we hope that is not true. And I think that 
you have proven that it is not.

                        HIV/AIDS STRATEGIC PLAN

    When the CDC developed its strategic plan for HIV/AIDS last 
year, were any cost estimates developed during the planning 
process? It is my understanding that significant additional 
increases of approximately $100 million each year for three 
years would be necessary in order to meet the goal of reducing 
new HIV infections by half by 2005. President Bush's budget 
states that it will meet this important goal, yet the proposed 
increase for domestic HIV prevention is only $11 million, an 
amount that does not even keep pace with inflation. Could you 
comment briefly on that, Dr. Koplan?
    Dr. Koplan. We put a lot of effort in last year towards 
trying to create a new look at how we are approaching the HIV 
epidemic in this country. With that, we used our partners 
outside, in communities and a variety of different groups to 
come up with, as you indicated, a strategic plan for the next 
few years to kind of rechart where we are going, create a 
blueprint for what we do. We are trying to shift our own 
priorities internally and thus what we do out in communities 
around the Nation to decrease new infections from HIV and to 
better serve those already infected.
    The new blueprint, the strategic plan, involves a goal of 
decreasing new infections by 50 percent by the year 2005, to 
increase the people who know they have HIV from about 70 
percent to 95 percent, and to increase the number of people 
from 50 percent to 80 percent who have HIV and now have a link 
to both preventive services and care systems, and then to 
strengthen the whole system. We are pleased that the 
President's budget does have an increase this year of about $11 
million for domestic activities, $12 million for global work. 
There is a lot to be done.
    Ms. Pelosi. Dr. Koplan, I am sorry, maybe I am not hearing 
correctly. How can we possibly meet those goals with funding 
that barely meets inflation when we are talking about such an 
ambitious and necessary challenge?
    Dr. Koplan. We will work as hard as we can with the funds 
allotted to us.
    Ms. Pelosi. And you are pleased with the increase that is 
in the President's budget? Was that your professional judgment 
of what would be needed to the goal of the reductions you 
described?
    Dr. Koplan. My judgment is that we need to do these 
activities in the blueprint to make an impact on the outbreak.
    Ms. Pelosi. And your professional judgment in terms of the 
budget?
    Dr. Koplan. I am supportive of the President's budget. We 
are going to try to get the activities done that are in the 
blueprint.
    Ms. Pelosi. It sounds like the miracle of the loaves and 
fishes all over again. I appreciate your answer, your response 
anyway.

                       BREAST AND CERVICAL CANCER

    I strongly oppose the Administration's proposed cuts of 
breast and cervical cancer screening program. It is one I 
really do not understand. Early diagnosis increases the five 
year survival rate for breast cancer from 21 percent to 97 
percent. And current resources only allow 12 to 15 percent of 
women eligible for these services to participate. Would a cut 
in this program of $7.5 million mean that even fewer uninsured 
women would be served by this important program?
    Dr. Koplan. This has been an effective program, as you have 
indicated, and you have been a great supporter of it.
    Ms. Pelosi. Yes, indeed, as have Congresswoman Lowey and 
Congresswoman Delauro, and everyone else on the committee.
    Dr. Koplan. The whole committee. This has led to a marked 
increase in underserved women being screened, cancers being 
detected at an earlier stage, and women's lives being saved 
through this process.
    Ms. Pelosi. So why do we cut the program?
    Dr. Koplan. There are, obviously, competing budgetary 
demands on the Government and others make those decisions as to 
where the priorities are.
    Ms. Pelosi. Would it your professional judgement to have 
cut that program?
    Dr. Koplan. In this particular program, there will be a cut 
in funding per State and it will mean fewer screenings per 
State.

                      NATION-WIDE HEALTH TRACKING

    Ms. Pelosi. Thank you. One more question. The recent 
release of CDC's national exposure report was a significant 
step forward in the effort to understand the effects of 
humanexposures to toxic chemicals. Earlier this year, you recall, Mr. 
Chairman, our former colleague, Representative Lou Stokes testified on 
behalf of the Pew Commission and eloquently described the need to 
expand the CDC's efforts in this area by developing a coordinated 
nation-wide health tracking network among all States to identify and 
track chronic diseases and their related environmental factors. The 
need for such a tracking network was also emphasized during hearings we 
held last May in the subcommittee on children and environmental health.
    Report language was included in last year's bill requesting 
the CDC put together a plan for a chronic disease tracking 
system that looked at environmental factors. Is the plan ready? 
And will the CDC expand its efforts in this area?

                          ENVIRONMENTAL HEALTH

    Dr. Koplan. Two key elements there. The environmental 
report that you noted that has come out this year identified 27 
important chemicals, heavy metals, other toxins in the 
environment; I think it is extraordinarily important for the 
Nation's public health and we will reap those benefits year in 
and year out for years to come as we have that new information 
and the basis to compare it with. Indeed, in this coming year, 
our scientists are working on creating 25 more items that we 
can put in that report to get more information to other 
scientists and the American public about exposures. We are also 
trying to transfer that technology to States with grants to 
States so that we are not the only ones doing it but that that 
can take place in State health departments nearer to the 
sources of activity.
    On a separate item, the Pew Commission came out with a 
report with recommendations on how to better link environmental 
exposures and chronic diseases and a national monitoring system 
for that. We have both embraced that report and concur with its 
findings, and have already put in place at CDC three working 
groups that span every part of CDC are looking at how to 
implement those and get those going as, again, a blueprint for 
how to approach environmental health for the next 10-15 years.
    Ms. Pelosi. And I hope that takes within the environmental 
health project at the CDC. Thank you, Dr. Koplan. The Chairman 
is telling me my time is up. I was doing the Patrick Kennedy 
approach, Mr. Chairman. We learn from our newer members, you 
know. But your work is so important. It is very important to us 
that you are in that job, all that you bring to it. I wish you 
much success and want to help any way I can for you to succeed. 
Thank you.
    Dr. Koplan. Thank you.
    Mr. Regula. Mr. Jackson.

                            COOLEY'S ANEMIA

    Mr. Jackson. Thank you, Mr. Chairman. Thank you, Dr. 
Koplan, for your outstanding work. Mr. Chairman, I have a 
number of questions that I would like to ask in the second 
round, if in fact there is a second round opportunity.
    Mr. Regula. There will be.
    Mr. Jackson. Thank you, Mr. Chairman. Dr. Koplan, earlier 
this year the subcommittee heard some compelling testimony from 
a father and a daughter speaking on behalf of the Cooley's 
Anemia Foundation. With regard to CDC, they testified to the 
need for funding for a thalassemia blood safety program. Mr. 
Chairman, you may remember the young lady when she said she was 
concerned about coming before the committee when she knew that 
her request was for $3.8 million and she said there is no way 
in the world this committee is going to fund this program, and 
her father assured her that $3.8 million was a small drop in 
the budget, a small pittance for what this committee could do 
if, in fact, it decided to.
    So, Dr. Koplan, as you know, your hematology branch has 
produced the outline of such a program. I am very interested in 
whether or not you could comment on the importance of this 
proposal and the role such a program could play in protecting 
the blood supply for all Americans. I am also very interested 
in knowing whether or not the information from the CDC 
indicates that the entire program could be implemented for 
about $3.8 million? And if the subcommittee appropriated this 
funding, how long would it take to get the system up and 
running?
    Dr. Koplan. We have been interested with both issues, in 
the safety of the blood supply and, in particular, individuals 
who have clotting disorders, including Cooley's Anemia, 
Thalassemia, sickle cell disease, hemophilia, for some time. We 
have put into place a system which looks at blood transfusions 
and blood products, both their safety and then factors related 
to that safety, and then the outcomes in those individuals and 
how they can best lead a healthy and active life. Cooley's 
Anemia is not a significantly funded piece of this at the 
moment, but it is an area that could be meshed into it and 
supported.
    Mr. Jackson. If we funded it for $3.8 million, how long 
would it take to get the system up and running?
    Dr. Koplan. I would have to get back to you on that. I am 
not sure of the timeframe for that.
    Mr. Jackson. I am very interested in that answer, sir.
    [The information follows:]

                  Cooley's Anemia Surveillance Program

    Approximately 10-12 months would be needed for initial 
implementation of a surveillance program.

    Mr. Jackson. Many Cooley's Anemia patients are treated at 
about five clinical centers. For those that are not, I am 
wondering could the Cooley's Anemia Foundation play a role in 
identifying and referring those patients to be a part of the 
project?
    Dr. Koplan. I would think they probably could. Again, I 
would have to check into it further.
    Mr. Jackson. Mr. Chairman, I will save the remainder of my 
questions for the second round.
    Mr. Regula. Ms. Pelosi?
    Ms. Pelosi. Mr. Chairman, have you had your questions?
    Mr. Regula. I will get some. [Laughter.]
    I am just deferring because I know you have a committee 
hearing you want to get to.
    Ms. Pelosi. No, no. That is fine.

                  DISSEMINATION OF HEALTH INFORMATION

    Mr. Regula. Okay. Well, I think one of the things you 
mentioned is that information does not get out to the people 
that need it. That covers a whole range of concerns. What can 
we do to help to ensure that people do have access to the 
information that your agency produces?
    Dr. Koplan. Thank you. I think several of the programs 
mentioned earlier are probably good examples of just that 
issue, that we have acquired the information scientifically, 
our research community has, it is written in medical journals, 
but we have not necessarily got it into play. And sometimes 
that information has to get into the hands of patients or 
consumers and then they can make the choices and make the 
difference, in some cases it has to get into the physician's 
hands, the health care community, and in some cases both. Some 
examples of that:
    In the diabetes example I gave earlier, we know what needs 
to be done. People have to get in a doctor's office, have to 
get their feet examined, they need a retinal exam, an eye exam, 
they need to get under better control of their diabetes. That 
involves our working with both patients so that they know what 
to ask for, and then both physicians and very much nurses play 
a crucial role in this. Diet issues and physical activity, 
which are crucial to our control of this chronic disease 
epidemic, involve working with people and getting the 
information to them.
    In the health education model, the first step is knowledge, 
and that has been true in our successes in tobacco, people 
understanding what the issues are; that a given diet is good, 
tobacco may not be good, more physical activity is good. But 
then a part of our public health approach is to work with them 
and make it easier for them to either adhere to a diet, to stop 
smoking, or to engage in physical activity. So it is both the 
information but then also a health promotion public health 
program that gets them to change in behavior.

                             SCHOOL HEALTH

    Mr. Regula. Do you have any access to the schools? I am 
talking about K through 12. Because this is where a lot of this 
could be brought into health courses or other means of 
educating young people on a whole range of things that could be 
important to their health in the future.
    Dr. Koplan. Absolutely. Currently, we offer not the actual 
curriculum, that is up to States and local education 
departments to decide, but we support having as part of a 
curriculum some information about health. My view is that we 
teach kids to be literate, we teach kids to be mathematically 
competent, we should also teach them to be health literate so 
that when they leave school they have some understanding about 
how to improve their lives and their lifespan.
    We are in 20 States now, and these comprehensive programs 
cover a range of issues. We encourage a curriculum that is 
grade-specific, so when you are in kindergarten you learn some 
things, and so on. Maybe you have had this experience with 
youngsters in your own family or friends' families, kids come 
back from school with some of these messages and they can have 
an impact on their own family. You do not always want to hear 
it when your child comes home telling you to change this or do 
that, but it is effective.
    Mr. Regula. I think seatbelts is a classic example, it's 
the children oftentimes that are urging parents to wear 
seatbelts.
    You state that prevention is an important thing. Yet, as I 
understand it, you do not recommend PSA testing as a way of 
early detection of prostate cancer.

                   PROSTATE-SPECIFIC ANTIGEN TESTING

    Dr. Koplan. PSA testing, prostate-specific antigen testing, 
is one of those technologies that kind of sprang up around us 
before the scientific institutions had a chance to really 
evaluate it. Do not get me wrong, I think if we go to a doctor 
and we are over the age of 40 and we are male, we are going to 
get PSA tested, and then you have to do something based on that 
information. The difficulty has been we have not had that large 
study or clinical trial that has given us hard evidence to say 
what are the effects of this over time. And I believe our 
colleagues at the National Cancer Institute are doing such a 
long-term study now looking at PSA testing. But we thought it 
was premature for us as a Federal agency to come out with a set 
of recommendations before such a trial reported what its 
findings were. There are recommendations out from the American 
Cancer Society I believe on PSA testing.
    Mr. Regula. That are positive?
    Dr. Koplan. That suggest, yes, that it should be done at 
certain intervals over a certain age.

                              YOUTH MEDIA

    Mr. Regula. One other question. In the fiscal year 2001 
budget, we provided partial funding for a National Campaign to 
Change Children's Health Behaviors. It is obviously a 
multiagency initiative. What have you done on this? It goes 
along with the previous question.
    Dr. Koplan. Thank you. This is a youth media campaign and 
it is geared towards counteracting many of the negative 
influences that kids get through a variety of media sources on 
a daily basis. This campaign was funded last year at I believe 
it was about $125 million. However, if one thinks of the 
billions that are spent daily on a variety of less healthy food 
choices, tobacco use, a range of other unhealthy activities, it 
puts somewhat in perspective what a counter campaign would 
involve.
    We have been working with a variety of partners both in 
other parts of the Federal Government, States, and communities 
to design what such a program would be. It is largely aimed at 
focusing on preteens, 9 to 13 year-olds, where a lot of these 
behaviors get decided. It would be a multimedia campaign, not 
just TV and print, but web-based, and all the ways kids get 
information these days, and it would be ethnically diverse. It 
would cover all the different communities of kids and try to 
provide some positive models for them as both how to spend 
their time and what decisions to make, and link it into other 
programs we have got in communities, in schools, et. cetera.

                       INFLUENZA VACCINE SHORTAGE

    Mr. Regula. This fall we had a shortage of flu vaccine. I 
think CDC is involved in that. What caused thatshortage and are 
steps being taken to prevent that from reoccurring?
    Dr. Koplan. Last fall we saw a number of items coalesce to 
cause a shortage or at least a slowness in proper delivery 
dates of the flu vaccine. One was one of the components of the 
flu vaccine, it is made up of three different types of 
influenza virus, and one of them was particularly difficult to 
grow on eggs, which is where flu vaccine is still grown. And so 
the manufacturers, it took longer for them to produce this same 
number of multiple gallons of vaccine that they would have been 
able to do earlier if the vaccine had grown more quickly.
    Some of the other issues that came up last year that were 
striking is that we have had an increasing decline in the 
number of manufacturers that make our different vaccines. It 
puts us in a more fragile situation in terms of availability 
there. Fewer and fewer companies are making vaccines, and that 
is certainly true of influenza vaccine.
    And then, finally, the distribution system that before had 
not really been an issue in how the vaccine got distributed 
became a concern as many of your constituents and many people 
who we work with were concerned with why were some folks 
getting it and not other folks. In part, it is a market-based 
system of distribution. Those who placed their orders first and 
placed the biggest orders get vaccine first. And that led to 
many doctors with smaller practices who may have placed their 
orders a little later not getting it when they needed it.
    We are taking active steps this year to try to address each 
of those, although we certainly do not control the market 
economy or how vaccine gets distributed. We are working with 
the American Medical Association, we are working with some of 
the distributors, and we are working with manufacturers and our 
colleagues at FDA to try to smooth out this system and make it 
a little more responsive to times when we do not have enough 
vaccine.
    Mr. Regula. You mentioned that fewer and fewer companies 
are making the vaccine. Is this just because it is not 
profitable?
    Dr. Koplan. It is unclear to us. I think that may be part 
of it. It may be the fickleness of vaccine purchases worldwide. 
One of the things we would like to do, and I think the 
Secretary intends to do over time, is engage some of these 
manufacturers in a discussion. This is very much an issue of a 
private-public partnership. This has been a tremendously 
successful story of immunization programs in the U.S. and we 
want to keep that going. So I think that we will engage 
actually with the manufacturers and see what are the issues 
here, what makes this less attractive to them. Is it this 
particular vaccine, or is it a more generic issue.
    Mr. Regula. Mr. Wicker?
    Mr. Wicker. Thank you, Mr. Chairman. Dr. Koplan and 
friends, we are glad to have you again. As you know, I am a big 
supporter of what you are doing. I have visited your facilities 
in Atlanta, and I was glad to see that the Secretary spoke to 
the issue of better facilities for you when he testified 
yesterday.

                          YOUTH MEDIA CAMPAIGN

    Let me get to a number of topics. You answered a question 
by the Chairman concerning the youth media campaign. I think 
that figure was $152 million. Just help me understand, why was 
that a one-time appropriation? Was that by design or was that 
just something that fell off the table this year during the 
budget request?
    Dr. Koplan. Programs like this are more effective if 
maintained over time. All public health programs have a 
cumulative effect on the population, or at least need to be 
evaluated over a cumulative time unless it is a very targeted, 
brief disease that you are focusing on. Nevertheless, some 
programs have been evaluated and shown that even in a one year 
period they can raise awareness and change some people's 
perceptions of a health issue. I believe this program was 
initially designed to be a multiyear program. However, it is 
not part of the budget request for this year.
    Mr. Wicker. Okay. So when we appropriated the money last 
year we did not make a flat statement that this would be a one 
year only program?
    Dr. Koplan. I do not believe so.

                       CHRONIC DISEASE PREVENTION

    Mr. Wicker. Okay. I asked the Secretary yesterday about the 
chronic disease prevention and health promotion aspect of the 
budget. Even when you take the $152 million in supposedly one 
time money out, there is still a $23 million cut in that 
particular item of chronic disease prevention and health 
promotion. I asked the Secretary to be willing to work with us 
about moving some numbers around. We are committed to research, 
but also there comes a time to put that research into practice. 
I think nobody does that better than the CDC.
    I would like for you to comment on that generally. Also 
there are at least two types of prevention. One is when we know 
there is a bacteria or a virus out there that people can catch. 
We need to figure out a way to cure that and to prevent other 
people from getting it. But the other is sort of the behavioral 
type of prevention. And that is where I had an interesting 
discussion with one of my colleagues yesterday.
    This colleague said the Federal Government cannot and 
should not try to be a mother hen to all Americans. This 
particular colleague questioned whether we are trying to do too 
much in controlling behavior that leads to obesity, and 
controlling behavior that leads to heart disease. As you know, 
I have a chronic heart disease program that is State-based that 
I would like to see go nationwide. The causes of so much of 
that disease are behavioral. And yet I do not want to have a 
pride of authorship and just have this program expand when 
really it is not the role of the Federal Government to be a 
mother hen. So, tell me if we are right or wrong to pursue sort 
of behavioral preventions?
    Dr. Koplan. Thank you, Mr. Wicker. I think the last thing 
any of us would think we are doing or trying to do is ``control 
behavior.'' Those of us with kids certainly know better than 
expecting that to occur under any circumstances. What we try to 
do I think in public health is give people the information such 
that they can make decisions themselves and they can decide any 
way they want. But our view is that if given adequate 
information on health risks and what the effects of different 
behaviors are, most people over time will choose one that 
maximize the health to them.
    This would be less of a public issue if the Government 
already did not spend a good chunk of its revenues on taking 
care of people from chronic illnesses who are sick and do not 
need to be sick. We can prevent a chunk of these illnesses that 
some other people will come and appear before you are going to 
talk about our having to pay for. Whether it is the Veterans 
Administration, Medicare/Medicaid, Bureau of IndianAffairs, 
whatever, the Federal Government pays for a big chunk of health care. 
Lots of that is preventable. And we are talking about diabetes, we are 
talking about heart disease, we are talking about a number of the 
cancers. None of us are going to live forever, but the goal is to live 
to what is our potential lifespan, which these days is 90 or above----
    Mr. Wicker. And to live well while we are doing it.
    Dr. Koplan. And to be healthy and pain-free and productive 
while we are doing it. And the big thrust I think for public 
health in the next 10 years is going to be not just pushing 
that lifespan out so we can spend our last 20 years in pain, 
uncomfortable, in a place we do not want to be, but keeping us 
healthy and active and enjoying our families and work for those 
last 20 years. And, indeed, we have the capability of doing 
that in a way that we are not applying.

                         CARDIOVASCULAR DISEASE

    Mr. Wicker. Okay. Then speak specifically to the 
cardiovascular State-based program and tell us if there is a 
way for us to know whether we have done any good. Are there 
results that the CDC can tell this subcommittee? And based on 
those results, where should we go from here?
    Dr. Koplan. Heart disease remains the number one cause of 
death in this country. We have made some advances from it in 
the last 20 years, considerable advances, in large part because 
of what we learn about cholesterol and high blood pressure and 
improvement in treatment as well. Nevertheless, it is a good 
example of what I would say is a gap between research findings 
and its application.
    We have invested, again in the last 20 years, in programs 
in Paducah, Rhode Island, Stanford, Five Cities, Minnesota 
Health Project and from that information we have learned that 
there are interventions that we can put in place in communities 
that can prevent heart disease and lower the rates. Other 
countries have done it. Finland is the best example of a place. 
In one of their provinces which had the highest rates of heart 
disease in the world they made a combined political and public 
health effort and knocked those rates down considerably, so 
that men do not have to die in their late 40s and early 50s 
from heart disease. And the interventions were dietary change, 
physical activity, decreasing smoking, getting blood pressure 
under control, getting people to know their cholesterol and 
alter it. It is simple stuff and we know it.
    We currently have comprehensive programs in six States; 
meaning, we are trying a package of things that can make a 
difference. In 22 States we are at a much more preliminary 
level of activity. But what we are trying to do is apply these 
results of these major research studies done, and done well, by 
the National Heart, Lung, and Blood Institute 10 years ago and 
we still have not put them into place in the U.S.
    Mr. Wicker. Thank you. Thank you, Mr. Chairman.
    Mr. Regula. Mr. Wicker, if you can take the Chair. Ms. 
DeLauro was next, and then we can go to a second round. I think 
Mr. Jackson has some additional questions and you may also.
    Mr. Wicker [assuming Chair]. Ms. DeLauro?

                       CHRONIC DISEASE PREVENTION

    Ms. DeLauro. Thank you very much, Mr. Chairman. Let me just 
say from the outset I am not going to mince my words on this. I 
have a couple of questions. But, quite frankly, I think it is 
outrageous that given what the CDC does, and given what we know 
about the ability to curb and stop some of the illnesses that 
we are plagued with today, that when we take a look at a CDC 
funding cut by $165 million, 4 percent below where we were last 
year, the largest cuts coming in chronic disease prevention and 
health promotion, $173 million, 23 percent below this last 
year, I think it almost borders on the criminal because we know 
we can prevent illness and disease here.
    Just go down the line here: Cancer prevention and control, 
a 6 percent cut. Heart disease and stroke programs, a 21 
percent cut. Diabetes, and we talk a lot about diabetes in this 
committee, an 11 percent cut. Arthritis, a 9 percent cut. And 
what we have done to the youth media campaign, the buildings 
and facilities. I never went to CDC until this year and it is 
an outrage to watch where people who are doing the kind of work 
that they are doing in these circumstances under which they are 
doing it. You can go down the line.
    I think if we are committed to doing anything, and that is 
disease control and prevention, and we have the tools and the 
wherewithal to do it, and all of a sudden we just refuse to 
engage in doing this. I am not going to point to the facts of 
why, I have my reasons why, but I just want to lay that out.

                               WISEWOMAN

    And then let me get to two issues about which I care very, 
very deeply. We talked about cardiovascular considerations. 
Let's talk about the WISEWOMAN Program. In 1995 this program 
was initiated. It is preventive services for low-income, 
uninsured women who work through the National Breast and 
Cervical Cancer Early Detection Program, and we are cutting 
that program as well. I understand that my colleague, Ms. 
Pelosi, addressed that issue. But we know that when we have a 
population in the facility, if we are going to check for breast 
and cervical cancer, why not check to see what is going on with 
high blood pressure, high cholesterol, physical activity 
interventions, lifestyle interventions which we talk about in 
this committee. This is the place where we should do it.
    Tell me how we deal with the impact of this budget on the 
WISEWOMAN Program. We had three sites in 1995. Approximately 
10,000 low-income and uninsured women age 40 to 64 have been 
screened. Once the program is fully implemented in the seven 
sites funded in the year 2000, 25,000 women will have these 
kinds of lifestyle interventions. Why are we not making a move 
to do these things like the breast and cervical cancer centers, 
in all of these centers across this country so that geography 
does not determine whether or not you are going to be healthy? 
Maybe then we can affect lifestyle while we are also testing in 
a scientific way about cholesterol and high blood pressure and 
all those other things. What is going to be the effect on the 
WISEWOMAN Program with these cuts?
    Dr. Koplan. Let me concur with you that the WISEWOMAN 
Program is terrific. For economists present, it has a minimal 
marginal cost and a huge marginal benefit. It involves having 
women who come in for breast and cervical cancer screening, 
while they are there and have already made the effort to come 
to a health care facility, they can get tested for cholesterol, 
have their blood pressure checked, get information on diet, 
physical activity, smoking, if they are smoking.
    In the programs, as you have indicated, where this has been 
done, we have done evaluations that show that women takethis 
advice to heart and blood pressures improve, cholesterols get lowered 
at the same time that they are getting their breast and cervical cancer 
early detection program.
    The program currently is in 12 States, 4 with a full 
program, 8 with a start-up program. It will probably continue 
at about the same rate next year in the new budget.
    Ms. DeLauro. What would it take for us to have these 
centers across the country, or this facility across the 
country?
    Dr. Koplan. It is roughly $1 million a State to implement 
this.

                             OVARIAN CANCER

    Ms. DeLauro. Let me talk about ovarian cancer. That is a 
subject near and dear to my heart. It is the fifth leading 
cause of cancer in women. 23,400 new cases will be diagnosed, 
13,000 women will die of this disease. They die within five 
years. If we detect it early, the survival rate is at 95 
percent. If it is detected in its late stages, the survival 
rate drops to 25 percent. I just want to say thank you to CDC 
for hosting the Comprehensive Ovarian Cancer Workshop. Rather 
than cutting this program, we should be doubling the funding to 
really do something about a very silent killer. It is a $15 
million cut proposed in the budget. In my view, it inhibits the 
CDC's ability to deliver on these priority areas. What will 
happen with State health departments, and relevant partners to 
be able to expand effective prevention strategies for ovarian 
cancer?
    Dr. Koplan. Your leadership on this has really helped us 
along. As you indicated, we had a workshop this year which I 
think was significant. It pulled together leadership both from 
academic experts, various advocacy groups, State health 
departments, scientists from all over the Government in cancer 
treatment programs to take a look at this and focus on, just 
what you say, is there a prevent mode, what can we learn, how 
can we get to this earlier and make a difference. An outcome of 
that is our doing a program and supporting a program at our 
prevention center at the University of Texas in Houston where 
they are actually going to do an analysis of several hundred 
ovarian cancer patients diagnosed over a two to three year 
timeframe and try to see if there are specific factors that 
distinguish women diagnosed at later stages than those from 
earlier stages, and can we tease something out from that that 
helps us do some prevention programs.
    We are also doing a similar analysis at the University of 
Alabama in Birmingham. And we are using our cancer registries, 
a crucial piece of the cancer prevention and control effort, to 
give us more information on ovarian cancer. So ovarian cancer 
is an area that we are putting a significant thrust in in 
trying to get a better handle, get a better public health 
approach to it.

                           Cancer Registries

    Ms. DeLauro. What will happen to the cancer registries in 
this effort? Is that affected?
    Dr. Koplan. I think most of our chronic disease programs 
would suffer some curtailment.
    Ms. DeLauro. I do not know what to say to you, I really 
don't. I think it is nice if we make the trips and get the 
information. I think you have discharged your duty, and if you 
do not discharge it, you keep us informed, you help us to 
understand. We are not experts in this process. We are people 
who come to these things, we learn about these issues, and we 
are charged with trying to do the best we can. I would just 
simply say to you from my view, I do not believe we are doing 
the best we can. I believe you are, I believe your folks are 
doing the best that you can with limited resources, limited 
from the beginning.

                            Cervical Cancer

    I just find this very depressing that even with limited 
resources we are going to further limit our ability to deal 
specifically with areas where we know we could get some things 
under control. I will go back to cervical cancer. Four thousand 
women die every year with cervical cancer. We can wipe out 
cervical cancer. If we could do that, why would we want to cut 
back the dollars in funding for it. And I am not asking you to 
comment.
    Thank you for what you do. Thank you for being here today. 
And thank you for listening.
    Mr. Wicker. Mr. Jackson?

                                 ATSDR

    Mr. Jackson. Thank you, Mr. Chairman. Dr. Koplan, I 
understand that funding for the Agency for Toxic Substances and 
Disease Registry, ATSDR, is under the jurisdiction of the VA-
HUD subcommittee. But since I do not sit on that subcommittee, 
this is the only opportunity I have to ask you about the 
agency. It is my understanding that ATSDR has proposed a 
significant cut in fiscal year 2002 for its partnership with 
the Nation's minority health professions schools. I am 
wondering, Dr. Koplan, one, are you aware of this; and two, 
what can we do to continue this important program at or near 
its current levels?
    Dr. Koplan. We can make the best case we can for the 
activities that ATSDR does, which is largely focused on toxic 
substances in communities around the country. I will have to 
get back to you in writing on your earlier question about the 
minority health programs. I do not have the complete 
information on that, but we will get it for you.
    Mr. Jackson. I would certainly appreciate that, Doctor.
    [The information follows:]

                 Minority Health Professions Foundation

    FY 2001 represents the final year of the current 5-year cooperative 
agreement with the Minority Health Professions Foundation (MHPF). 
Funding available in FY 2001 coupled with funding to be provided in FY 
2002 should allow completion of the ongoing research projects in this 
cooperative agreement cycle. In order to satisfy the need for 
additional resources, the Agency for Toxic Substances and Disease 
Registry proposes to provide additional funding in FY 2002 to enable 
the member institutions to complete their research projects. Also in FY 
2002, ATSDR proposes to work with the MHPF to develop a third 5-year 
cooperative agreement program to address the highest research 
priorities associated with the Superfund program. It is anticipated 
that this new cooperative agreement will be awarded early in FY 2003.

                              Hepatitis C

    Mr. Jackson. Dr. Koplan, also as you know, African-
Americans suffer disproportionately from hepatitis C. I am 
wondering if you can update the subcommittee on your efforts to 
combat this infectious disease in minority communities.
    Dr. Koplan. As you indicated, hepatitis C is currently the 
major cause of illness and long-term liver disease and any form 
of hepatitis does disproportionately affect minority 
communities. Our focus is on working with blood collection 
centers and hospital transfusion services and we have tried to 
promote their engaging in a program of what is called targeted 
look-back notification of transfusion recipients, people who 
received blood from donors who later tested positive. We also 
have cooperative agreements with 25 States now which get them 
to coordinate activities around hepatitis C, focusing on 
counselling, testing, referral, surveillance, and then 
treatment for those where it is appropriate. And there is a 
focus on minority communities in that.
    Mr. Jackson. Dr. Koplan, for the past several years the 
subcommittee has encouraged CDC's chronic disease program to 
initiate a national inflammatory bowel disease surveillance 
program to further our understanding of the prevalence of 
devastating intestinal illnesses. Can you update the 
subcommittee on the status of this program.
    Dr. Koplan. This is something for which we had not 
particularly had resources. I believe we have met and talked 
with a number of groups around this issue. It is not an easy 
area for us to get public health surveillance information on. 
Some data is collected on this I believe in our National Health 
and Nutrition Exam Surveys which should permit us to get some 
better data on the rates of it in the American population.
    Mr. Jackson. Thank you, Dr. Koplan. And thank you, Mr. 
Chairman.

                          State-Based Programs

    Mr. Wicker. Thank you, Mr. Jackson.
    Dr. Koplan, let me just ask you a question. And you may 
have to answer part of it on the record because it is in 
several parts. But I would like a brief update on the status of 
each of the State-based prevention programs. And I count at 
least nine of those. What is the capability amount of these 
programs? Are each of them ready to go nationwide? How much 
would it cost? And how do we assess their performance, what is 
the mechanism for doing that? And then are they more effective 
when delivered by the State health departments, voluntary 
health agencies, or community-based groups? And have there been 
any studies on this? [Laughter.]
    Dr. Koplan. Could we get back to you on some of those. If 
we could start on the back first, though. The one thing I could 
answer here and probably is most appropriate to answer here is 
your question about how are they most effective. I think one of 
the things we have learned over the last 10 years which is 
really different from when I started in public health is we 
used to think that the only way to do a public health program 
was us at the Federal level working with a State partner in 
trying to get a public health program out. And that worked 
pretty well for a lot of things for a lot of years. But in the 
year 2001, to deliver an effective public health program you 
have got to involve community groups, there has to be 
involvement of the State health department, the local health 
departments, and us to some extent sometimes is useful, 
certainly that is not always necessary. But with that coalition 
you get things done and you have an impact that you cannot have 
otherwise.
    Communities know themselves better than folks even in the 
neighboring county or the other parts of the State. And so that 
linkage has made a real difference. I think a very good example 
is the syphilis program that I mentioned earlier. In the three 
counties where we have these intensive programs, the State is 
involved, we are involved at a CDC level, the county health 
departments are actively involved, and they have largely 
engaged community groups, their youth groups, their communities 
of faith are heavily involved in these. The chair of some of 
these syphilis eradication efforts in some of these cities, and 
Nashville is a good example, is headed by a minister from one 
of the minority congregations there. So that this mixture of 
players that in the past would have been considered either not 
a health partner or a very untraditional health partner are 
part and parcel of modern public health.
    And we will get answers to your other questions for you.
    Mr. Wicker. I will submit that question to you so that you 
can answer it part by part.
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                                OBESITY

    Mr. Wicker. The last thing I want to talk about is a 
statistic that I saw when I visited CDC in Atlanta with this 
subcommittee. It was a startling statistic about the epidemic 
of obesity, particularly childhood obesity. The map of the 
United States that you showed us showed that the real epidemic 
began sort of in the lower Mississippi Valley close to where I 
live. Year by year by year, it has grown and grown and grown to 
the point where we have kids all over the country grossly 
overweight and, as you have pointed out, this affects their 
lifestyle and their ability to resist other diseases. It 
strikes me that a good part of this is in the home. I know 
starting with breast feeding even you have some statistics that 
breast feeding helps to prevent childhood obesity. Am I correct 
there?
    Dr. Koplan. I think there is an association. It may be the 
breast feeding or it may be just the other aspects of that home 
life that alter the way kids grow up and how much weight they 
put on.
    Mr. Wicker. And then in addition to home life, it strikes 
me that we spend about 98 percent of our time in public schools 
educating the minds of our children, as we should, but very, 
very little time helping them to keep healthy bodies so that 
they can enjoy their minds for an extended period, a healthy 
lifetime. So I am just wondering what progress we are making? 
How long you have been working on this? Iassume you would not 
have shown us these statistics if we did not have something going 
there. Dr. Koplan, maybe you are swimming against a very, very strong 
current or maybe we are just being unsuccessful there. Are there any 
success stories at all?
    Dr. Koplan. Yes.
    Mr. Wicker. Or is this just an area where the Government 
cannot control family life and behavior?

                                DIABETES

    Dr. Koplan. Yes, and yes. Yes, the Government cannot 
control family life and behavior, and yes, we can make public 
health difference. And again the examples I think are good 
ones. There has been a marked increase in childhood diabetes. 
Type II diabetes when I trained in medicine was called a delta 
onset diabetes. It is particularly striking that soon about 
half of the cases of diabetes in kids will not be what we used 
to refer to juvenile onset, insulin-requiring, but will be a 
delta onset in kids largely because of the weight gain and 
obesity that you have just described, and that is a mixture of 
too many calories and not enough physical activity.
    We have programs that are being shown to make a difference. 
We have a program that was sponsored by the University of Texas 
at Houston at their School of Public Health that was able to 
demonstrate success in altering kids' dietary practices and 
levels of physical activity in schools, a level of success 
enough such that it was picked up by the Department of 
Education in Texas and many schools there, I think it is over 
several hundred, now have it in place.

                           PHYSICAL ACTIVITY

    One striking aspect of this change in obesity over the last 
20 years, in the last 10 years, has been we can pick apart 
elements that have contributed to it. One is, the decline in 
physical activity in schools, physical education programs. Now, 
many of us might not have been crazy about our gym classes or 
recess, recess we liked but gym classes maybe not----
    Mr. Wicker. They are surely not mandatory much anymore.
    Dr. Koplan. It did get us out of the classroom. And, in 
fact, they are not in conflict with proper intellectual 
learning. They enhance intellectual learning. When we do 
studies we ought to take advantage of what the studies show. It 
is important to get new information but we better apply it or 
we are undermining the moral basis for having done the study in 
the first place. And studies done in Australia show that kids 
who are taken out for a half hour physical activity one or two 
times a day in school come back and do better at their school 
studies. It is not hard to understand. We cannot sit and listen 
to a lecturer, like me, for four hours at a time. You have got 
to break it up; you have got to get up and move around, go 
downstairs for a vote, come back up here. It helps.
    Mr. Wicker. We are in recess now, subject to the call of 
the Chair. [Laughter.]
    Dr. Koplan. So some of these stand to reason. And it stands 
to reason to me that you cannot just keep kids in class 
teaching them one thing after another all day long. A break is 
good and some physical activity is better.
    Mr. Wicker. Thank you very much. I have no further 
questions. Our Chairman has returned.

                       SCHOOL NUTRITION PROGRAMS

    Mr. Regula. Pursuant to that question, one of the things 
that concerns me is the proliferation of Coke or Pepsi 
machines, soda machines----
    Dr. Koplan. Remember, I am from Atlanta, Mr. Chairman. 
[Laughter.]
    Mr. Regula. That does not matter. The proliferation of 
machines in the schools that dispense soda pop in one form or 
another, and I think the diminishing use of milk--and, of 
course, you pointed out obesity--all those things are harmful. 
I know one of the reasons schools do it is because they make 
money for the school. But would it not occur to someone that 
this might be a bad practice?
    Dr. Koplan. Certainly, our schools ought to be places of 
health promotion. Whether it is encouraging physical activity 
or whatever the curriculum involves, it should be a healthy and 
safe environment. I think school lunch programs should reflect 
what we know about good nutrition and kids should be encouraged 
to eat it. Some of the complaints are that they will not eat 
the stuff if it is healthy and good. But I think there are 
other ways to deal with that and encourage it and make it 
attractive. We have all been to salad bars where you would not 
want to touch it, and we have been to salad bars where they are 
attractive and you choose it over something else.
    Your point about carbonated, sugar-laden soft drinks is a 
good one. There have been studies made that show in some of 
these studies that 10 percent, fully 10 percent of children's 
total caloric intake comes from these beverages, which is an 
extraordinary thing when you think about what the components of 
your nutritional intake should be. So these are some of the 
important changes.
    Other things you mentioned that have contributed to this 
outbreak of obesity are, just what you said, mega sizing. In 
the old days, small, medium, and large seemed to mean 
something. But now you start with something that was bigger 
than large was before and usually the contents of that mega 
sized item is something that is high in calories, high in sugar 
content, sometimes high in fat and salt.
    Mr. Regula. Could we get a copy of these studies that you 
mentioned for the record?
    Dr. Koplan. Sure.
    Mr. Regula. I think that would be very useful information 
that should be available.
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                       CHRONIC DISEASE MONITORING

    Mr. Regula. I think that you responded to the question of 
setting up a nationwide health tracking network, this was 
mentioned by Mr. Stokes in his testimony, to monitor chronic 
diseases. You might enlarge a little bit on your answer here.
    Dr. Koplan. This is a very important breakthrough which 
would be linking the chronic diseases for which we have some 
information, that we would try to improve the information we 
have for those, but also create closer links to environmental 
exposures of different kinds. Currently, it is very hard to 
determine, always, the relationship between an environmental 
exposure and a subsequent health outcome. There are a variety 
of ways that we can try to improve that system. One is the 
cancer registry, as we mentioned earlier, another is a markedly 
improved monitoring system such as that proposed by Mr. Stokes, 
by the Pew Commission as well.

                             YOUTH VIOLENCE

    Mr. Regula. Another area of concern of course is the 
growing incidence of youth violence. It takes many forms. I 
notice you published a source book for preventing youth 
violence. You might expand on that a little bit as to what you 
see as possible ideas that would help to prevent that.
    Dr. Koplan. In many ways it is similar to the point you 
made earlier about how we have an important role to play in 
providing information to different players. In the course of 
the last year, we have put together information on youth 
violence on both a web site and then a dial-in 1-800 number. 
And what we have found is we have gotten an extraordinary 
number of contacts or hits from school teachers, from 
principals, from parents.
    So, again, our constituency at CDC and customers have 
markedly widened over the years, and this is a good example of 
that. And what they are able to do by tying in to that system 
is get up to date information on programs that are effective in 
decreasing youth violence, information on their State related 
to tendency towards violence in that State. And we are trying 
to come up with some best practices, of places where kids are 
taught how to resolve conflicts in ways other than resorting to 
physical violence, and in how to engage kids in how to make 
decisions that do not necessarily mean succumbing to peer 
pressure that might relate to more healthy behaviors in 
schools.
    Mr. Regula. This is a little bit of an aside, but has there 
been any evidence that school size might contribute to the 
growing incidents of violence?
    Dr. Koplan. I do not know the answer to that. I have not 
seen data on size as a related factor. But we can certainly 
check on that. I do not know the answer.

                            SCHOOL VIOLENCE

    Mr. Regula. I note that you have completed and will soon 
publish a study of school associated violent deaths. Any 
comments you might want to make on this study?
    Dr. Koplan. Just some of the preliminary results that have
come out from that. One is that in these multiple victim, the 
mass, horrible events that we have seen with some frequency 
over the last few years, the offenders in them, the 
perpetrators were more likely to have expressed suicidal 
behavior than offenders will express in single homicides, one-
on-one crime. There seems to be a suicidal element in that. 
That is not a final answer but it does lead us either towards 
more research or towards looking for some risk factors in 
people who might be most susceptible to this.
    Another is, offenders, the perpetrators were more likely 
than the victims to have experienced some disciplinary action 
in the past. And then third, schools that experienced a violent 
death were less likely to have had some required course in 
violence prevention than those schools that had such a course. 
So that there may be some evidence of real value in having 
these violence prevention activities in schools.

                              BIOTERRORISM

    Mr. Regula. Another area we hear discussion of is 
bioterrorism. I would be interested in your comments in a 
general way as to what is happening or what are you aware of, 
and what do you see as ways to prepare or prevent this type of 
thing from happening. You could see where it would create panic 
if there were an idea spread among the population that there 
was a virus out loose that could cause serious problems or 
maybe death.
    Dr. Koplan. This remains an area in which we cannot afford 
to be complacent. We are not a security agency, but we are told 
by colleagues in security agencies that the threats are real, 
they are consistent, and they are ongoing. There are malevolent 
individuals out there and they have access to biological and 
chemical agents. And so it is both prudent and it is our 
responsibility to be prepared for these types of potential 
attacks.
    I think one aspect of this worth underlining is that as we 
prepare for bioterrorist attacks in this country, and that 
means both at our level of having our facilities and staff 
capable of dealing with it, but also at the State and local 
level, that improving our capability at all these levels is 
extendable to other threats. So that our ability to strengthen 
State and local health departments against bioterrorist threats 
is vital. But at the same time, that strengthening permits us 
to be better prepared for naturally occurring events that may 
occur as well.
    So unlike our defense system for, say, a nuclear threat, of 
having the radar screen across Canada that was only being used 
for that, it did not get used for traffic control for 
commercial airliners, our putting into place improved 
laboratory capability, epidemiologic capability, surveillance 
capability, training of people in State and local health 
departments means that right there--in fact, a month ago I was 
out giving a talk at Ohio State and visited the State health 
department in Columbus and they indicated that our input to 
them for bioterrorism preparedness had already improved their 
communications and computer capabilities in every county health 
department and was making a difference every day already even 
as it was a good preparation for bioterrorist threat.
    Mr. Regula. How do you coordinate with the various agencies 
that would be involved, such as FBI, public health departments, 
perhaps some other Government agencies that ought to be 
sensitive to this possible threat? Is your agency a 
clearinghouse, or do you have some contact to ensure that we 
are all on the same track?
    Dr. Koplan. We are a player among several other players in 
this. In the Department, the Secretary's office plays the key 
role in coordinating things. We may be the first involved in 
some instances and not in others. But as you would imagine, an 
early bioterrorist attack can look like an outbreak of the kind 
that we are investigating everyday. So everyday we may have 20 
or 30 people out investigating different health problems which 
may subsequently be found to have been purposeful in a 
bioterrorist event.
    What we have now is even in the earliest stages of 
ourroutine outbreak investigations, we are in regular contact with a 
variety of other agencies, both other health agencies, our partners, 
and sister agencies in HHS. As these things progress, we are in close 
contact with the Department of Justice and the FBI, in some instances 
with other departments. In fact, last spring we had an exercise called 
``Top Off'' in which we tested our readiness to deal with a 
bioterrorist event and it was actually coordinated by the Department of 
Justice. We had Department of Defense, all the security agencies, and 
many parts of the Public Health Service and HHS involved. And we found 
areas of improvement, but it also indicated to us how all of these 
players are vital in one of these things. You need everybody from the 
FAA, to the Governor's Office in the State, to the Department of 
Defense. It becomes pretty extensive as these things play out. With 
each passage of a generation of more cases, it gets bigger and bigger 
and bigger, and our job is to keep it smaller and smaller and smaller 
and find it soon.
    Mr. Regula. Is there any agency that has been assigned the 
role of being the lead agency in the event there is this type 
of threat?
    Dr. Koplan. I think through now the Secretary's office, in 
this case, Secretary Thompson himself has taken on as the point 
of contact and the coordinator for these things.
    Dennis, do you have a comment on that?
    Mr. Williams. That is true inside of the Department. But we 
also work closely with the National Security Council which has 
broader coordinating responsibilities for the Government as a 
whole. Dr. Koplan has already mentioned some of the agencies, 
Defense Department, Justice, FBI, the Federal Emergency 
Management Agency are other agencies that are deeply involved 
in this effort.

                          Health Alert Network

    Mr. Regula. So there is a communications network? Because 
this could happen rather quickly and move rapidly in our 
society. So what you are telling me is that there is in place a 
good communications program to address any threat?
    Dr. Koplan. The communications occur actually at two 
levels. One is the communications at a higher level of 
coordination amongst Federal departments. But also a crucial 
piece that had been missing until the last couple of years and 
we are supporting now is something called the Health Alert 
Network which is a communications network in the States. Still 
in many health departments in this country there is no way to 
receive an emergency notice. If we get an emergency notice 
right now of a health problem that might affect a county in 
Ohio, right now they can receive that information because we 
have put the computers and the internet and the secure access 
all into play. But there are many counties around the country 
still without that capability. So that means a phone call, 
letters obviously are ineffective, faxes are not always picked 
up. It remains an imperfect system. And until every one of the 
counties is up to running speed, then we are only as strong as 
our weakest link. A bioterrorist is not necessarily going to 
pick the place that, oh, you put a computer in last week, we 
will choose you because you are better prepared. It is not 
going to work that way. So we need a system that is strong 
throughout. And that makes for a stronger U.S. public health 
system. It makes routine activities in the Mississippi Delta or 
in rural counties in Ohio or Texas all the better for their 
routine activities.
    Mr. Regula. Mr. Wicker, if you want to break in at any 
time.
    Mr. Wicker. I have nothing further, Mr. Chairman.

                      International Communication

    Mr. Regula. Is there any international communication? For 
example, in Japan when they had the problem in the subways, we 
had no way of knowing whether that was the type of thing that 
could have been spread to other localities, other nations. Is 
there any type of international network of communication? 
Because it would seem to me that there could be an attack in a 
number of different countries that would be coordinated.
    Dr. Koplan. Yes. In fact, the World Health Assembly is 
meeting in about a week's time in Geneva and this will be one 
of the issues discussed, worldwide surveillance for infectious 
diseases. It works in two ways. One, individual countries will 
report to the World Health Organization and, in turn, the World 
Health Organization will disseminate that information. And in 
other cases, we have a bilateral relationship with other 
countries such that they would report and keep us informed 
directly, much as we would do with others. This is particularly 
relevant for things that happen in proximity to our borders. So 
it is very important to us to know what is going on in Canada 
and Mexico, and vise versa for them.

                                Genetics

    Mr. Regula. In the area of genetics, and the Genone Project 
is I understand at the threshold, what is your role, if any, at 
this point, and what do you see as the role of CDC 
prospectively?
    Dr. Koplan. Thank you. Obviously, the genetic revolution 
and breakthroughs are spectacular and well worthy of both 
praise and prizes, and I am sure the prizes will come. However, 
for those of us at kind of on the floor in public health, the 
question is how do you use all this information to the best 
advantage of the American public. There will be dozens, if not 
hundreds, of new tests that come out of this genetic 
information. Should they all be applied to all of us everyday? 
Once a week? Once a month? Once a year? If we have new neonatal 
testing procedures, how many of them should be added to what we 
already test for? Just because we have the test does not mean 
we should necessarily apply it to every newborn in the country. 
And those tests are going to cost money.
    So there is going to be a cost issue, economic issues. 
There are legal and ethical issues attached to these tests. We 
see that as the role of public health. Again, it is another 
example of terrific scientific advancement made and we should 
all celebrate it. But now we also have to think about what are 
we going to do with it, and how do we put it in place in a 
rational, reasonable way that benefits everybody to the maximum 
ability. We see that as a CDC role.
    Mr. Regula. So you would have the role of working with 
public health agencies to disseminate the useful information 
that is derived?
    Dr. Koplan. We would work with our colleagues at NIH and 
the universities to take this important information gained. We 
would then work with our colleagues in the state health 
department, in local medical organizations, and professional 
groups and say, okay, now which of this stuff makes sense to 
put into play on a regular basis. Can we afford it? Which has 
the highest priority, and what are the implications down the 
road?
    When you find that someone has a liability to a given 
disease they may get later, how do you use that information? Do 
you use it so that they can worry for the next 20 years, or do 
you use it in a way that has a productive, positivehealth 
benefit to it.
    Mr. Regula. Well, I note that you are assessing three DNA-
based tests for clinical and public health utility in fiscal 
year 2001, with plans to assess five in fiscal year 2002. Tell 
me a little more about this initiative.
    Dr. Koplan. I think it is, in part, what I was referring 
to, which is starting to take some of these tests that are now 
available to us and, in a pilot project, putting them into 
play, and saying, have we anticipated all the ramifications 
that these tests have.
    Let us do it on a small scale first, see what the benefits 
and costs are, and then be able to come back and say, you know, 
this is great, we ought to use it everywhere; or, you know, we 
really had not thought of some aspects of this, and is this 
really ready for prime time or not.
    Mr. Regula. Well, I think sometimes these types of tests or 
information get into the press and creates expectations that 
probably are not real, or are certainly premature.
    Is it perhaps the role of CDC, though the web site and 
various other means of communication to say, now the reality is 
thus and so?

                    Health Information Dissemination

    Dr. Koplan. I think our role is to do both. Our role is to 
take things that work, and as many of the things that we have 
discussed this morning, we have lots of things that work. Our 
role is the one that we have got to work, to shout from the 
highest roof, these things work; we need to get them out there 
and use them. I will be shouting that continually to you.
    Then the other things that probably are not so useful, or 
are too costly, or have downsides to them, similarly, we need 
to be more conservative or more restricted in the way we apply 
those. So it is a mixture of the two.
    There are lots of things we need to be doing more of. There 
are probably some things that we could be doing less of.

                              Food Safety

    Mr. Regula. Just this morning, one of the people that I ran 
into said, ``Do you still eat beef?'' I said, ``Yes.'' He said, 
``I am not eating any more beef.''
    Well, I think that is an example of how you could probably 
put out information in some form or another, maybe on the web-
site, that at least to the best of your knowledge, or the 
Agency, there is no threat in the United States.
    I was just in Europe recently, and they are not eating beef 
in the countries that we were in, partly because of fear, 
probably.
    Do you have a role in that, and is this a well-founded 
concern, that this person articulated to me?
    Dr. Koplan. There would be a variety of reasons for eating. 
We all have very peculiar preferences in our food sources, and 
I would not inflict mine on anyone else here.
    But the reasons for eating any item get weighed. Certainly, 
beef is a terrific source of protein. You know, it needs to be 
part of a balanced diet. My greatest concern would be that it 
is balanced in terms of saturated fats and cholesterol.

                    Bouvine Spongiform Encephalitis

    If the concern is bovine spongiform encephalitis, mad cow 
disease, there are no cases of that in the United States, at 
the moment. It is largely under control, even in many of the 
European countries that had some issues with it before. It is 
an extraordinarily rare event, even in those countries 
currently.
    It is something that we have to be on extreme guard for, 
not just for its human toll in the United States, but because 
of its devastation of major agricultural part of our economy 
and way of life.

                        Creutzfeld Jacob Disease

    The part we play in this is that we look for the human 
cases that occur in this. It has a technical name. It is 
Creutzfeld Jacob disease, and it is a variant of that disease, 
as an encephalopathy brain disease in people.
    Our job is to look for that through surveillance operations 
in the United States. So much the way the Department of 
Agriculture and FDA are concerned about what happens in the 
cattle, we are concerned about what happens in the people. We 
have a system in which we are looking for it all the time.
    Might there be a case at some time in the U.S.? Certainly, 
there could be a case. It could be someone who lived in Europe 
and moved here. That is something that we have to worry about 
and anticipate.
    But we are actively looking for cases of this. I would urge 
you only to change your diet in healthy ways for other reasons, 
but not necessarily for that. We all make choices on a variety 
of reasons for our diet.

                              CDC Web-Site

    Mr. Regula. I understand. As a practical matter, would 
someone who had a certain fear be able to plug into your web 
site, and get reassurance that there are at least no known 
cases.
    Dr. Koplan. Absolutely, yes, we have updates on our web-
site.
    Another good example of just the importance, obviously, we 
had no web site. I started at CDC 28 years ago. There was no 
web. There were no web sites. There were lots of things we did 
not have.
    This has really changed the way we do our operations. We 
now have direct access, and they to us, to the American public 
and people around the world, for health information. So we have 
put a considerable amount of investment and energy into those 
web sites that have lots of information for people.

                               Spongiform

    Bovine spongie encephalitis would be one example of where 
people that are concerned can get updated, current information 
that is useful to them. We get about four million different 
users a month on our web site, that are looking for different 
information.
    Mr. Regula. For a whole variety of requests?

                       Information Dissemination

    Dr. Koplan. Travel information, information on 
immunizations, on heart disease, on diabetes, on bovine 
spongieform encephalitis, on work place injuries. There is just 
a wide range of things.
    Mr. Regula. For those that have not gotten into the 
technological age yet, do you have an ``800'' number, where you 
can get the same kind of information?
    Dr. Koplan. We have ``800'' numbers for a variety of pieces 
of that, but not all of it. I mean, we are always, I hope, 
accessible to the public, and if any individual called up and 
just took our general number, hopefully, it would take a little 
effort, but we get them to someone who could answer their 
questions, or refer them to someone in a state or local health 
department, who had the answers.
    But for things such as travel, where we get a lot of hits 
where people want information, that can be done by fax, phone 
call, web, and all kinds of different ways.
    Obviously, for yourself, we would make it very easy. 
[Laughter.]
    Mr. Regula. You have a rapid response capability. Now what 
I am thinking about is at the Ford Company, there was an 
outbreak in Cleveland recently of Legionnaire's Disease. Were 
your people on the job in a hurry on that one? That involved 
public concern, families whose members worked there, and so on. 
Fear is part of the problem in something like this.
    Dr. Koplan. Absolutely, and a reason for a quick 
investigation and a thorough one is that reason, because in any 
outbreak, you are as liable to get false information as real 
information. Lots of fear takes place in the workers, in their 
family members and the community at large.
    The sooner you get an answer to one of these things, the 
better it is for all concerned; not just in terms of decreasing 
the amount of disease and risk, but also just the emotional 
upset that gets caused.
    We did have a team there rapidly. All of our investigations 
take place at the behest of a State Health Department. So we do 
not just come in anywhere. In this case, it was the State of 
Ohio, and folks there called us and asked us to participate.
    We work in partnership with them and, indeed, they play the 
lead role. We play a supporting role to the state health 
departments.
    I think one of our things that we are proudest of at CDC is 
that over the years, many of our graduates and folks have been 
in our programs and people the state health departments, and 
the universities throughout the country, so that the competence 
and level of skill around the country is quite high, in most 
places, to deal with these things.
    Mr. Regula. Do you routinely feed your latest information 
on different possible threats or cures to the state health 
departments, so that they, in turn, can relay this to their 
local units?
    Dr. Koplan. Absolutely, and that is exactly why these 
health alert networks are so important; that yes, we can call 
or e-mail, and we will do it multiple ways, when there is a 
real urgent threat to a state health department.
    But in some of these outbreaks, obviously, it is not 
limited to the geographic confines of that state or county. So 
that rapidly, you need to get that information out to 
everybody, so that they similarly share in what to look for and 
what to be concerned about.
    Again, it is relatively easy for us to do that at the state 
level, but getting that information down to the county level 
does require an improved communication capability that we have 
started to work on with your help, and we need to continue to 
beef that up.
    Mr. Regula. Which leads me to the next question. Is there 
anything that you think this committee can do to improve the 
dissemination of information and the important role that the 
public health agencies play in the country's use of the 
information in the protection of its citizens? Is the system 
pretty complete, or are there gaps that we should be trying to 
fill?
    Dr. Koplan. The system is about half complete. We have only 
gotten started on this in the last several years, and it is 
through several programs. One is called the Health Alert 
Network, another is we are trying to improve electronic data 
transmission.
    But basically what we are talking about is the public 
health infrastructure of the country, and in the President's 
budget this year, there is an increase for improving the public 
health infrastructure. This is an area that is extremely 
important for our capability of dealing with bio-terrorism, 
emerging infections, et cetera.
    So this can be a real contribution to the health of the 
American public, to improve our overall capability of dealing 
with public health.
    Mr. Regula. Are these competitive grants? I note that the 
staff advises me, we have provided money for this program 
historically, and then you just said there is requested 
increase. Is it based on competitive grants? How does the 
County Health Department in Stark County, Ohio, access this?
    Dr. Koplan. They are competitive grants to states, but our 
goal is not to be exclusionary. We work with the states, and it 
depends on their level of ability to absorb the grants.
    Then they get to choose what they are going to apply for. 
There are various components of this that they may be more or 
less ready to undertake. When they get the funds within their 
state, then they distribute it in a similar manner, county by 
county, to improve it.
    I was struck recently, and I try to visit State Health 
Departments regularly, and Ohio has done a particularly good 
job of meshing funding from different sources into trying to 
improve its overall system. That is what we are trying to 
continue to do, state by state.
    Mr. Regula. Well, I am sorry we had to cut off your 
statement today because of the vote, but it will be in the 
record. I am sure that we will have an opportunity to read it.
    I think our visit to your facility was extremely helpful. I 
would like to get the Members that were not along on the first 
visit, down to see CDC if time permits.
    There are so many things in our society that we take for 
granted. I will tell you, frankly, until I became a Member of 
this Committee, I did not really fully appreciate the important 
role that CDC plays.
    I think we Americans just take for granted that somebody is 
out there, looking out for us; and you are, and we certainly 
appreciate it. It is a story that ought to be told more 
extensively.
    I am sure that if I go to my local village of about 1,400 
people, and ask them about CDC, they will say, well, what is 
that, a new disease? [Laughter.]
    Yet, your team down there is extremely important to all of 
us, and we appreciate what you do. I hope we can get the 
message out, and I hope that we can, within the fiscal 
constraints that we have, as is the case with every budget, 
give you the help you need.
    I saw some really nice facilities, and some that probably 
could stand a degree of improvement. I was truly impressed by 
the dedication of the people there, You told me about the team 
that was dealing with the Ebola outbreak, and that they even 
requested an opportunity to go back, in what would be an 
extremely threatening environment.
    My staff is tired of hearing me say this, but the Bible 
says there are two great commandments, love your Lord and love 
your neighbor.
    This is the ``Love Your Neighbor'' Committee. What you are 
is the love your neighbor beyond the United States, 
andthroughout the world in the work that you do. Certainly, we are 
blessed to have an agency like this in the United States, and many 
other countries are, likewise.
    I had some visitors in the office this morning, and I told 
them I was going to the hearing. Of course, they said, ``What 
is that?'' I said, ``Well, you should sleep better . . .''. 
They all had children, and I said, ``You should sleep better 
because of CDC,'' and I gave them just a quick overview.
    John, you are here just at the right time.
    Mr. Peterson. You were ready to wrap it up.
    Mr. Regula. I was getting close.
    Mr. Peterson. I will be brief.
    Dr. Koplan, I had the chance to visit with you in Atlanta 
and on the plane, and since then. I guess I would just like for 
the record to say that I would like to work with the Chairman 
and others of this committee to help get the information that 
you have that is so vital to the public in this country.

                            PUBLIC EDUCATION

    Because I think the number one health crisis in this 
country is not a lack of technology; it is not a lack of new 
drugs. I mean, we are at the world's edge on all of those. But 
we have a population who is probably in poorer health today 
than they were 20 years ago or 10 years ago, and that is a 
tragedy.
    People, for some reason, seem to have forgotten that they 
have a whole lot more to do about how long they are going to 
live and how healthy they are going to be than anything else in 
their own decisions, somehow.
    I guess I am so impressed with the data information that 
you have that I just want to offer to work with you, along with 
this committee, to figure out how to educate the American 
public to live healthier.
    It is more important than NIH research and, I am sorry, but 
it is more important than any of these other fields, because 
that only helps us when we are acutely ill. That is about acute 
diseases, but a lot of them can be prevented.
    Somehow, you know, I was in state government for a number 
of years, and it never reaches the level or plateau that it 
needs to reach where we educate people to help themselves live 
a healthy and happy lifestyle.
    So I just look forward to working with you. I apologize for 
being here late. I got detained at another meeting. But I just 
want to share with you publicly that I look forward to working 
with you, and to try to creatively figure out how to educate 
Americans to be healthier.
    Mr. Regula. You might be interested, Mr. Peterson, to know 
Dr. Koplan closed his testimony with Ben Franklin's ``an ounce 
of prevention is worth a pound of cure.''
    Mr. Peterson. It is cheaper, too.
    Mr. Regula. We want to help you with the ounce of 
prevention in every way possible. Thank you for coming. We will 
do the very best we can in giving you the help you need in 
being your partner in this success story.
    Thank you.
    Dr. Koplan. Thank you, sir.
    Mr. Regula. The meeting is adjourned.
    [The following questions were submitted to be answered for 
the record:]

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                                            Thursday, May 10, 2001.

       SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

                               WITNESSES

JOSEPH H. AUTRY, III, M.D., ACTING ADMINISTRATOR
BERNARD S. ARONS, M.D., DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES
RUTH SANCHEZ-WAY, Ph.D., ACTING DEPUTY DIRECTOR, CENTER FOR SUBSTANCE 
    ABUSE PREVENTION
H. WESTLEY CLARK, M.D., J.D., M.P.H., DIRECTOR, CENTER FOR SUBSTANCE 
    ABUSE TREATMENT
DONALD GOLDSTONE, M.D., DIRECTOR, OFFICE OF APPLIED STUDIES
JANICE M. KLINK, DIRECTOR, DIVISION OF FINANCIAL MANAGEMENT, SAMHSA
DENNIS P. WILLIAMS, ACTING ASSISTANT SECRETARY FOR MANAGEMENT AND 
    BUDGET, DHHS
    Mr. Regula. Welcome. We will get the hearing started this 
morning. We have two agencies, so we will have to move right 
along.
    We are pleased to welcome Dr. Autry. Doctor, your full 
statement, every word, will be put in the record, and I 
guarantee you my staff will read every word, won't you? Okay. 
If you will summarize, it will help so we can move along. And I 
don't know if you want to get to the swearing in for--Mr. 
Walters?
    Dr. Autry. Unfortunately that is happening at 10 o'clock 
also.
    Mr. Regula. Oh, I thought it was 11:00. Well, you will have 
a tough time making that one.
    Dr. Autry. Fortunately the Secretary is there.
    Mr. Regula. We are happy to welcome you and your team. You 
might want to introduce them. Are you the only one that will be 
testifying?
    Dr. Autry. I will introduce my entire team. They will be 
helping to answer questions, although I will be presenting a 
brief statement for the record, and knowing your staff over the 
years, they have already read every word that we have turned in 
to you, so it can be very brief.
    I am accompanied today by Dr. Westley Clark, Director of 
the Center for Substance Abuse Treatment; Dr. Ruth Sanchez-Way, 
Director of the Center for Substance Abuse Prevention; Dr. 
Donald Goldstone, Director of the Office of Applied Studies, 
responsible for our epidemiology and surveys; Janice Klink, 
Director of the Division of Financial Management; Dr. Bernie 
Arons, Director of the Center for Mental Health Services; and 
Mr. Dennis Williams, who seems to be everywhere.
    Mr. Regula. I might say at the outset--well, first of all, 
you have a great friend in the Governor's wife in Ohio, and she 
keeps in close touch with me. And secondly, I am totally 
convinced that we will have far greater success in the 
prevention and reduction of demand than we ever do by going 
down to Colombia and trying to dry up supply, because there is 
too many sources. If you plug one leak on supply, there will be 
another one open up right next to it.
    So with that, we look forward to your testimony and happy 
to welcome all of you.
    Dr. Autry. Well, thank you, and I appreciate those words 
coming from you in the introduction. We, too, believe that if 
you don't have a very strong demand reduction program, you are 
not going to be able to solve the drug epidemic. We also 
recognize that there is underage use of alcohol and tobacco 
that we must address as part of that demand reduction strategy, 
and I think you will hear in the swearing-in ceremony of John 
Walters this morning a commitment on the part of the 
administration to do more in the treatment and prevention area, 
recognizing that that is a source that we really have to deal 
with in order to make an impact.
    So with that, let me thank you for submitting the written 
testimony for the record, and I really am pleased to be here to 
present the President's 2002 budget for the Substance Abuse and 
Mental Health Services Administration, or SAMHSA, as we are 
known in the Washington lingo. When you hear that, that is what 
it really means.
    Overall the President has proposed a budget that is 
slightly more than $3 billion in 2002 for SAMHSA, a net program 
level increase of 3.4 percent, over 2001. To help fund the 
President's drug treatment initiative, a $100 million increase 
is included in the Substance Abuse Prevention and Treatment 
Block Grant and the Targeted Capacity Expansion Program. The 
block grant is basically a program that provides funds to 
States for the support of infrastructure for prevention and 
treatment activities. Targeted capacity expansion programs are 
monies that go to cities, sub-State regions such as counties, 
and to Indian and Alaskan Native tribes to meet unmet and 
emerging needs that come up in those communities that may not 
be able to be met through the block grant. And I will come back 
and talk about that a little bit later.
    In total, SAMHSA's budget proposes $2.2 billion 
forsubstance abuse treatment and prevention activities.
    In the area of mental health services, the budget includes 
$766 million, a decrease of $16 million from FY 2001, but a 
$135 million increase over fiscal year 2000. Highlights within 
the mental health budget include a total of $420 million for 
the Mental Health Block Grant to States to provide primarily 
community-based care for adults with serious mental illness and 
children with serious emotional disturbances; $90 million to 
address violence in our children's schools; and $9.5 million 
for a program to treat mental disorders that are related to 
HIV/AIDS.
    In our budget document, we discuss how our proposed budget 
builds upon past accomplishments and new research knowledge; we 
highlight how the budget will enable us to address new emerging 
trends, and we detail priority areas for re-investment of funds 
that become available as existing grant programs end.
    What I would like to do in the short time I have this 
morning is to emphasize some key points out of the written 
testimony. Our mission, as envisioned by Congress, is to fully 
develop the Federal Government's ability to target effectively 
substance abuse and mental health services to the people most 
in need and translate research in these areas more effectively 
and more rapidly into the general health care system. To that 
end, SAMHSA works in partnership with the National Institutes 
of Health (NIH) and others to bring the latest research 
discoveries to community-based care. For example, our Center 
for Substance Abuse Treatment is assessing whether an NIH-
developed model of methamphetamine treatment is effective for 
diverse populations in community-based treatment settings. In 
other words, once you take it out of an experimental small-
scale clinical trial study, does it work as well out in the 
community?
    The Center for Mental Health Services is using the latest 
research on violence prevention in a unique collaboration with 
the Departments of Justice and Education. The Safe Schools/
Healthy Students Program supports 77 school districts in their 
efforts to implement policies and mental health services to 
reduce the risk of school violence. Almost 450 school districts 
applied for these awards.
    I noticed on the brick that you have in front of you, you 
quote Diogenes: ``The foundation of every Nation is the 
education of our children,'' and if we can't deal with the 
violence that impacts our education in our schools, then we 
have a serious problem in this country, and this program helps 
address that need.
    Next week the Center for Substance Abuse Prevention will 
announce the names of 20 substance abuse prevention programs 
that have achieved model status. To achieve model status a 
substance abuse prevention program must undergo an independent 
and extensive review process that examines its effectiveness. 
Over 400 substance abuse prevention programs have been reviewed 
by CSAP, our colleagues at the National Institute on Health, 
the National Association of State Alcohol and Drug Abuse 
Counselors, and others, and only 39 of this 400 have achieved 
model status.
    There was a recent Institute of Medicine report that came 
out just a few weeks ago which pointed out that, unfortunately, 
15 to 20 years may pass between discovery of an effective 
treatment or intervention and its adoption as part of 
community-based care. With the near doubling of the Federal 
investment in clinical research and development, it is all the 
more important that increasing emphasis be placed on how 
scientific advances are incorporated into community care.
    SAMHSA works to use research findings to assist 
practitioners and consumers in selecting the best prevention 
and treatment options and delivering the safest and most 
effective and efficient interventions through our discretionary 
grant programs, including the Targeted Capacity Expansion 
Program that I referenced earlier.
    Mayors, town and county officials, the Congressional Black 
and Hispanic Caucuses and Indian tribal governments repeatedly 
have emphasized the need for Federal leadership to provide 
strategic and rapid responses to help communities address 
emerging drug use trends, mental health needs and related 
public health problems, including HIV/AIDS at the earliest 
possible stages.
    SAMHSA's Targeted Capacity Expansion (TCE) Grant Program 
was created to help local governments respond to these current 
and emerging services needs with state-of-the-science 
prevention and treatment tools. Not only do we require that our 
discretionary grantees use evidentiary-based interventions, we 
also require that they do evaluation both on the effectiveness 
and the efficiency of those interventions when you put them 
into practice in the community.
    The TCE grants are one way that SAMHSA spans the continuum 
from research to practice to bring services to a community-wide 
scale and assist other Federal agencies, States, tribal and 
local governments, community-based and faith-based 
organizations in their efforts to improve and sustain substance 
abuse and mental health services.
    Finally, we are also working on closing the treatment gap. 
According to the National Household Survey on Drug Abuse, there 
is a drug treatment gap of almost 3 million individuals in 
severe need of drug treatment. The Substance Abuse Prevention 
and Treatment Block Grant is the cornerstone of States' efforts 
of substance abuse programs. It provides support to over 10,500 
community-based treatment and prevention organizations and 
clearly is aimed at preventing substance abuse in the first 
place, a critical part of our strategy to close or reduce the 
treatment gap. In other words, if you can stop the number of 
people who are becoming users, you reduce the treatment gap 
because they don't become users in the first place.
    In the area of people with serious mental illness, the 
severity of gaps in community-based system of care was brought 
to the forefront in 1999 with the Supreme Court's Olmstead 
decision. To open more doors to needed mental health care for 
people with serious mental illness, the President is proposing 
to continue to fund the Mental Health Services Block Grant for 
a total of $420 million.
    As we work closely to close the treatment gaps for people 
with mental and addictive disorders, the newly expanded 
National Household Survey on Drug Abuse provides a yardstick 
against which annual progress can be measured both across 
States and across the years. And with the graying of America, a 
new survey component focuses directly on this population whose 
mental health and substance abuse problems all too often are 
overlooked or seen as just a part of aging. I would like to 
think for those of us who are getting grayer with the years, 
that those problems are not just a part ofaging.
    Over the years SAMHSA studies have shown that prevention, 
early intervention and treatment pay off in terms of reduced 
HIV/AIDS, crime, violence, suicide, homelessness, injuries and 
health care costs. They also result in increased productivity, 
employment and community participation.
    It is clear that the human and economic cost is much lower 
when we prevent or intervene early with the best research-based 
tools available. One way or another substance abuse and mental 
illness exact a cost on our society. Our choice is how we 
invest our resources to pay the bill. We can invest in proven 
prevention, early intervention and treatment services, or we 
can try and repair the damage that untreated substance abuse 
and mental health problems have created for individuals, 
families, communities and our society as a whole.
    I would like to take just a minute to try and put a face on 
who the people are who are in need of these services. These are 
people who look a lot like me. They look a lot like you. They 
look a lot like the people in this room. They look a lot like 
your family members, your friends and your colleagues. They are 
all at risk for mental illness or substance abuse at some point 
in their lives. Clearly, all of these people are in need of 
prevention messages, and there are times when all of them may 
actually be in need of treatment services. If indeed their 
health care program does not provide adequate treatment, then 
they may have to fall back on the public health service system 
in order to get that care.
    If you have a child who has become too old to be carried on 
your insurance policy, he or she may be in need of public 
sector dollars. If you become unemployed, which some of us in 
this room are at risk of every 2 years, and lose your health 
care coverage, you, too, may fall back on the public health 
system.
    I would also like to thank the Agency staff, most of whom 
obviously are not here, for all the work that they have put 
into developing this budget, and I would also like to thank the 
Department for the support that they have provided in bringing 
this budget to the Congress. We at SAMHSA appreciate the past 
support of the subcommittee and welcome the opportunity of 
working with you, Chairman Regula, and the Members to advance 
SAMHSA's mission. We will be pleased to answer questions. Thank 
you.
    Mr. Regula. Thank you.
    [The written statement of Dr. Autry follows:]

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                               RECIDIVISM

    Mr. Regula. I have a couple of questions.
    What is the recidivism rate; do you have any evidence on 
the treatment programs as to the percentage that slipped back 
into a pattern of usage?
    Dr. Autry. Let me start by giving you part of the answer, 
then I will ask Dr. Clark from the Center for Substance Abuse 
Treatment to comment on it.
    There are a couple of things that we know. Recidivism 
varies by type of drug, severity of drug use and duration of 
drug use. It also varies by the length of time in treatment. 
The longer you stay in treatment, the less likely you are to 
have recidivism, and there is variability depending on those 
two factors.
    So, Dr. Clark, would you like to add to that?
    Dr. Clark. Mr. Chairman, recidivism is also a function of 
how you characterize it. As the issue of alcohol or drugs is 
contemplated, we know that early in the process people have 
slips and are unable to recompose their lives and have 
sustained periods of abstinence. We know from health care 
professionals who have problems with alcohol and drugs that we 
can get a recidivism rate that decreases to around 20 to 30 
percent, which means we have an abstinence rate of 80 percent, 
again, depending on the intervention strategies employed.
    We know from our workplace drug testing partnership with 
the Department of Transportation that indeed the drug test 
positive rate has dropped dramatically over the past 5 years. 
So we know that with early intervention strategies, you can 
reduce your recidivism rate quite dramatically.
    We know from our treatment of--just community-based 
treatment we can reduce the number of people who are using to a 
much lower rate if we are using best practices. So in some 
context you need to use cognitive behavioral therapies, 
methadone maintenance. We can achieve an acceptable recidivism 
rate with best practices and adequate treatment.
    Dr. Autry. Let me add one comment to that. The American 
Society of Addiction Medicine came out a few years ago with a 
strategy for matching the level of care based on the severity, 
type and duration of drug use, so we can better target which 
type of program an individual needs to go to. By using the best 
practices in those programs, we have driven down recidivism 
rates over the years.

              COLLABORATION WITH BUREAU OF INDIAN AFFAIRS

    Mr. Regula. I think the Native American population has a 
growing problem. Are you involved with the Bureau of Indian 
Affairs, and is there an effort made to address that problem?
    Dr. Autry. Thank you again for that question, Mr. Chairman. 
We are very actively involved in dealing with American Indian 
and Native Alaskan populations. The entire senior management 
team, center directors and myself, just dida consultation out 
to the Southwest tribes about 6 weeks ago. We also work very closely 
with the Indian Health Service, who provides much of their care, and 
recently there has been a collaboration that has been developed between 
the Center for Substance Abuse Prevention and Bureau of Indian Affairs 
(BIA), which has recently reconstituted their substance abuse 
initiatives. We are very concerned about them because they have either 
the highest or second highest rate of illicit drug use, and alcohol 
use.
    Mr. Regula. As the Chairman of the committee for 6 years 
that funded the Bureau of Indian Affairs, I know what a 
difficult problem it is. Do you have a web-site on the 
Internet, so that if I were a superintendent of a school where 
there is a growing problem, I could at least look there to get 
some resource information? Obviously your Agency can't be 
everywhere, but do you have that type of capability?
    Dr. Autry. We do indeed have a web-site that is 
www.SAMHSA.gov, and there are hyperlinks to 
www.mentalhealth.org which also talks about substance abuse.
    Mr. Regula. Let me interrupt you. Do you put information in 
Scholastic Magazine and various publications that go out to 
teachers and so on so that they know about it?
    Dr. Autry. We do, in point of fact, have a plan for this 
fall to have a major investment with Scholastic Magazine 
because it not only gets to the kids, but it gets to the 
teachers and the parents, which will be a major help for us. We 
have a variety of publications that are available in print form 
and on our Internet that can be accessed through the SAMHSA 
web-site.
    Mr. Regula. Mr. Kennedy, I know you are interested in 
mental health.

                        PARITY FOR MENTAL HEALTH

    Mr. Kennedy. Thank you, Mr. Chairman.
    Let me just say it is interesting to me that in this 
country right now we have come so far, and yet we are so far 
back in the Dark Ages when it comes to our approach to this. It 
is just the fact there is only a few of us here at today's 
hearing says a lot about what people see as a priority in terms 
of mental health and substance abuse treatment.
    It seems to me it is absolutely fundamental to all the 
other health issues that we address in this committee, because 
all the areas of behavioral health and the like all come back 
to one, mental health. Just the fact that we are still do not 
have parity in health insurance coverage for mental illness is 
a perfect example of the fact that while we are in the 21st 
century, we are really back in time when it comes to making 
sure that for millions of Americans who suffer from mental 
illness are not relegated to the shadows of our society.
    It is absolutely incredible to me that as much as we talk 
about this is the land of opportunity, we really shut the door 
of opportunity to millions of Americans who are relegated 
because we don't have adequate copay, you know, or even the 
Medicare system. Our Medicare system doesn't even pay the same 
in terms of reimbursement that it does for other illnesses. 
What is that supposed to make us think, that mental illness is 
less important than other physical illnesses?
    In light of all the science that we have, National Academy 
of Science, Surgeon General's report, we still treat mental 
illness as if it is not a physical illness, and it is 
absolutely incredible to me, even with all the people in the 
popular culture today in terms of rehabilitation and the like 
and the knowledge that people have, that we are still 
underfunding part of our budget that could make an enormous 
difference in the quality of life of millions of Americans.
    I have so much I want to talk about today, Mr. Chairman, I 
don't know where to begin, but let me start with the whole area 
of the substance abuse block grant which you have increased. I 
find from folks that I am talking to in my State that one of 
the single greatest problems to addressing people's mental 
health is that we have such a silo effect between the mental 
health block grant and the substance abuse block grant. The 
substance abuse treatment folks are here, and the mental health 
folks are here, and no one wants to give up turf. We have got a 
bunch of people who have commercial, and financial self-
interest in maintaining their part of the pie, and it has 
absolutely been destructive to the comprehensive treatment of 
individuals in my State, and I am sure across the country, when 
we have this silo effect.
    What are you proposing to do to eliminate this silo effect 
so we don't have mental health here and substance abuse 
treatment here when we both know that they overlap? When it 
comes to funding, each side is protecting its turf rather than 
working in a comprehensive way to address the needs of the 
patient rather than their own self-interests, what are we doing 
to address that?
    Dr. Autry. Again, thank you for that question, Mr. Kennedy. 
There are a couple of things that I think we need to highlight. 
We have been aware of this concern for quite some time, and we 
have worked with the National Association of State Alcohol and 
Drug Abuse Directors and the National Association of State 
Mental Health Program Directors to do a ``white paper'' to talk 
about how we can use the funding that is available to the 
States more effectively, and that has been, I think, a major 
step forward.
    The second is that we continue to work with our colleagues 
at NIH to look at developing more effective treatment 
interventions, particularly for those who have co-occurring 
disorders, which is where this kind of problem becomes most 
acute.
    Thirdly, one of the things that you will see in the 
proposed budget is that there is a 20 percent transfer 
authority that would allow funds to be shifted back and forth 
by the State in order to meet areas of acute need that might 
not be met, and as you put it, by one silo or another silo. So 
that is a growing area of concern.
    Fourthly, in our Treatment Capacity Expansion Program, you 
will find that there is a specific focus on co-occurring 
because we share your concern that, and our data show that 
anywhere from 40 to 65 percent of people may have a co-
occurring illness.

                        TREATMENT EFFECTIVENESS

    Mr. Kennedy. Speaking of that, what are you doing in the 
translational science area? How do you get the modern science 
that comes up in terms of various modes of treatment, how 
effective they are, out into the community so it is not just 
amongst the experts, but it can be translated into the 
community? What are you doing?
    First of all, if you can get me that white paper that you 
are talking about, I would like to share it with my folks back 
home, but to get to the point you just raised, how do you get 
the research out into the field?
    Dr. Autry. That is an issue for which we have a number of 
different avenues. First of all, as I mentioned earlier,we have 
a number of print and Web-based ways of communicating. We have programs 
that are geared to requiring that our discretionary grantees use 
evidence-based practices and evaluate those as they are out in the real 
world. We work with our colleagues at NIH to make sure that our staff 
are aware of the latest research findings. We provide feedback to the 
NIH staff by our staff as to the areas in which we are developing new 
programs based on evidentiary-based practices, and our senior staffs 
consult with one another to make sure we are aware of what each other 
is doing in each area.
    In working with the communities and requiring evidence-
based practices, we are finding that we are upgrading the 
quality of both prevention and treatment intervention and early 
intervention practiced.
    It is clearly an area that we need to do more. As we make 
more investments in NIH to bring forth more interventions, we 
need to put more emphasis on translating best practices to the 
community. That is the role of our Agency and others in this 
service arena.
    Mr. Kennedy. If you could get me some more information 
about why you think it is an area that you need to continue to 
do more in, because I think you are right. The key is now with 
the modern sciences getting it out into the field.
    You talked about this in your opening remarks, and you said 
Diogenes said the foundation of society is education of 
children, you mentioned in regard to the Safe Schools/Healthy 
Kids. That has been cut in the Department of Education, and the 
whole idea of sharing information between the different 
agencies is so critically important to the treatment of the 
kids and addressing their needs rather than, again, this silo 
effect.
    So will you encourage your counterparts in the Department 
of Education who work with you in the Safe Schools/Healthy Kids 
program to see that the Department of Education increases their 
budget?
    Dr. Autry. We will certainly work with them, and I can 
assure you they are aware of the need to continue to fund this 
type of program.
    Mr. Kennedy. It has been cut over 40 percent, though, in 
the Department of Education, and that is a program everyone 
tells me works.
    Dr. Autry. We have a recent example within the past several 
weeks where one of the schools that is part of the Safe 
Schools/Healthy Students grant had students who called in and 
talked to authorities in that school when they became aware of 
a potential threat of violence. Yes, it does work.
    Mr. Kennedy. Okay. Well, in regards to the Olmstead 
decision and implementing it given the President's New Freedom 
Initiative, given the fact that it is considered discrimination 
to keep people in institutional settings, and given all of this 
and the fact that 20 percent of Americans have a mental 
disorder in any given year, what are we doing given the 
shortage of community-based mental health services to increase 
community-based mental health services? This budget, I might 
add, flat funds community-based mental health grants, which to 
me again is the wrong message that we need to be sending.
    Dr. Autry. Let me start by answering that, and then I will 
ask Dr. Arons to contribute to that. Clearly community-based 
services is the way that this country is moving for several 
reasons. One, we are finding that they are not only more 
effective, but they are more cost-effective.

                  Community Mental Health Block Grant

    Mr. Kennedy. Right. But right now, Mr. Chairman, in my 
State, we are having a crisis in our hospitals. We have all of 
our psychiatric hospitals--Bradley, one of the most premier 
children's psychiatric hospitals, in the Nation tells me on any 
given night there are 30 percent of those kids that don't need 
to be there if they were just able to get into community-based 
treatment. So why are we wasting all this money and not 
integrating these kids, and violating the whole spirit of the 
ADA and not implementing Olmstead? Why have you not funded an 
increase in the Community Mental Health Block Grant? It doesn't 
make any sense. It doesn't correspond whatsoever to the 
President's New Freedom Initiative. It absolutely is against 
the Olmstead decision.
    There is just no answer. There is no excuse for it. I 
really hope that--I know all of you are institutional folks 
over there. I know you know that what I am talking about is the 
way to go, but we need to make sure the political folks up top 
understand that and that this is not going to be permissible.
    Dr. Autry. Interestingly enough I think the Secretary, in 
response to some earlier testimony, made a commitment to work 
with the Congress to address those mental health concerns. We 
share with you a continuing concern about implementing 
Olmstead, and we have some technical assistance and training 
programs that we are proposing to work with the States to make 
that possible.
    Let me ask Dr. Arons if he would like to add to that.
    Dr. Arons. I think that was well stated, and we would agree 
with what you said initially that the quality of life of all 
Americans, really the health of the Nation, is very much 
intertwined with our ability to provide these kinds of services 
throughout the country. We do have effective services both for 
children, for adults and for the older Americans for community 
services that we think are effective, and we want to help 
communities implement those effective practices.
    Mr. Kennedy. I would be very interested in getting your 
specific proposals for how you are going to deal with the 
senior boom, the baby-boom generation in terms of addressing 
their mental health needs.
    Mr. Regula. We will have hopefully a second round. I want 
to try to get to----
    Mr. Kennedy. I am sorry, Mr. Chairman.
    Mr. Regula. We want to try to finish this panel up by 
11:00, so if we have time, we will get back to you.
    Ms. DeLauro.

                           Children Violence

    Ms. DeLauro. Thank you, Mr. Chairman. Thank you very much. 
Thank you all for being here and appreciate your time.
    Dr. Autry, every year there is more than about a million of 
our youngsters who are abused or who are neglected in their 
home in some way. We have got about 3 million kids in this 
country who are witnesses to violence in their lives. The 
statistics are truly staggering. We have got 600,000 children 
are victims of violent crime, 20,000 are wounded by gunfire, 
and a growing number are either injured, or they are killed at 
school.
    There is evidence that children who survive or whowitness a 
violent experience suffer from psychological trauma in some way that 
could last a lifetime. The symptoms manifest themselves after the event 
or after months or even after some years. And leaving the problem 
without any treatment can lead--and you all know this better than I 
do--to future trauma for the child, whether it manifests itself again 
in anxiety, depression, learning difficulties and their own violent 
behavior. So we have got a whole set of circumstances that result 
either from the witnessing of or being the victim of abuse by our 
youngsters.
    We moved to try to address this issue last year, and I'm 
very excited about the creation of the Post-Traumatic Stress 
Disorder Program, and which is for children and youth who 
survive or witness violence. It was funded at a level of about 
$10 million, a good first step in my view, but I am of the view 
that we have to do better in this effort.
    I am from New Haven, Connecticut, where I have watched the 
community policing program develop where you have people from 
the Yale Child Study Center working with the New Haven Police 
Department in one of the most exhilarating partnerships that I 
think we have seen come down the pike, and looking at police 
officers who are, you know, these kind of burly, crusty guys 
who have been on the force for years and years, sitting with 
the clinicians and talking at the case study meetings about 
what needs to get done for the children that they often witness 
firsthand in a circumstance of violence, and it has been 
tremendously successful and replicated.
    But we started this program here, and my hope is that with 
all of you--and I say this to the Chairman, and the Chairman, 
most of you know, was a principal and I think probably has much 
firsthand experience in watching what has happened to kids as 
they come through the door and what some of those circumstances 
are at home and elsewhere for these youngsters.
    But my hope is that we can deal with full funding for this 
program, and that is at a level of authorization of $50 
million. From what I understand, there is great interest in the 
program. I know in my State we are interested in it, people 
from Hawaii, California, Massachusetts.
    If you could just tell us about interest in the program, 
what it has been since its inception and what we might be able 
to accomplish with the full funding level.
    Let me just say, Mr. Chairman, I want to enter into the 
record an editorial that appeared on May 2nd in the Miami 
Herald, which I think lays out the need for the program. If I 
can have it inserted in the record.
    Mr. Regula. Without objection.
    [The information follows:]

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    
    Ms. DeLauro. Thank you.
    And then, Dr. Autry, I would like to have you address this 
issue of the level of interest and what we could do with full 
funding for this program.
    Dr. Autry. Thank you for that question. Let me start by 
saying how much we appreciate the starter funds, as you 
indicated, that we received for 2001. It has been a very 
exciting program area for us because we recognize that these 
children are at much higher risk for developing mental illness 
and substance abuse as they grow older. Let me ask Dr. Arons if 
he would respond and tell a little bit both about where we are 
developmentally with the program and also about the interest we 
have heard expressed so far.
    Dr. Arons. This is a very important program. This is a $10 
million program, and we will see within the next several weeks 
a request for application--an announcement about the program.
    In addition to the editorial that you mentioned, there was 
also one in a paper in the Boston Herald. This is receiving 
increased attention because of the possibility that young 
people, who have been the victims or witnesses of violence, 
move on as adults to perpetuate the violence. We need to 
address this issue early on.
    We have received a lot of phone calls and interest in these 
grants, and we expect to see a tremendous number of 
applications which will be reviewed, and we will be awarding 
the first grants in September.
    Ms. DeLauro. If it isn't proprietary at this moment, I 
would just love to know where the requests are coming from, 
what parts of the country, et cetera, because, again, I just 
think that this is one of the most forward-thinking things that 
we have done to reach out and to try to deal with the problem 
that exists at a tremendous level here. I would love to work 
with you, and the Chairman knows my interest in this effort, 
and work with him to see what we can do about being able to 
build and get full funding for this program. I think it would 
make a tremendous difference.
    Dr. Autry. One of the things we can provide to you is the 
number of applications. It will indicate where they came from 
geographically. It will show the number that were scored and 
the number we were able to fund out of those that were scored.
    Ms. DeLauro. Terrific, and I am going to try to make to 
available to my colleagues information from people I know who 
have done a lot of work in this area and see if I can get those 
people up here to sit down with my colleagues so that on a 
broad base they can get a sense of what this is about and look 
for support here.
    The PATH Program, transition from homelessness, mental 
health services for homeless people, serious mental illness is 
authorized at 75 million. The President's budget request, 37; a 
freeze in funding from last year. Can you tell me what funding 
level the Agency recommended to the Department for PATH in 
fiscal year 2002, what is SAMHSA's estimate of the number of 
homeless people who could benefit from PATH services, and what 
is your estimate of the level of funding that is necessary to 
assure that all homeless people who could benefit from PATH 
services are able to access the program? My colleague Marcy 
Kaptur, recently spoke about a staggering number of the 
homeless who are suffering from mental illness and a very, very 
high percentage of them being veterans in this country, so we 
ought to be able to look at this, and the President's budget 
request, $37 million. What had you all recommended, and if you 
can address the other two issues.
    Dr. Autry. Let me answer part of your question, then I will 
ask Mr. Dennis Williams to address part of it.

                                Homeless

    Ms. DeLauro. Half of the homeless veterans have mental 
illness. That is a staggering number of people.
    Dr. Autry. And we can certainly get that information for 
you.
    In terms of what we submitted to the Department, that is 
typically confidential information, but, Dennis, you may want 
to comment on that.
    Mr. Williams. Ms. DeLauro, OMB has reminded us that 
predecisional information on the budget is to be held within 
the administration, and we are not to release that information. 
The Director of OMB has reminded us--all agencies of an 
instruction a couple of weeks ago, and so we are asked not to 
release that predecisional information.
    Ms. DeLauro. Well, what about your estimate of the level of 
funding necessary to assure homeless people--certainly if you 
have got those numbers in your head--and you have seen them and 
so forth, maybe you can tell us what it is going to take to try 
to deal with the folks who need these kinds of services.
    Dr. Autry. We will submit for the record an estimate of the 
number of people in need of services and the cost per services.
    Ms. DeLauro. And what that recommended level of funding 
would be in order to be able to reach the number of people who 
need the services, can we get that from you?
    Dr. Autry. I think if you have the numbers and the average 
cost per services, that will be a number we can derive.
    [The information follows:]
                                  PATH
    Of the 600,000 individuals who are homeless on any given night, 
approximately one-third have a serious mental illness. However, there 
are no definitive, or frequently cited, annual estimates of the 
additional persons with serious mental illnesses or serious emotional 
disturbances (1) who cycle into homelessness; or (2) become at risk of 
homelessness. Because there are no definitive estimates of the larger 
annual number of persons eligible for PATH-funded services, we cannot 
accurately answer your question. However, we estimate there are at 
least 200,000 persons eligible during the year.
    In FY 1999, PATH-funded community based agencies served 59,000 
persons with serious mental illnesses or serious emotional disturbances 
who were either homeless or at risk of homelessness. The federal 
funding contribution was approximately $441 per person.

    Ms. DeLauro. Okay. Thank you.
    Thank you, Mr. Chairman, I have some other questions I will 
submit for the record.

                       Losing the War With Drugs

    Mr. Peterson [presiding]. The Chair thanks the lady.
    I would like to ask a question about kids. I guess one of 
the concerns I have is I look on all the charts and graphs 
here, and from evidence in my own communities, young people are 
seemingly involving themselves in drugs younger and younger, 
and that is the population, I guess, that scares me. Lives 
are--kids are pretty fragile, 10, 11 and 12 years of age, to 
get illicit drugs in their bodies at that age, and I guess it 
is frightening for a grandparent. It scares me. My 
grandchildren get tired of me talking about it, too.
    But what is the most important thing we can do for that 
youngest group where it seems the growth is the fastest? The 
scary part right now is we have made some progress, but where 
we seem to be losing the war is with very, very young kids. 
Where is the best place to spend money there? Where is our 
system the weakest there?
    Dr. Autry. Let me start by addressing that question, 
Congressman. First of all, you are quite right, there is an 
increasing concern that the younger you are and the younger you 
start using drugs or alcohol, the more likely you are to become 
addicted or dependent on that drug or alcohol. That has been an 
increasing concern for us at SAMHSA.
    One of the things that we are doing is beginning to look at 
our household survey and the younger populations sample. We are 
also beginning to develop a module that will allow us to track 
the same children across time to look at risk and protective 
factors, and predict who might be at higher risk for, or have 
more protection from the use of drugs.
    We know that there are several proven interventions that we 
can use, and we have one element of our program that actually 
focuses on the zero to 6 years of age, looking at behaviors 
that develop very young that might predispose someone to try 
drugs at a later point in life.
    Allow me to ask Dr. Ruth Sanchez-Way if she would like to 
comment in terms of the prevention aspects.
    Ms. Sanchez-Way. Yes, I would like to add to that because I 
think that was a wonderful question that you asked. We, over 
the years, funded a number of programs that address high-risk 
students and young people. We did a large cross-site evaluation 
of over 400 programs, and they looked at the results of over 
10,000 young people. We found that we were able to reduce the 
use of substances 11 percent at the end of project and 28 
percent 18 months after the end of the project.
    The strongest effects or the most important areas that we 
found that delay the use of substances is through family 
bonding, relationships with peers, as well as clear values and 
standards, and having consequences for those standards that are 
violated, reasonable consequences. We also knowthat the 
perception of use by family and peers or their attitudes toward the use 
of substances is very important as well. Bonding to school as well, 
doing well in school, being able to feel that they can achieve in 
school, having the ability or the feeling that they are heard at home 
and that their concerns are taken into consideration are all strong 
indicators as to whether a young person uses substances.
    Mr. Peterson. I guess, how does--there is a list of five 
that I have seen given, too; if young people are involved in 
three family meals a week, if they have an annual vacation with 
the family, if parents interact in homework once or twice a 
week. It had five issues. If you do those five things, your 
kids are very unlikely to be involved in drugs, but that is not 
the world we are dealing with.
    In my view, you know--I don't know what the percentage is. 
I guess that it is close to a third of young people who are 
kind of raising themselves, and I am from rural America. I am 
not from urban America. I am from the most rural of America, 
but there are a lot of young people out there that are sort of 
raising themselves. They will have one parent in the household 
who may be holding down two jobs or have other problems, and 
once the children reach that age where they can do things for 
themselves, they are kind of turned loose.
    Ms. Sanchez-Way. When we talk about family bonding, we are 
talking about not only a two-parent family, but also if there 
is one parent that is able to bond well; but we are also 
talking about grandparents, mentors, coaches in schools, 
schoolteachers. That ability to bond with the school or the 
family is an important aspect to prevent substance abuse.

                    Treatment Programs for Children

    Mr. Peterson. How do we--if children--once they get 
involved and have a habit at that young age, isn't that a 
specialized treatment program? I mean, do we actually have many 
treatment programs to deal with young teenagers that are 
available to kids that young that are focused on their age 
group?
    Ms. Sanchez-Way. We have a number of prevention programs 
that focus on young people when they start using substances 
that have been shown to be effective, but we identify these 
young people, and then we refer them to the treatment system. 
And I would like to refer that question to Dr. Clark.
    Mr. Peterson. Proceed.
    Dr. Autry. Allow me to make one comment before I turn it 
over to Dr. Clark. One of the things that we have become 
increasingly aware of, is that many times the treatment 
programs that are designed for adults do not work as well in 
adolescent populations, and for those who have raised 
adolescents or currently are raising adolescents, that 
shouldn't come as a surprise. We are seeing that both us and 
our colleagues at NIH are increasingly focusing on developing 
interventions that are targeted to those populations. Allow me 
to ask Dr. Clark to talk about our involvement in this area.
    Mr. Peterson. I am going to have to suspend and go run and 
vote and be right back. I guess I am down to 2\1/2\ minutes.
    [Recess.]

                    Coordination with Other Agencies

    Mr. Regula [presiding]. We will reconvene, and I know Mr. 
Peterson has some additional questions, and probably Mr. 
Kennedy, when they get back.
    It seems like there is a proliferation of programs. DARE 
deals with one facet with the drug problem. Is there 
coordination, or is turf a problem? I hate to characterize it 
that way, but I have observed occasionally in the past that 
turf does interfere with coordinating programs. What are your 
observations on that issue?
    Dr. Autry. Mr. Chairman, allow me to make a couple of 
comments on that. I think you are quite right that in the past 
turf has been an issue. One program may be contending for the 
same buck that another program is contending for. But I think 
increasingly over the past several years, we have had much 
better coordination and collaboration.
    Within the Department we have something called the 
Prevention Round Table in which we meet regularly to talk about 
both actual programs and proposed programs. We have our own 
Internet site, where we can post what is coming up and solicit 
partners in that respect.
    Secondly, working with our colleagues at the Department of 
Justice, at ONDCP, Department of Education and the Department 
of Labor, we are increasingly coordinating our efforts in that 
regard. One of the programs is called the State Incentive 
Grants Program, a grant that goes to the Governor or his or her 
designee, and allows the State to pull together all of the 
substance abuse funding resources that come into that State for 
prevention, in order to do a better coordinating job. Eighty-
five percent of those funds actually go out to community 
organizations, which is a very effective way of not only 
leveraging additional resources, but making the best use of 
those resources that are there. That is a commitment on the 
part of those of us in the prevention community to continue to 
do that type of activity.
    Mr. Regula. Do you work through the public health agencies, 
which, of course, every State has an agency of that type?
    Dr. Autry. Mr. Chairman, we work primarily with the 
National Association of State Mental Health Program Directors, 
National Association of State Alcohol and Drug Abuse Directors. 
We also work with our colleagues at the Health Resources and 
Services Administration, who work with health officers in the 
States, our colleagues at the Centers for Disease Control and 
Prevention work with the regional directors and regional health 
administrators (RHA) in order to better coordinate our efforts.
    We had a series of meetings around the country, regional 
meetings, regarding substance abuse prevention about a year and 
a half ago. The RHAs, and the State directors for health, 
mental health, and substance abuse all were invitees to that 
meeting. A little over a year ago, we sponsored a conference 
with the Department of Justice and ONDCP in which we invited 
law enforcement officials from both the local community and the 
State community to meet with the health directors, the mental 
health directors and the substance abuse directors, because we 
recognize the fact that the populations that we deal with 
overlap significantly.
    Mr. Regula. Do you feel that you are having some success?
    Dr. Autry. We are having success. I also feel like we need 
to be able to do more in terms of coordination and 
collaboration. We have seen that by doing this, it does have 
payoff, but unfortunately, many times I think at the Federal 
level, since we get our budget sort of in ``silos'', if you 
will, it is hard to sort programs across those silos. Ithink we 
are making progress, and I think we have more that we need to do.
    Mr. Regula. Mr. Kennedy, Mr. Peterson hadn't finished, but 
to use our time, I will turn to you and then back to him when 
he gets back.

                          SENIOR MENTAL HEALTH

    Mr. Kennedy. Thank you, Mr. Chairman. Maybe I can get the 
answer to the question I was looking at before in regards to 
senior mental health and what we are doing to prepare for the 
senior boom, and addressing the fact that seniors are obviously 
at a great risk of late-life depression as a result of the loss 
of loved ones, their health, a whole host of situations. Maybe 
you could address for us what programs and initiatives you are 
undertaking to address this in a systemic level.
    Dr. Autry. Allow me to answer, then I will ask Dr. Arons if 
he would add to that.
    We have a strategic planning process that addresses the 
aging population in both substance abuse and mental health 
illness, and although I am personally more into strategically 
aging, we are looking at how to address the aging population 
more strategically and are in a planning process that involves 
all the component parts of the Agency.
    Dr. Arons, do you want to add to that?
    Dr. Arons. This is a very exciting time because just 
yesterday we had as part of that strategic planning process a 
seminar to summarize what we know about aging and mental health 
issues. We are just completing a multiyear program on how to 
best provide mental health services and substance abuse 
services to older Americans in the primary care setting, in 
their doctor's office. By the end of this month we will have 
screened over 50,000 older Americans to see whether they are 
having difficulty with alcohol or depression, or severe 
anxiety. We are looking at whether services are more 
effectively provided in the doctor's office or by referral to a 
mental health center. We think that--the findings of the study 
will then become something we can bring to the Nation. So we 
are very excited about what we have to offer in this area.
    Mr. Kennedy. When is the study to be completed?
    Dr. Arons. The study will be completed by the end of the 
year, by September.
    Dr. Autry. Allow me to ask Dr. Westley Clark to talk about 
what they are doing in the substance abuse area, and then maybe 
Dr. Goldstone would like to talk a little about the module we 
are expanding in the household survey to get a better 
understanding of mental health, disability and substance abuse 
in the elderly population.
    Dr. Clark. Mr. Chairman, Mr. Kennedy, one of the things we 
are trying to do when you raise the issue of knowledge 
transfer, we at the Center for Substance Abuse Treatment have 
developed a treatment improvement protocol series, and we have 
one of our Treatment Improvement Protocols (TIPS), we call 
them, substance abuse among older adults, and we promote this 
to practitioners in the field, whether they are substance abuse 
counselors, psychologists, social workers, et cetera. We make 
sure that they get the state-of-the-art information in an 
applied form that they can use in their settings.
    Another thing that we do is we make the treatment of older 
adults a priority in our Targeted Capacity Expansion Program. 
For instance, we have a project in Canton, Ohio, Stark County, 
where the Senior Workers Actions Program is in the process of 
reaching out to older citizens in the Stark County area in an 
effort to deal with their services, and they are discovering in 
an applied sense how to reach out to and deal with issues of 
stigma. There is often a reluctance on the part of older 
Americans to admit that they have either a mental health or a 
substance abuse problem, and we are working with our Targeted 
Capacity Expansion effort so that we can enhance our knowledge 
on how to provide better services in an applied way.

                                MEDICARE

    Mr. Kennedy. Well, to the extent that you can do that 
please do. We know--by the way, Mr. Chairman, the project that 
you mentioned in Ohio and others are going to be cut by, as I 
see it in this budget, $15 million. Regarding the mental health 
programs, you flat-funded the Mental Health Block Grant, and 
you have cut discretionary funding for mental health in the 
budget. I just want to make that clear because it is not again 
where we need to go. We need to be doing the opposite. So just 
to do these kinds of programs, we need the funding that is now 
being called for to be cut.
    So I can't beat this down enough. It is just not where we 
need to go. I appreciate what you are saying, but it doesn't 
reconcile with the budget that the administration has put 
forward.
    When are you going to get Medicare to realize that 
overutilization of Medicare is happening as a result of 
untreated mental illness? When is somebody going to realize we 
are going to save a lot of money on the Medicare side if we 
just treat depression and mental illness among seniors so they 
don't have to go to 15 different doctors because they just want 
a little attention.
    Dr. Autry. Let me address that for starters, and then I 
would like Dr. Goldstone to talk a little bit about what we are 
doing in terms of the data area, and about the treatment 
facility locator, a tool that is available for a variety of 
people, including the elderly.
    One of the concerns that we do have is that Medicare does 
not fund mental health services on par with other services. 
This is an ongoing dialogue that we have with HCFA and our 
colleagues there. We have one of our very senior staff on 
detail there to help make sure these issues are at the 
forefront of their thinking and to continue the dialogue with 
us around those issues. I would suspect that as this 
administration goes forward, we will continue to grapple with 
and address those issues.
    Mr. Kennedy. I would love to be in contact with that 
person, and I know I am already trying to work on HCFA myself 
to try to get them.
    Dr. Autry. It is Dr. Frank Sullivan. I would be glad to get 
you his name and contact number.
    Dr. Goldstone, would you like to talk about the survey and 
facility locator?
    Dr. Goldstone. Just to comment about the problem of 
understanding what goes on in substance abuse and mental health 
in the aging, the fact is we have very little data on this part 
of the population. There was a survey done about 5 years ago, 
but it stopped at the age of 55, and so we are really lost in 
understanding what the dimensions of this problem might be. And 
in our request for 2002, we have proposed the addition of a 
somewhat larger sample in the National Household Survey on Drug 
Abuse to study the elderly, and as well we are developing a 
special module which will try to get at the particular problems 
of this group.
    Almost as it stands, we know that we run about--almost 
1percent now is our estimate of people over 65 have a substance abuse 
problem that is related to the use of illicit drugs.
    Mr. Kennedy. One percent?
    Dr. Goldstone. One percent.
    Mr. Kennedy. What is that, a joke? That must be a joke.
    Dr. Goldstone. No.
    Mr. Kennedy. Well, I would assume 1 percent shows that you 
obviously don't know anything about the situation.
    Dr. Goldstone. And that is based on a very small sample, 
and it does not get at the whole----
    Mr. Kennedy. That is ridiculous. Any one of us going into 
any senior high-rise in any of our States will tell you that 
there is a serious mental health crisis and substance abuse.
    Dr. Goldstone. And all I am relating to is the question of 
the use of illicit drugs by the population who are over 65. I 
am not talking about mental health problems, only illicit 
drugs, and I am not talking about the abuse of prescription 
drugs, which we expect is a much more serious problem.
    Mr. Kennedy. Okay.
    Dr. Goldstone. And alcohol, I think there have been some 
studies, and we know that is a serious problem, but illicit 
drug use alone in a population group where we don't expect to 
see any of it we think is a more serious and a growing problem 
than we have ever seen before.
    Mr. Kennedy. Well, if you could put that, again, in some 
further statement in the record, I think it will help convince 
our colleagues we need to do more in this area.
    Dr. Goldstone. The other----
    Mr. Kennedy. I know we have to go back to my colleague Mr. 
Peterson.
    Dr. Goldstone. The only other comment I would make is that 
one of the initial questions had to do with what we are doing 
to try to make services known and available to the population. 
We do a survey of facilities across the United States to find 
out what kind of services they offer, where they are located, 
whether they take Medicaid or private health insurance, whether 
they will provide free care. We have developed a system which 
will take an address or ZIP code, on the kinds of services the 
individual is looking for or the problem he or she would like 
to have treated and provide over the internet a map showing all 
the facilities near them that can meet their needs, including 
information on whether the facility can treat them if they have 
a language different than English.
    Mr. Kennedy. Provided you have health insurance.
    Mr. Regula. Mr. Peterson.

                     ADOLESCENTS TREATMENT EFFORTS

    Mr. Peterson. I was awaiting, Dr. Clark, I guess, was going 
to respond to my last question. Dr. Clark.
    Dr. Clark. Mr. Chairman, Mr. Peterson, one of the things we 
recognize is that indeed once prevention efforts fail, you need 
to have treatment efforts that address the needs of 
adolescents. In fact, in the President's budget, we propose $14 
million for youth treatment, and we will focus on the broad 
spectrum of youth treatment, but we will have both outpatient 
and residential treatment. We have previously supported three 
youth-focused discretionary grant activities, adolescent 
treatment models, cannabis youth treatment and our Targeted 
Capacity Expansion projects focusing on youth populations. And 
in addition to the treatment models, we have also developed 
treatment improvement protocols that focus on adolescents for 
providers in the community, and we are attempting to educate 
providers and coaches and teachers, those who are concerned 
about adolescent substance use, about the nature of it, how to 
screen for it and how to recommend, a corrective course of 
action.
    We have a treatment locator in our database. It is a SAMHSA 
database where we can also enhance the ability of people in 
their local communities to identify treatment programs in their 
own communities. So we are working with that. We recognize 
adolescent treatment, residential treatment does cost more, and 
that is an issue, but we are trying to address that.
    We also recognize that you need to deal with adolescents 
who are involved in the juvenile justice system. We are working 
with the Justice Department. We have proposals within the 
budget to deal with reentry, adolescents coming from the 
juvenile facilities, coming back into the communities, 
recognizing that they need support so that they don't relapse 
not only in terms of substance use, but also juvenile 
activities that brought them to the attention of the juvenile 
justice system in the first place.

                              WAR ON DRUGS

    Mr. Peterson. I have always looked at the drug issue as a 
three-legged stool. We have education and prevention, we have 
enforcement, and we have treatment. How would you rate our 
efforts in this country on those three issues? Which of the 
legs of the stool are the longest, and which are the shortest, 
because it is not setting even in my view?
    Dr. Autry. Allow me to address this issue by saying that it 
depends on your yardstick. If your yardstick is money, the 
three legs are not equal. If you look at the effectiveness, I 
believe that prevention, early intervention and treatment have 
been shown to be the most effective way to address use, 
particularly among the youth in this country.
    Mr. Peterson. Should our efforts be more focused on the 
general public understanding the signs? I find families--I am 
always--you know, I have always been fond of kids, watch kids. 
I often can tell for some reason. I was a retailer for 26 
years. I knew when kids were in trouble, but a lot of parents 
have kids, you know, under their noses, and they don't realize 
what their kids are doing. Don't we have to somehow do a better 
job of getting the general public aware of what the telltale 
signs are of kids, because their behavior does change when they 
get involved in drugs?
    Dr. Autry. Allow me to address this issue, Mr. Peterson, 
and then ask Dr. Sanchez-Way to comment on it.
    You are quite right that there is a tremendous amount of 
education that we do need to do. Dr. Sanchez-Way was talking 
earlier about family bonding being one of the stronger ways of 
preventing drug use and abuse. Yet I think we have a long way 
to go in terms of educating parents. The significant caregiver 
really does have an impact on that kid's use of substance and 
their behavior in the future.
    We think in prevention there are a variety of methods that 
you have to intervene with. The sort of general intervention 
that you are talking about is certainly a key part of that. If 
you look at the Institute of Medicine model, there are also 
other parts that need to go hand in glove with getting out the 
message about the dangers of drug use, what it does to your 
potential, et cetera.
    Let me ask Dr. Sanchez-Way to talk about that a little bit 
more.
    Ms. Sanchez-Way. Yes. What we need is a comprehensive 
approach. Providing information is one aspect of this approach. 
Yes, we do need to give information to the general public, to 
teachers, et cetera, as to what the signs are, but you also 
have to give them the knowledge and skills to address these 
issues. It is not only identification, but what do you do 
afterwards. We have developed many, many materials that help 
caregivers address these issues with their young people. We 
also need to provide opportunities for young people to take 
part in community activities, to contribute to our communities. 
We need ability to educate them in skills development and how 
to confront the issue when somebody does offer them drugs, how 
do they deal with that. We need to change society's norms when 
it comes to looking at the use of substances and how the 
community deals with alcohol and drug issues. So we can't just 
pick out one aspect. They are all important, and they are all 
important in prevention. Thank you.

                            Treatment Models

    Mr. Peterson. We had a group in here from California a 
month or so ago that I was taken with that--in drug rehab, it 
is a technical school, and everybody in America--corporations 
have invested in that program, and every one of those students 
comes out of there with a trade and skills in their--and they 
all get a job. They all are back--they are into the workplace 
in probably a better job than they ever had in their life, and 
I am not so sure that we shouldn't be thinking about that; that 
when people, especially young people, when their whole life is 
ahead of them, if we can somehow salvage them, the sooner the 
better. I mean, are there many models like that where skills 
are taught along with treatment?
    Dr. Autry. Again, let me start by addressing it. Certainly 
three are models like that. When you look at prevention, there 
is a model that you have three different kinds of intervention: 
universal, selected and indicated. The part you are talking 
about is the indicated where somebody clearly has a problem, 
needs this treatment, and then you have to work on either 
habilitation or rehabilitation in order to get them back out 
into the community.
    The selected models are those that focus on kids who are at 
higher risk for drug use, and the universal models are those 
that you were talking about earlier where you need to get the 
message out to everyone. There are a number of programs, I can 
think particularly of one in Detroit, that also is geared to 
make sure that kids who come out of treatment with skills that 
are needed in order to get them a job, get them to be a 
contributing member of society, and get them to be taxpayers 
rather than tax burdens. If you will, we can certainly provide 
you a list of some of those that we know about.
    Mr. Peterson. Final question.
    Mr. Regula. Okay.

                             School Testing

    Mr. Peterson. The military had a huge problem 10, 12, 15 
years ago. They went to random testing. Their problem dropped 
immensely. Corporate America and the employers of this country 
have been having a huge problem with drugs in the workplace, 
and I am here to say that in the very near future there will be 
most jobs when you sign an application, you are going to be 
notified that you are going to be randomly drug tested. It 
happens in many, many companies in my district, and I am 
thinking most major companies are doing that today.
    What would be wrong with a program in our schools of 
testing where schools can opt in to test kids randomly, parents 
can opt out, and if the parents don't opt out, the kids are 
randomly tested? That is a negative peer pressure not to do 
drugs because they know they are going to get caught. What 
would your reaction be to that?
    Dr. Autry. Allow me to give you two responses to that. 
First of all, there was a Supreme Court decision about 2 years 
ago in which they said that schools could test athletes because 
athletes are many times viewed as being leaders within the 
school. For selected populations in the school, that has been 
something that we have been able to do, and you see some school 
districts doing that. There are school districts, and I am 
thinking about New Orleans as a case in point, where they have 
a program exactly as you describe where parents can opt in or 
opt out.
    I think once you move down into doing drug testing for 
children under the age of 18, that is an issue that does have 
some legal difficulties that goes with it, and that is one that 
needs to be examined very carefully. I think in New Orleans, if 
you talk to the people who participate, they will tell you it 
works. I can tell you that in Oregon at the schools where they 
test athletes, they will tell you that it does work.
    Mr. Peterson. Yes. The New Orleans people have talked with 
me, and they say it is astounding how well it works.
    Mr. Regula. Ms. Pelosi.

                    Treatment on Demand (Whatworks)

    Ms. Pelosi. Thank you, Mr. Chairman. I want to associate 
myself with the comments of Mr. Kennedy and Congresswoman 
DeLauro regarding mental health services. Particularly the 
question I am geared to is about children.
    Ms. DeLauro recognized that children who experience and 
witness violence often experience substantial psychological 
harm. I just want to say that parity in mental services--in 
health services, including giving parity to mental health 
services, is absolutely essential whether you are talking about 
seniors, as Mr. Kennedy was, or children, as Ms. DeLauro was.
    I am very concerned that the Children's Mental Health 
Services Program through the Center for Mental Health Services 
was frozen in this budget, and I don't know that the need has 
decreased. But I want to register my dismay at that. I am 
certain that the need has not decreased, but if you have a 
different view, please let me know.
    My primary question, though, follows up on what Mr. 
Peterson was asking about, what works. I understand at the 
beginning of the hearing Chairman Regula stated his belief that 
demand reduction is more effective than efforts to reduce 
supply in Colombia and elsewhere. I certainly endorse what you 
said and thank you for your leadership, Mr. Chairman, and 
commend to my colleagues the Rand Corporation report which said 
that of course prevention is far and away the least costly, but 
after the intervention of drugs, that treatment on demand is 23 
times more effective than eradication of the coca leaf in the 
country of origin, 23 times more effective. That means it costs 
$34 million to reduce demand in the U.S. By 1 percent, it costs 
23 times--fight treatment on demand. It costs 23 times that to 
do so by eradication of coca, so over $700 million to get the 
same result. It is 14 times more effective than interdiction at 
the border, 7 times more effective than law enforcement.
    Treatment on demand is the most cost-effective way to go, 
and yet we have at least 2\1/2\, 3 million people who are not 
getting this treatment. So I would hope that this committee 
would focus on demand reduction in a cost-effective way rather 
than fooling ourselves into thinking the more money we send--if 
we want to send it for another reason, democracy-building or 
something, call it that, but let's not fool ourselves into 
thinking we are in a cost-effective way reducing demand.
    I wanted to submit, and I will submit it for the record, 
because at my request the Surgeon General prepared a review of 
all peer-reviewed scientific studies of needle exchange 
programs completed since 1998. In the report the Surgeon 
General stated that senior scientists of the Department have 
unanimously agreed there is conclusive scientific evidence that 
syringe exchange programs as part of a comprehensive HIV 
prevention strategy on effective public health intervention, 
that reduces transmission of HIV and does not encourage the use 
of drugs.
    If you could submit for the record the impact of 
intravenous drug use on the current state of the HIV/AIDS 
epidemic in this country. As you know, it is my understanding 
that 75 percent of the AIDS cases among women are linked to 
injection drug use, and 75 percent of new HIV infections in 
children are a result of injection drug use by a parent.
    So unfortunately I have to go to my other committee, but I 
wanted to put those questions on the record, the one about why 
has the Administration proposed to freeze the funding of the 
Child's Mental Health Services Program of the Center for Mental 
Health Services and the last question I just asked.
    Again, I want to thank you. Your work is so important and 
so worthy of support of this committee. It is one of the 
reasons why it is so satisfying and gratifying to serve on this 
committee. I hope we can do more for you. You certainly produce 
results.
    [The information follows:]
                     Impact of Intravenous Drug Use
    Substance abuse remains a major public health problem in the United 
States, with more than 1.5 million people categorized as injection drug 
users. HIV/AIDS is the number one cause of death among Americans 
between the ages of 25 and 44 and has now surpassed tuberculosis and 
malaria as the leading infectious cause of death. Injection drug use 
(IDU) is clearly a significant factor, as this mode of exposure, 
directly or indirectly, accounted for 35.7% of all cases of AIDS as of 
June 2000 and 29.2% of all AIDS cases from July 1999 to June 2000. The 
African American and Hispanic communities, however, have been more 
severely impacted by the epidemic and by IDU. As of June 2000, 
injection drug use accounted for 44% of all Black and Hispanic male 
adult and adolescent AIDS cases. For Black and Hispanic women as of 
June 2000, the AIDS case rate for adult and adolescent females was 
substantially higher than men, at 56% and 53%, respectively.
    Among total pediatric AIDS cases reported through June 2000, 52.2% 
of all cases were attributed to maternal injection drug use or sex with 
an injecting drug user. From July 1999 to June 2000, a total of 224 
pediatric cases of AIDS were reported to CDC and 73, or 32.6%, of the 
cases were related to maternal injection drug use or sex with an 
injection drug user. The substantial reduction in the number of 
pediatric cases of AIDS is directly attributed to early perinatal 
treatment of pregnant women with anti-retroviral drugs.
    It is imperative to both prevent drug abuse and treat those who are 
already abusers; because of the strong interrelationship, drug abuse 
prevention and treatment can be considered to be HIV/AIDS prevention as 
well.

    Dr. Autry. Allow me to thank you for those comments, we 
certainly will submit the answers for the record. I will only 
say that about two-thirds of the kids who do need treatment in 
this country for mental health disorders don't get it, and that 
although your numbers for HIV linked to substance abuse are a 
little bit high, they are not off by that much.
    Ms. Pelosi. I appreciate that very much. I would be 
interested in seeing what your figures are. Hopefully you have 
better news. Thank you so much, all of you.
    Mr. Regula. Mr. Sherwood.
    Mr. Sherwood. Thank you, Mr. Chairman.
    I have sort of a two-prong question. I would like you to 
explore for me--and I am talking now about young people because 
I think that is where we can make a difference. I would like 
you to explore for me the personality traits or the genetic 
traits. Or we know the sociological and environmental causes of 
drug and alcohol use, but it has been my personal experience 
that all the environmental and sociological temptations and 
positions can be there, and the bad environment can be there, 
and some kids are resistant, and some aren't, and then when you 
go to situations where you think they have everything going for 
them, some are resistant, and some aren't.
    So I am interested in somebody helping me understand what 
makes a given young person make a choice. And then once we have 
done that, I want to know--I think probably the best way to get 
to kids is through the school system, and I wonder what your 
links are to the public and private secondary school systems to 
get that information out.
    Dr. Autry. Allow me to give you a very brief answer for the 
record today and promise you a longer answer in written form 
for the record, because it is a convoluted question, as I am 
sure you know.
    Let me put on my clinician hat for a minute instead of my 
administrator hat. There are a couple of things that we know 
about kids who do tend to get into alcohol and drugs. Some you 
have heard that they come from difficult family environments 
where there is substance abuse in the environment, or there may 
be physical abuse in the environment. We also know that there 
are some studies that have clearly shown there is a genetic 
factor that plays in the development of alcoholism. We also 
know that kids who do not have strong family bonding or strong 
bonding to the schools, or who may have antisocial personality 
traits as kids, or who may have other illnesses such as anxiety 
disorders or depression are more prone to using drugs as they 
develop.
    All of these factors can play into the decisions about 
whether or not to use drugs, and I will submit a longeranswer 
for the record with more detail on that.
    [The information follows:]
                    Subtance Abuse Prevention Grants
    Since 1987, CSAP has supported substance abuse prevention grants at 
the local/community and State level. Based upon the results from these 
grants and other prevention research studies, we have identified risk 
and protective factors that play into a young person's decision to use 
or not use drugs. The table below summarizes these factors by specific 
domains (i.e., individual, family, peer, school, community, and 
society). Effective prevention programs targeting specific domains 
enhance one's protective factors while reducing his or her risk 
factors.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    Dr. Autry. In reference to the issue of schools being an 
effective place for intervention, I believe we have to look at, 
as Dr. Sanchez-Way said, a comprehensive approach in which 
schools are a partner in the kinds of prevention interventions 
that we do, also in terms of early assessment in recognizing 
when there are problems and kids may need to be referred for 
intervention such as treatment or early intervention. But they 
need to be part of a program that also takes into account the 
role of the family, that takes into account the mores or the 
acceptability of drug use in the community, that takes into 
account a more comprehensive approach in order to address the 
substance abuse or the likelihood that someone will become a 
user. Again, we will give you a more detailed written answer 
for the record.
    [The information follows:]
                     High Risk Youth Grant Programs
    Prevention research has shown that many of the risk and protective 
factors for drug abuse are interrelated. For instance, parents' lack of 
adequate supervision of their child is likely to influence not only the 
child's use of drugs but his or her academic performance and sexual 
behavior, among other things. Since drug use often begins during 
adolescence, which is a period of continual developmental change, 
effective prevention programs must be prepared to address the multiple 
risk and protective factors affecting youth during this period of 
development.
    CSAP's High Risk Youth grant program has demonstrated that a 
comprehensive approach targeting multiple risk and protective factors 
is very effective in reducing substance use and abuse among youth. 
Since 1994 SAMHSA has funded over 400 High Risk Youth grants across the 
country. The recently completed cross site evaluation of these grants 
found that programs that combined life skills, interactive delivery, 
intensive participation, and strong implementation consistently 
produced stronger and longer lasting positive effects on reducing 
substance use among youth. Overall, the evaluation highlights excellent 
results. Substance use rates for youth in these projects is 11% lower 
than control groups at the end of the project. Even better, rates are 
28% lower than controls 18 months after the end of the program.

    Mr. Sherwood. Being a public school board member for many 
years, I think one of the things we have to factor into the 
equation is the resistance of parents to have young children 
categorized, and sometimes for good reason, and that is an 
ethical question that I think needs a lot of exploring. And 
there is a lot of community distrust, maybe--I hope I have put 
that--I hope I have phrased that properly--about early 
diagnosis, and we have to somehow work through those issues if 
we are going to make a real difference there.
    Dr. Autry. Again in my clinician hat, I have spent a large 
portion of my career trying not to label kids, particularly 
young kids. But I think there are ways to talk about risk 
factors without necessarily attaching a label to them, that may 
flag kids who may be at risk for later development of substance 
abuse. Some of our early childhood studies have given us a 
knowledge of what some of those risk factors are. We will 
submit a longer answer for the record to make you more aware of 
what some of that research is.
    [The information follows:]
                     Risk Factors--Early Childhood
    Substance abuse prevention research has contributed important new 
understandings in the relationship between social, emotional, and 
cognitive development in early childhood and the risk factors that 
contribute to later substance abuse. CSAP's High Risk Youth Program 
confirms and explains the importance of bonding to family and school as 
central factors related to substance use among adolescent youth in high 
risk situations. Less bonding puts youth at higher risk for substance 
use, and stronger ``connectedness reduces that risk. CSAP's evaluation 
of this program demonstrated that strong connectedness to family 
requires positive bonding, plus a family environment that supports 
effective communication and positive social time. Similarly, school 
connectedness is positive bonding with school plus a feeling the school 
is fair, caring and rewarding. School connectedness has its strongest 
association with reduced substance use when youth also perform well in 
school. A third major area of risk for substance use among youth is a 
lack of self-control, which detracts from school connectedness and 
performance.
    Research has shown that these factors are strongly shaped by a 
child's early experience in the infant and pre-school years. CSAP's 
Starting Early Starting Smart (SESS) program, an early childhood 
program, addresses the roots of these risk factors in the early family 
experience of children in high risk situations. Initiated in 1997, this 
program is a private/public partnership supported by Casey Family 
Partners and the federal SAMHSA. This program supports integrated 
behavioral health services for families with young children at either 
primary medical care settings or early childhood centers. The SESS 
program seeks to strengthen the bonding between the youth with the 
family and the schools.
    By engaging families in pediatric care or early childhood education 
settings, SESS projects address the interaction of care givers with 
children that impacts the development of self-regulation and family 
connectedness. The study also addresses family environment and early 
childhood social and emotional development needs that prepare youth for 
school, and provide the foundation for school connectedness. 
Preliminary findings with respect to intermediate outcomes are 
positive, showing that families exposed to integrated services at both 
primary care and early childhood centers access significantly more 
parenting and behavioral health services and perceive fewer barriers to 
meeting a variety of service needs, compared with families receiving 
the usual standard of care. Early results show positive parenting-
related outcomes.

    Mr. Sherwood. Thank you very much.
    Mr. Regula. As I understand it, Mr. Jackson, you don't have 
any questions?
    Mr. Jackson. I will submit some for the record, Mr. 
Chairman.
    Mr. Regula. Well, thank you. We could all ask you a lot 
more because you are dealing with something that is very 
important to this Nation, but unfortunately we have a time 
constraint. So we thank you all for being here and wish you 
well.
    Dr. Autry. Thank you, Mr. Chairman, and the other members 
of the committee. We have always enjoyed a very good working 
relationship with this committee, and we look forward to 
continuing that relationship.
    Mr. Regula. Thank you.
    [The following questions were submitted to be answered for 
the record:]

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                                            Thursday, May 10, 2001.

               AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

                               WITNESSES

JOHN M. EISENBERG, M.D., DIRECTOR, AHRQ
CAROLYN CLANCY, M.D., DIRECTOR, CENTER FOR OUTCOMES AND EFFECTIVENESS 
    RESEARCH, AHRQ
RITA KOCH, DIRECTOR, DIVISION OF FINANCIAL MANAGEMENT, OFFICE OF 
    MANAGEMENT, AHRQ
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, OFFICE OF BUDGET, 
    DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Mr. Regula. Next will be the Agency for Healthcare Research 
and Quality.
    We will take a brief recess to allow for witnesses to come 
to the table.
    [Recess.]

                       INTRODUCTION OF WITNESSES

    Mr. Regula. Okay. We will get started here. Dr. Eisenberg, 
we are happy to welcome you and Dr. Clancy and Ms. Koch.
    Ms. Koch. Koch.
    Mr. Regula. Koch. I have heard it pronounced a number of 
ways, but I have heard my name pronounced a number of ways, 
too.
    We are pleased to have all of you here, and we look forward 
to your testimony. Your full statement will be a part of the 
record, so if you can summarize, it will be helpful.
    Dr. Eisenberg. Thank you, Mr. Chairman, Mr. Jackson, Mr. 
Peterson.
    I am very pleased to be here today to present the 
President's fiscal year 2002 budget request for the Agency for 
Healthcare Research and Quality, A-H-R-Q, or what we call AHRQ. 
With me, as you mentioned, Mr. Chairman, are Dr. Carolyn 
Clancy, who heads our Center for Outcomes and Effectiveness 
Research; Rita Koch, who heads our Division of Financial 
Management; and Dennis Williams, who is here, as you know, from 
the Department.

                             AHRQ'S MISSION

    Mr. Chairman, we are 1 of 13 agencies in the Department of 
Health and Human Services, and we are a research agency that 
focuses on research about health care. Eighty percent of our 
funds go to the universities and other institutions around the 
country, and we do have a relatively small intramural research 
program on these issues as well.
    Our focus, as I mentioned, is on research about health 
care. It is about the health care services that are delivered 
to people, Americans, every single day, and our research 
addresses what kind of services work best, for whom, when and 
is what kind of situation, and also at what cost, as well as 
what the quality of that care is.
    Research that has been sponsored by our Agency in the past 
has shown that, even when we know that the treatments do work, 
many people who would benefit from them don't get those 
services. Our goal, therefore, is to get the results of 
research about effectiveness, outcomes, cost, and access done, 
but also to be sure then that that research gets put into the 
hands of the people who can put it to use--doctors and nurses 
and health plans and hospitals, patients, their families and 
purchasers. Those are the people whom we think of when we 
sponsor the research because it gives them information to make 
better decisions about health care.
    Let me give you an example. There is research that has been 
done that we have sponsored that showed that, while aspirin and 
a drug called beta blockers can reduce the recurrence of heart 
attacks, both medications are greatly underused. So having--
    Mr. Regula. Underused?
    Dr. Eisenberg. Underused, yes. Being concerned about that, 
we sponsored a trial to determine whether or not we could 
increase the use of those drugs, based upon research about how 
to improve physicians' practices and how to improve the 
performance of health plans and hospitals. I am pleased to say 
that an AHRQ-supported researcher doing this research in 
Minnesota found that the proportion of eligible elderly 
individuals with this intervention who were given aspirin and 
the drug I mentioned, beta blockers, increased dramatically, 21 
percent for aspirin, 33 percent for beta blockers. Because the 
study was so well done and disseminated so well, we are very 
pleased that other organizations are now emulating that 
research, putting it to use. So it really is translating 
research into practice.
    Mr. Regula. What are beta blockers? Is this a generic name?
    Dr. Eisenberg. It is a generic name for a class of drugs 
which basically relax the heart.
    Mr. Regula. Would you go to the drugstore and ask for beta 
blockers, or do they have different labels?
    Dr. Eisenberg. They have different brand names.
    Mr. Regula. That is what I mean.
    Dr. Eisenberg. You would need a prescription, but they have 
different brand names.
    Mr. Regula. You do need a prescription?
    Dr. Eisenberg. Yes.
    Mr. Regula. So it is up to the doctor which brand is 
selected.
    Dr. Eisenberg. Exactly.
    Now, that is an example of how the research that we sponsor 
informs clinicians or patients about clinical issues.

                            AHRQ'S RESEARCH

    We also sponsor research that helps people make decisions 
so they can be more active partners in their own health care 
and make better choices about the health care that they are 
going to get, whether they are choosing a plan or a hospital. 
We have, for example, funded researchers to develop a survey 
which is called the Consumer Assessment of Health Plans Survey, 
or CAHPS. This is a survey that people choosing plans can use 
so they can get better information about how other people in 
those plans feel about the plans. All of us as Federal 
employees have a chance to use it. It is in our FEHBP booklet. 
You can get, based upon this very good research, a valid sense 
of how other people who are using those plans have felt about 
those plans, having experienced them, and you can make a more 
informed choice.
    These are two examples of the research that we sponsor to 
help people make better clinical decisions, but also how to 
make better decisions about working in the health care system 
to make the system work for you.
    Mr. Regula. That is the consumer report on health care?
    Dr. Eisenberg. Yes, it is. Yes, exactly.
    So let me describe, if I may, our budget priorities for 
fiscal year 2002 because the request in essence allows us to do 
a better job of funding research of this sort and then getting 
it translated into practice.

                            FY 2002 REQUEST

    For 2002, we are requesting $306 million, which is a $36 
million increase over 2001, and it allows us to focus on five 
priority areas. Let me mention the five priorities first, and 
then I know time is limited, so I will describe some of them, 
but we can go back and discuss them more if any of you would 
like.
    The first category is to fund research that is generated by 
the best and brightest researchers around the country who 
compete for grants to answer critical questions in health care. 
They apply to us in a way comparable to the way that the NIH, 
for example, has people compete for their grants, and we fund 
as many grants as we have funds available and our study 
sections or our review panels tell us are good science about 
important topics.
    The next is our National Healthcare Quality Report, which 
will be starting in 2003 and we are working on already.
    The third is our patient safety data initiative, a very 
important initiative that we are starting.
    The fourth is our National Healthcare Disparities Report to 
understand more about the disparities in health care in this 
country.
    And the fifth is our Medical Expenditure Panel Survey, 
which gives us better information on cost and use and access to 
care.

             RESEARCH ON HEALTH COSTS, QUALITY AND OUTCOMES

    Let me talk a little bit about the quality issue in 
general. You know, the Institute of Medicine (IOM), which is a 
part of the National Academy of Sciences, issued a report they 
called Crossing the Quality Chasm. They said there is a chasm, 
a serious quality gap, in this country between the quality of 
care that we know how to provide and the quality of care that 
we do provide.
    This report made a number of recommendations about how we 
can improve the health care system, one of the most important 
of which is that we need more scientific evidence about 
measuring quality and about the gap between the quality we can 
provide and the quality that we do provide so that we can get 
that information to the American public, but also to providers 
so that they can close that gap.
    In fiscal year 2002, we are proposing to support and 
conduct and disseminate research that does examine the outcomes 
and the effectiveness of health care services, examines ways of 
improving the quality of care, and examines these questions of 
cost and use in access to care in this country. We are 
requesting $16 million of the $36 million for this important 
research.

                   NATIONAL HEALTHCARE QUALITY REPORT

    We are also asking for $2 million to help to support the 
National Healthcare Quality Report, which Congress required in 
our 1999 reauthorization, and which is first due out in 2003. 
This will be the first time this country has had a report 
across the country that tells us what the trends are in the 
state of quality in the United States. It will begin with 
information that we have at AHRQ, but it will also use 
information from the private sector, as well as other public 
sector organizations, and will allow us to gauge quality in the 
same way that we get reports on what is happening to the 
economy; is it getting better or worse, and in what areas is it 
getting better or worse. We are very excited to be able to 
provide to policymakers like you a report that gives us 
quantitative information that tells us how well we are doing 
about quality in the country.

                    PATIENT SAFETY DATA DEVELOPMENT

    Secondly, we are grateful to the Congress for having 
provided us with funds for this year, fiscal year 2001, to 
support research on medical errors and patient safety. We all 
know from having read the newspapers and Institute of Medicine 
report that medical errors and patient safety is a very big 
issue in this country. We are pleased that we were able to fund 
the first research that identified this to be a problem, and 
that we are able now to continue to do research or sponsor 
research on how errors can be reported in an accurate way, how 
those reports can be used so that clinicians can improve and so 
that hospitals can determine where they stand with regard to 
other hospitals to know where they need to improve, and also 
research to help them understand ways in which they may improve 
the quality of care, especially reducing medical errors.
    We are requesting in fiscal 2002 an increase of $3 million 
to help us to work with our partner agencies, the CDC, the FDA 
and HCFA, to put together a framework for a user-friendly 
system of reporting on medical errors that will help hospitals 
and clinicians understand that they can do better, but it won't 
require more information being reported. It simply provides a 
better system for reporting the information and then analyzing 
the information so we can make something of the data that we 
are already collecting in this country.
    As a former chief of a hospital service in Washington, I 
recall how I often felt like I was driving a car with my 
windshield fogged and no instrument panel because I had no 
information about how we were doing, and I had no information 
about how we were doing compared to others. That is the job 
that we want to take on so that hospital leaders and clinicians 
will know how they are doing and will be able to compare 
themselves to others and know where they have improvements to 
make.

                 NATIONAL HEALTHCARE DISPARITIES REPORT

    We are also requesting $1 million dollars in the 2002 
budget to get us started on the National Healthcare Disparities 
Report. We are very pleased that our Agency was able to fund 
some of the earliest research that documented that there are 
disparities among races, among genders in this country in the 
quality of care and the access to care, but we don't have a 
national snapshot of how we are doing as a country to 
understand where those disparities are for which groups so that 
we can address as clinicians, as those who deliver care, but 
also as policymakers, what we can do to improve access to care 
and reduce those disparities.

                    MEDICAL EXPENDITURE PANEL SURVEY

    In addition to the $3 million that we are asking for in the 
Medical Expenditure Panel Survey for the quality and 
disparities reports, we know that we need to get a better 
sample of patients, of people in this country, to have better 
information on more people in this country to understand what 
the problems are in use and access to care. Many of you have 
seen the reports from the Medical Expenditure Panel Survey. It 
told us about a month ago that there are 43 million Americans 
who are uninsured. We would like to have more data to drill 
down and say who those people are, which racialgroups, what 
kind of businesses, which parts of the country are those people in, so 
that we understand where the challenge is that we need to close and the 
number of people who are uninsured in this country.

                            CLOSING THE GAPS


    Mr. Chairman, our name, A-H-R-Q, which we say AHRQ, I 
think, is really remarkably symbolic because it is an AHRQ that 
allows us to close this gap that the Institute of Medicine 
identified, to bridge the gap between what we need to know and 
what we know about the quality of care and the effectiveness of 
care in this country, and also allows us to bridge the gap 
between the science, the biologic science, of health and the 
delivery of care to Americans. That is the gap that we want to 
close.
    We have already started to close the gap in understanding 
cost and use in access, and let me tell you one other 
application of our research that we are proud of. The 
Department of Commerce has decided to use the Medical 
Expenditure Panel Survey to calculate the health care 
expenditure component of the gross domestic product. Frankly, 
that makes us very excited. When we sponsor research and it 
gets used by fellow agencies or by the private sector or by 
States, we feel as if we are using the public's resources in an 
effective way, getting good research done and then getting it 
translated into practice by our users, our partners.
    So let me thank the committee for giving me the opportunity 
to present the President's budget for 2002. As you can tell, I 
am very excited about the budget because I think it is going to 
give us a chance to make a difference in health care in this 
country, to get better care to more people with fewer 
disparities, and to deliver higher quality care at a more 
affordable cost, and we thank you for giving us the chance to 
come and talk with you about our agenda. Thank you so much.
    Mr. Regula. Thank you.
    [The information follows:]

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    Mr. Regula. Mr. Jackson.

                             MEDICAL ERRORS

    Mr. Jackson. Thank you, Mr. Chairman.
    Welcome, Director Eisenberg, to our subcommittee, and thank 
you for your testimony.
    I have two questions. My first question is about medical 
errors. According to a Robert Wood Johnson survey of 600 
physicians, 400 registered nurses and 200 senior-level hospital 
executives, some 95 percent of doctors say they personally have 
witnessed a serious medical error. I know that you are well 
aware of the IOM report on medical errors which said that 
medical errors were a possible leading cause of death. I find 
this information quite incredible.
    I know your Agency is charged with focusing on health care 
quality, specifically improving health care quality. The 
President has asked for $306 million for your budget. I am 
wondering if this is enough for your Agency to improve health 
care quality, reduce errors in medicine and advance health care 
outcomes information.
    Dr. Eisenberg. Will we with this budget be able to make a 
tangible difference and improve quality? Yes, I believe that we 
will be able to. This challenge is a huge challenge, of course, 
but I think we can make a difference.
    And to the point of your comment about 95 percent of 
physicians having witnessed an error, as a physician I would 
submit that 95 percent of physicians have made an error. I 
have. I know I have made my share of errors, and one of my 
professors in medical school told me, John, it is okay to make 
an error, just don't make it twice. And I would also like my 
colleagues to know about the error so they don't make the same 
mistake. But if we don't have a reporting system or we don't 
have the research agenda so that other clinicians know about 
the mistakes that others are making, then we will all make the 
same mistakes.
    If you will allow me, I gave a commencement address at a 
medical school not too long ago and asked the medical students 
to raise their hands if they had made a mistake. Every medical 
student raised his hand or her hand, and I said, well, that is 
a challenge for us to try and figure out a way that we can 
reduce the number of mistakes that you are making, or when you 
make the mistake, to be sure it is caught early enough that it 
doesn't do damage to your patient. I got some nodding from the 
medical students and some horrified looks from their parents 
who said, you mean my kid, who isn't even graduated from 
medical school yet, has been making mistakes, but we have 
systems of care in this country that don't pick up those 
mistakes?
    The solution is not only to make the clinicians, doctors, 
nurses, and pharmacists better, but also put systems in place 
where the inevitable, when it happens, will get caught; that we 
will have computerized systems, for example, that willpick up 
the fact that I wrote the wrong drug or I wrote an order for a drug 
that conflicts with another drug that the patient is on. That is what 
we have to do. We have to put those computerized systems in place so 
that we have better clinicians, but also better systems in which they 
operate.
    And I think you are right, at least 95 percent of 
physicians have witnessed a medical error.

                             MEDICAL ERRORS

    Mr. Jackson. And it is your opinion that your budget is 
sufficient to help reduce the number of errors, or at least the 
reporting process will be increased under your budget?
    Dr. Eisenberg. Yes.
    Mr. Jackson. My second question is about quality of health 
care in the United States. According to a World Health 
Organization report, the World Health Report 2000, health 
systems improving performance, the U.S. Ranked 37th in the 
world in overall health system performance and 72nd on 
population health. Obviously these findings are at odds with 
the popular conception that the U.S. has the best health care 
system in the world.
    When this report was released, there were a few days of 
media coverage, yet policymakers took no action, and there was 
no sustained public outcry. Dr. Eisenberg, I am wondering 
whether or not--the fact that there is a problem with the 
quality of health care in the country is clearly not new, but 
given the fact that poor-quality health care affects everyone, 
why is it, from your perspective, so difficult to sustain 
public interest in the problem?
    Dr. Eisenberg. It is hard to explain to people that quality 
could be better unless you can make it tangible and concrete to 
them. I think that is why the Patient Safety and Medical Errors 
Report got so much attention. When you tell people that there 
are 98,000 Americans who are dying every year because of 
medical errors, it is concrete, it is tangible.
    What we need to do and what we are doing as an agency is 
developing better measures so that we can explain to the public 
where the gaps are in quality, and the National Quality Report 
will do just that so that the public wakes up to this problem. 
Sometimes the issue of quality seems kind of abstract, but it 
is real and it is tangible to every single American.
    I am pleased to mention that we have been working with the 
WHO to improve that report that they are doing. In fact, the 
World Health Assembly is meeting this week, and we have had our 
experts who developed the Consumer Assessment of Health Plan 
Survey help them to translate that into a worldwide survey so 
that the WHO report in the future will ask questions that are 
different from the ones that they have been able to ask in the 
past. I don't know that that will improve the United States' 
performance or ranking, but it will at least make the report 
from the WHO more accurate. It also will allow us since the 
surveys will be similar, to benchmark ourselves against other 
countries.
    We, in fact, have been meeting with British, the 
Australians and the New Zealanders to develop a system where we 
can understand better how we compare with them in the area of 
patient safety. This is a worldwide issue, and I am pleased 
that we are recognized as an Agency as being a worldwide leader 
in this area, but we will need to collaborate with our 
colleagues in other countries to solve it.
    And let me just mention that when the reports did come out, 
I think it is fair to say that we did take action. We started 
developing, for example, the agenda that is before you today to 
look at how we can solve this problem. And I think, as I 
mentioned in answer to your previous question, we can make a 
big difference in quality in this country.
    Mr. Jackson. Thank you, Dr. Eisenberg.
    Thank you, Mr. Chairman.
    Mr. Regula. Mr. Peterson.

                           CHANGING PRACTICE

    Mr. Peterson. I want to go back to your testimony. You 
talked about the use of aspirin and beta blockers in your view 
is underutilized, from your studies. How do you change that? I 
mean, what have you done to change it? What is your game plan 
to change that?
    Dr. Eisenberg. I think that there are several ways that we 
have demonstrated in research that we sponsored that are 
effective. The study that I mentioned was done in Minnesota 
used several strategies, and the combination of these 
strategies works. When one strategy alone is used, though, our 
research has shown it is not as effective.
    One strategy is to find physicians in the community who are 
the so-called opinion leaders to whom other physicians look for 
advice, and get that physician to be a leader in the change 
process. That is one of the key factors in the Minnesota study, 
that we identified opinion leaders and got those opinion 
leaders to help us to institute change.
    If you will forgive me, when I was at the University of 
Pennsylvania, we had a grant from this agency, and I wanted to 
do the same thing. I went to Geisinger, I went to Lancaster, 
York and Scranton, as well as Penn, to find the opinion leaders 
and to see if we could institute a program that would effect 
change. Unfortunately the agency had its budget cut, and so did 
I at that time, so I wasn't able to implement that, but good 
research has shown that opinion leaders are effective.
    In addition to that, there can be computer reminders; if 
you have a patient, for example, with a particular disease, a 
computer reminder that will say, have you remembered to 
prescribe this drug. We have sponsored a study at the 
University of Indiana on computer reminders that show that that 
is effective. In addition, there are other systems that can be 
put into place in the hospital using hospital systems, 
conferences. Plain old education sometimes will work even 
though it is not as effective as opinion leaders and systems 
interventions.
    I would love to come and talk with you more about this 
because it is an issue that our Agency has been dedicated to 
investigating, what is it that induces change in clinicians.
    One last item I will mention is that when you educate 
patients or families, that is effective as well. We want 
empowered patients. We want patients who are sharing 
decisionmaking and are part of the decisionmaking process.

              UNIVERSITY OF PITTSBURGH INFORMATION SYSTEM

    Mr. Peterson. We have the wrong people empowering the 
patients today. We have the drug companies telling them which 
drug they want, and they come to the doctor requesting it. That 
is working pretty successful, from what I hear. I am not so 
sure that should be the practice.
    But back to this issue, the University of Pittsburgh 
Medical Center in Pittsburgh now has 17 or 18 hospital 
networks, and they are investing millions and millions in an 
information system that is--are you familiar with that?
    Dr. Eisenberg. I sure am.
    Mr. Peterson. Do you think they are on the right track?
    Dr. Eisenberg. Not only that, I think that Pittsburgh is a 
model for the rest of the country. I visited Pittsburgh in the 
fall, visited with the Pittsburgh Regional Health Care 
Initiative. I am a fan of that program. We have funded 
individuals at the University of Pittsburgh. We funded a 
researcher by the name of Michael Fine to do research on the 
care of patients who have what we call community-acquired 
pneumonia, and I have to tell you an anecdote about this 
because it shows the effect that Fine's work has had, not only 
in Pittsburgh.
    When I left practice in Washington to come to take this 
job, I was still on the mailing list for a number of HMOs with 
which I was participating. I got a mailing that said we, the 
Washington-based managed care organizations--this was a group 
of them--want you to know about research that the Agency for--
we had a different name then--for Healthcare Policy and 
Research has funded at the University of Pittsburgh, and it 
shows that if you can take care of your patients with 
community-acquired pneumonia out of the hospital, not only will 
they be better clinically, but you will save money. Well, I 
thought it was wonderfully ironic that the week I was coming 
over to this Agency that the managed care organizations in 
Washington were taking research that we had sponsored in 
Pittsburgh and disseminating it. And that is another example of 
how we can change physicians' practices by getting good 
research disseminated through those kinds of mechanisms.
    So I know I----
    Mr. Peterson. But isn't it sort of like----
    Dr. Eisenberg. It is an example of how we can sponsor good 
research and change.

                      CHANGING PHYSICIAN BEHAVIOR

    Mr. Peterson. They are a leading center, and I think they 
are at the edge on information technology of how to practice 
medicine, successes, outcomes, measuring all that, but we still 
have doctors practicing 1970 medicine that have not changed and 
work in hospitals that seemingly have little ability to 
control. I guess I don't know how we make that system work to 
where 2001 medicine is practiced by the majority of physicians. 
That is not necessarily the case today.
    Dr. Eisenberg. It isn't, and we have what I would like to 
describe as a three-pronged approach to that. We often meet 
with professional associations and medical leaders, and we say, 
where do you think that the gap is greatest between what we 
know and what we ought to be doing, and they give us ideas. We 
call that a user-driven research agenda. With that we will do 
one of two things. If the research hasn't even been done, then 
we will sponsor the research. Carolyn Clancy's Center of 
Outcomes and Effectiveness Research will sponsor research on 
what the outcomes and the effectiveness is for those questions 
if we don't know.
    But often, as I mentioned at the beginning, we know what 
the outcomes and effectiveness are, but there is a gap between 
what we know and what has been practiced. Sometimes, therefore, 
we will meet with professional associations who will say, we 
would like to do a better job of educating our members, college 
of cardiology, college of physicians, family physicians, 
nursing groups. So, we take that advice, and one of the fellows 
who is here, the one in the uniform, who leads our Center for 
Practice and Technology Assessment, which sponsors a group of 
evidence--what we call evidence-based practice centers around 
the country, we give them the responsibility of answering the 
questions we get from managed care plans, from professional 
associations and from hospitals to put together a report that 
says here's what we know about how to take care of the problem 
you asked us about. We are going to give you this report, and 
we expect you to do something about it.
    Our Agency doesn't write guidelines, but we expect the 
people with whom we partner to institute a program that puts 
the research to work. So, more often than not, what will happen 
is these organizations who ask us for an evidence report or for 
more research will take the result and put out a guideline for 
their members. The American College of Cardiology, for example, 
put out a guideline based on an evidence report on ischemic 
heart disease. The American Academy of Pediatrics put out one 
on attention deficit hyperactivity disorder because it is so 
poorly managed in this country, and there are a number of 
others that I could give you examples of.
    Finally, in order that the guidelines not get lost, we have 
a National Guideline Clearinghouse, which is on the Web at 
www.guideline.gov, and we take the guidelines these 
organizations have put together. We verify that they are 
evidence-based, and if they are, they are available on the Web. 
There now are about 1,000 of them. We get about 28,000 visits 
per week.
    We count visits, not hits, because a visit, as I have 
learned, is when somebody stays there for a while and pays 
attention to it. A hit is just when they fly by, and we don't 
really want to know how many people fly by. We want to know how 
many people spend some time, and these numbers are continuing 
to increase. In fact, Medscape and a number of the other 
companies who are purveyors of Web-based information for 
physicians, are some of our biggest sources because when 
somebody goes to Medscape and says, what can you tell me about 
a particular topic, they send them to our guideline 
clearinghouse. In addition to that, some of the guidelines have 
been written for the average person, the lay public, and we 
designate to the person who goes to the site if there is a 
version for the public.
    So those are ways in which we can address your concern 
about how we are going to improve clinical practice. It is not 
easy, but we have a portfolio that I think is making a 
difference.

                              MANAGED CARE

    Mr. Peterson. Well, I think there was hope held out to us a 
few years ago when managed care was the oncoming thing that 
managed care was going to be the provider of information data 
for all the doctors that are in that system and the practice 
protocols and outcomes.
    But let me ask you one loaded question. I am not going to 
ask you to finger anybody, but don't we have as many HMOs 
practicing managed costs as managed care?
    Dr. Eisenberg. The term ``managed care'' is so ambiguous 
because so many people mean different things by it.
    Mr. Peterson. Originally it was primary preventative care, 
the right practice, you saw the right doctor in the right 
sequence for a cost-effective treatment, got the disease early, 
treated early, and lots of primary and preventative and testing 
up front so you don't get seriously ill, and that was the 
concept. But I think a large share of our HMOs today are 
managed costs and are not doing the managed care. That is just 
my own opinion.
    Dr. Eisenberg. As you might expect a research agency to 
say, we are studying that. We have some researchers we are 
funding in San Francisco, in fact around the country, studying 
what the impact of managed care has been because the term is so 
ambiguous. Some people, when they say ``managed care,'' mean a 
preferred provider network because it will tell you which 
doctors you can go to, but others mean Kaiser Permanente 
because they have what you were describing, an integrated 
system of care.
    Mr. Peterson. But should we as government define what 
managed care is?
    Dr. Eisenberg. My personal view--and, Dennis, if you will 
forgive me, I am not speaking for the Department is that we 
ought to have more information about the characteristics of 
what we call managed care and then understand whether those 
characteristics are positive or negative. Is the characteristic 
of case management, for example, positive or negative? We have 
so little research that has been done on case management, we 
have so little research that has been done on pharmaceutical 
benefit managers that we don't know if that is a positive or a 
negative attribute. We do know, however, that having a personal 
clinician, a personal physician, which many managed care 
organizations provide, is a characteristic that is an 
attribute. We also know that many people are frustrated by not 
being able to see a clinician when they want to see that 
clinician and having to get permission from their own 
physicians.
    So we could come and visit your office and we could go 
through the characteristics of managed care. We could say we 
have studied these, and there is a plus or minus next to them, 
and the rest of them are up for grabs because we need to study 
those characteristics.
    What I would like to have as a patient--I would like to 
know which of the characteristics of managed care have been 
proven by good research to work and not to be harmful, and then 
when I am choosing a managed care plan, I would like to know 
which of those characteristics describes that plan. I would 
also like to be able to look at the Consumer Assessment of 
Health Plan Survey and know how other people felt about that 
plan. That would be real informed choice. It wouldn't be going 
to a plan or staying away from a plan because of a stereotype 
of that plan.
    Mr. Peterson. I will just give you one closing word of 
advice: When you come up with good information, even if it is 
controversial, don't be afraid to put it out there. Don't be 
afraid to say it.
    Dr. Eisenberg. We have experience in being the messenger of 
bad news.
    Mr. Peterson. Not bad news, but facts. The facts are the 
facts.
    Dr. Eisenberg. Tough news, that is right. I think we have 
gotten a little smarter about it, but that does mean, as you 
point out, that we need to bite the bullet and ask the toughest 
questions. Thank you.

              UNIVERSITY OF PITTSBURGH INFORMATION SYSTEM

    Mr. Regula. I am interested in what the Pittsburgh model 
is. Both of you indicated this is a good procedure. What does 
it do?
    Dr. Eisenberg. What happened in Pittsburgh, and Mr. 
Peterson may know more about it than I do, but what happened in 
Pittsburgh was leadership from a number of the different 
components of the city. One was a foundation whose leader got 
together with a CEO of a corporation, which happened to be 
ALCOA. That CEO is not in Pittsburgh anymore, as you know. But 
this foundation and Mr. O'Neill created an organization that 
brought in the business leadership, the purchasers, got the 
physicians together, got the hospitals together and said, we 
all have to push this wheel with our shoulders in common 
because we can't fight against each other, which is the way it 
often is in many cities.
    A lot of us come from cities where there is more 
competition than collaboration among the health care providers, 
and what they did in Pittsburgh was almost magical. They were 
able to get people to get together and work together. The 
medical community is supporting this. They started getting 
data, including data like this Fine study that I mentioned, so 
that people weren't arguing about their stereotypes and their 
impressions about what was happening, but they could talk about 
what really was happening. They put together a program in 
patient safety. We all think of patient safety as sort of the 
tip of iceberg of quality; it is the most visible, and we all 
know it is not the only element to quality, but the people in 
Pittsburgh put together a real collaborative communitywide 
initiative that had data that built its initiatives on research 
and used leadership. It is remarkable. I urge you to take a 
look at it because I am from Memphis, and I keep telling my 
friends in Memphis that Memphis could be another Pittsburgh.

                     COMPETITION BETWEEN HOSPITALS

    Mr. Regula. I am curious, are there a number of different 
hospitals in Pittsburgh that were competing and are now working 
together as a result of this initiative?
    Dr. Eisenberg. They have. Pittsburgh has a complicated 
situation with its hospitals because a couple of them have had 
serious financial problems, and a few of the others have 
merged. And so there was tension in the Pittsburgh area among 
the hospitals, and they were competing, partially competing, 
just to save their lives. In that kind of a situation where 
there is that much competition and that much anxiety about the 
future of the hospital, it is remarkable that they have gotten 
these organizations to collaborate and to use research to 
improve----
    Mr. Regula. They agreed on specialties, so that maybe one 
hospital is noted for heart bypass and another one for cancer 
research and so on?
    Dr. Eisenberg. I don't believe that they had an agreement 
that any of the hospitals would stop a program, but my 
understanding is that the hospitals collaborated so that the 
care at all of them would be better rather than that the care 
in Pittsburgh would be made up of a war of other hospitals.
    Mr. Regula. So they are not competing with----
    Mr. Peterson. That is not, there are several competing 
systems, but the UPMC system has a number of hospitals in 
Pittsburgh and surrounding, and even up into my district there 
is a number of them. This is an information system they have 
designed that will track every patient, how they are treated, 
what practice protocols, success rates. It is going to be the 
very edge of technology for today, and they have spent locally 
50-75 million on it and are asking for Federal help, too. I 
would be glad to bring them in and have them brief the 
committee or brief your staff.
    Mr. Regula. We may want to do that.
    Mr. Peterson. They are at the edge. I mean, they are 
leading the world in this new information system with a group 
of hospitals, with all the specialties, you know, that they 
have. I am not so sure they are including their competitors in 
their system, but they have 18 hospitals of their own.
    Mr. Regula. Well, do they still continue to advertise? Are 
they competing for patients?
    Dr. Eisenberg. Oh, sure.
    Mr. Peterson. Absolutely.
    Dr. Eisenberg. The way I would put it is they are competing 
and cooperating. They always will compete, but they are 
cooperating in the way Mr. Peterson said, which is they have an 
information system which is remarkable. It does help to improve 
clinical decisionmaking by getting guidelines and better 
information. It also collects information on issue like patient 
safety so they will know how they are doing against the 
benchmarks of other hospitals, but it is not as if they are 
publicizing that such and such a hospital is terrible on 
patient safety, let us tell you what the results are. They just 
haven't got to that level.
    They look at it as an opportunity for improvement, which is 
one of the reasons I think it is so remarkable. The computer 
system is a terrific computer system, and I am pleased that it 
is built off of some of the computer systems we funded, like 
the one in Indiana. We also funded a program in Boston at the 
Brigham and Women's Hospital, which the folks in Pittsburgh 
have emulated. As I said before, we love that, when we have 
funded a group in one city and a group in another city emulates 
it.

                       PATIENT SAFETY TASK FORCE

    Mr. Regula. To follow up, Dr. Eisenberg, you have been 
recently appointed to chair a new patient safety task force. 
Now what is that all about?
    Dr. Eisenberg. There are four agencies in the Department of 
Health and Human Services who are participating in this task 
force. It is the Health Care Financing Administration, Food and 
Drug Administration, CDC and ourselves. We realized as we were 
working together addressing the patient safety problem that we 
shared a number of issues, one of which is that all of us were 
going to be collecting information on medical errors and 
patient safety. AHRQ would collect this information through 
demonstration projects that the Congress has allowed us to 
fund. The CDC has been collecting information on people who get 
infections in the hospital. The FDA, of course, collects 
information on adverse drug events. And the Health Care 
Financing Administration recognized the opportunity that it had 
in the Medicare program to collect information and then to feed 
it back to physicians and hospitals for improvement purposes.
    We imagined as we sat there talking about this a hospital 
administrator or physician or a nurse trying to do some 
reporting and saying, oh, yeah, which agency does this one go 
to, which form does this go on. Anybody who has ever practiced 
in a hospital before knows what a headache it is to remember 
which form to use for which report you are supposed to do. So, 
we figured we could make a system work that would be integrated 
among these four agencies, that would be easier to use, that 
would have a common vocabulary, and which would decrease the 
burden on the reporter and could remain confidential. That is 
our goal, all four agencies working together.
    Secretary Thompson kicked this off a couple of weeks ago. 
We are now working on a contract that will provide a common 
vocabulary and a common system for all four of the agencies to 
work together on. This system not only decreases burden on the 
reporter, but it also gives us an opportunity to have 
confidential data that we as a research agency can pull 
together and analyze so that we can help the hospitals to 
understand how they are doing, understand how we are doing as a 
Nation, but then also share with our colleague agencies so that 
we help them on the research side and the analysis side of 
their data. It is great. Frankly, it is four Federal agencies 
collaborating.
    Mr. Regula. So the net result is that patients can feel 
more confident that there won't be mistakes, that they will 
have a greater degree of safety as they are part of the medical 
delivery system?
    Dr. Eisenberg. That is our goal, and we are confident that 
with an integrated standard system of reporting, that will 
happen. The number of errors and the number of adverse events 
that occur from errors will be reduced.
    Mr. Regula. Thank you very much. You have a challenge, and 
I assume we can leave here this morning feeling more confident 
in our health care delivery system because of the activities of 
your Agency. Is that a fair statement?
    Dr. Eisenberg. I think you can, and you can hold us to it. 
Thank you.
    Mr. Regula. Okay. If we could just continue a minute, one 
of our subcommittee Members is on the way and he had some 
questions.
    Dr. Eisenberg. Okay. Good.

                             AHRQ'S WEBSITE

    Mr. Regula. I have asked every agency, do you have a 
Website?
    Dr. Eisenberg. We do.
    Mr. Regula. And the information that you gain is available 
to the public?
    Dr. Eisenberg. It sure is. Much of the information I 
described today, like the evidence reports that come from these 
evidence-based practice centers, are on the site. The guideline 
clearinghouse is there. In addition to that, if people have a 
question about a particular disease, they can type the disease 
in, and it tells them the kind of research that we have 
sponsored in that area. It will help them look at evidence 
reports and look at the guideline clearinghouse, and, of 
course, the grantees use the Website to see what we are 
funding.
    Mr. Regula. What kind of groups or individuals use the 
Website? I am curious as to who uses it. Can you tell from the 
hits that you get?
    Dr. Eisenberg. Well, we can't actually because we have 
confidentiality for the people who are coming in. We do know 
what their suffix is, if they are a dot-com or a dot-edu, and 
we know that there is tremendous diversity. In fact, a number 
of them come from other countries, because we are the only 
agency in the world who does what we do.

                    INFORMATION FROM OTHER COUNTRIES

    Mr. Regula. Do you get information statistically from other 
countries to factor into your base?
    Dr. Eisenberg. We don't yet, but as I mentioned, we are 
meeting with the British about developing, for example, on the 
medical errors issue, data from them so that we can compare how 
we do with that country. The Germans want to participate with 
us in the National Guideline Clearinghouse. So there are a 
number of collaborative projects, but we don't yet have a 
system where we can compare ourselves to the data from other 
countries. I think when we have the disparities report and the 
quality report and the errors information up, it will be easier 
to do that.
    Mr. Regula. So there is no comparable agency in other 
countries at least?
    Dr. Eisenberg. Not exactly like ours, no. There is one in 
England that does what Carolyn's group does, which is they do 
in essence evidence reports, but that is where the----

                            EVIDENCE REPORTS

    Mr. Regula. Tell me, what do you mean by evidence reports?
    Dr. Eisenberg. When we get a question from a professional 
society, ``would you tell us what the literature says in a 
particular area and/or sponsor more research in this area'', we 
say, ``sounds like an important question''. We will ask one of 
the 12 centers around the country with whom we have a 
relationship to do a project. We fund them to scan the world's 
literature and critically assess it and, in fact, do analyses, 
sometimes mathematical analyses----
    Mr. Regula. On that particular subject?
    Dr. Eisenberg. On that particular subject. They come back 
to us with what we think of as a synthesis of literature that 
basically says here is what the world's literature says on this 
issue, on, for example, the diagnosis and treatment of 
attention deficit disorder, because the pediatricians and the 
psychiatrists said we as an organization don't have the 
resources; you are a Federal agency, this is the kind of thing 
you are supposed to do, partner with us; and we say, yeah, that 
is what the Congress tells us, too. So we will partner with 
you, and we will address your questions. So we get that 
evidence report, and the evidence report is made available, of 
course, to the society or the health plan who asked for it, but 
it is also made available in general.
    Mr. Regula. So you would peruse the health care 
publications, resources of health agencies in other countries.
    Dr. Eisenberg. We do.
    Mr. Regula. And pull this information into a single source 
or a single publication that would then be available to 
whomever might be interested?
    Dr. Eisenberg. Precisely. We scan the literature. We pull 
all of the articles that look as if they have merit to them, 
and we review a literature which you describe--it is very tough 
literature to review. People call it the gray literature 
because it is not in journals, it is not in books, but somebody 
put it out as an agency publication, maybe another country's 
agency publication. It is very hard to get those, and the 
people who do these projects are masters at finding the gray 
literature. They know how to go to Websites around the world. 
They know how to go to libraries and to get this so-called gray 
literature in addition to using the literature that has been in 
peer review journals like the New England Journal or Annals of 
Internal Medicine.
    Mr. Regula. So, if there was a breakthrough in some type of 
medical procedure in Russia, and if it were at all published, 
this would get picked up and be made available to whomever is 
interested here?
    Dr. Eisenberg. That is right. If it is published in a peer-
reviewed journal, that is, a journal that goes through 
scientific review, then it would likely be on the National 
Library of Medicine's list but we also use lists from other 
countries.
    It is ironic that you mention Russia, because the Russians 
asked us to help them to create an agency like ours because 
they recognize that they face the same kind of challenge that 
we face, that some of the research being done in Russia needs 
to undergo the kind of scrutiny that the research being done 
here is. It has been a very satisfying relationship because 
they are emulating some of the work that we have done.
    And Gregg Meyer, you should take some credit for this. 
Gregg Meyer, raise your hand. Gregg has been the person whom 
they have been coming to saying, how do we do work like what 
your agency is doing? Gregg is the head of our Center for 
Quality Improvement and Patient Safety, and the Russians are 
still way behind us, but I am pleased to say that we have been 
able to help them make some progress in this area. Generically 
the area is called evidence-based medicine, and the Russians 
really have picked up on this concept of evidence-based 
medicine, as have the other countries with whom----

              OTHER COUNTRIES AND EVIDENCE-BASED PRACTICE

    Mr. Regula. What countries would you identify as being on 
the cutting edge or progressive in their medical procedures in 
terms of serving their population?
    Dr. Eisenberg. In terms of using evidence so that they 
provide the right services to the right people, you mean?
    Mr. Regula. Well, in effect do a good job on behalf of the 
people.
    Dr. Eisenberg. Right. The ones with whom we have 
collaborative arrangements and the ones who have published 
their results and I would say are doing a good job, if not a 
great job, would be the United Kingdom. I think that the United 
Kingdom's model is exemplary.
    Canada, has an agency that is not quite like ours, but 
overlaps with what we do and provides information to the 
provinces. As you know, in Canada the health care is very 
different in each of the different provinces. Ontario has a 
model program, for example.
    I would also say Australia.
    Mr. Regula. That is interesting.
    Dr. Eisenberg. And it may be no coincidence that they are 
English-speaking, because we do find it easier to share 
information with those countries.
    But I would say that Sweden has a magnificent program. The 
Swedes have a program that has been out in front for a number 
of years. As I mentioned, the Germans and the French have been 
interested in this. The country that surprised me is Catalonia. 
I never would have guessed that Catalonia would have a strong 
evidence-based medicine program, but they had some visionary 
people there. They had some people who had been trained in this 
kind of research, and they put a model program together around 
Barcelona. It surprised me, but as I have looked at what they 
have done, I have been very impressed at how they have 
translated research into practice in the Barcelona area.

                    STATE OF MEDICAL CARE WORLDWIDE

    Mr. Regula. Do you think medical care generally is 
improving worldwide?
    Dr. Eisenberg. In the developed nations it is fair to say 
that it is improving because of this movement towards evidence-
based medicine and a concern to using evidence-based medicine. 
There is, in fact, an international consortium with whom we 
collaborate, it is called the Cochran Collaboration, which has 
been active in a number of these countries in getting good 
information about evidence, some of which is evidence that we 
have sponsored, to the practitioners. And I think it is, 
therefore, fair to saythat we are doing a better job in 
developed nations, and I am proud to say we have had a little bit to do 
with that, but I am very worried about the developing nations.
    There are very few individuals who have been trained in 
this area in the developing nations. I had the privilege of 
working with the Rockefeller Foundation for a few years to 
train physicians in Southeast Asia, Africa and Latin America so 
there would be more people educated in this area, but there are 
very few.
    Carolyn, you can testify to the fact that it is an exciting 
area for these countries, but they just don't have the 
resources that they need in order to develop the workforce that 
they need to do this kind of research.
    And if I may just add one aspect to that, I believe that as 
a research agency, we do have a responsibility to train 
researchers to do this kind of research, and I am grateful to 
the Congress for providing us with funds that allows us to 
train the researchers of the future, but I also think we need 
to be training the users of the research. Physicians, the lay 
public, health plans, some of this stuff is a little difficult 
to read, and we try in our Agency to translate it to the lay 
public. But I would love it if we could do a better job of 
educating the lay public, including people who run health 
plans, about how to interpret this information.
    I often tell my colleagues that when I was in the 
university, I would put my white coat on, and the tradition was 
to ask, what is the evidence for that decision, and somebody 
would say, oh, AHRQ has done this study, or it is in the New 
England Journal. But then you take your white coat off and you 
go to the board room to make a decision about the organization, 
and somebody says, oh, let's start a disease management 
program, or let's hire nurse practitioners, or let's do 
something else that is an organizational decision, and nobody 
says, what is the evidence. My view is we have got to get 
managers of health care, purchasers of health care to ask the 
same kinds of questions we have been wanting clinicians to ask.

                  PRIVATE SECTOR USE OF AHRQ RESEARCH

    Mr. Regula. Well, that leads me to one last question, and 
that is, does the private sector use the information you 
develop? Do drug companies, hospitals, clinics, et cetera, use 
this information?
    Dr. Eisenberg. I would say that they are our best clients, 
not just clinicians in the private sector, but professional 
societies, health plans, hospitals. It is great, frankly, to 
have a clientele who really cares and who first tell us what 
they need, and then when we provide it, they actually use it.
    We do something we call telling the story, which is going 
out to these organizations and saying, how are you using the 
research, because someday I am going to go before a committee 
in the Congress, and they are going to ask me how does this 
stuff get used, and I would like to have some stories to tell. 
And we have lots of stories, but it is because we do go out and 
we say, tell us how you are using this research because it is 
important for us to know that somebody is using it and we are 
not just putting articles on a bookshelf somewhere.

           CENTERS FOR EDUCATION AND RESEARCH ON THERAPEUTICS

    Mr. Regula. Do you evaluate the efficacy of drugs? I mean, 
I see drugs advertised, and they have all these caveats about 
possible side effects.
    Dr. Eisenberg. You know that it is the FDA's responsibility 
to look at safety and efficacy.
    Mr. Regula. Yes, that is true.
    Dr. Eisenberg. What I have learned is that the term 
``efficacy'' means that a drug can work when it is in a 
randomized trial, a situation that is pretty much perfect. 
Researchers use a different term, which is ``effectiveness,'' 
when they mean ``does it work in real life, do people actually 
use it the way it is intended to be used?''
    Carolyn's program has really specialized in looking at 
whether drugs are used effectively, not just if they are 
efficacious and safe. We think of ourselves as partnering with 
the FDA in this area. The FDA looks at safe drugs. We look at 
safe use of drugs. Although the FDA partners with us, and, 
sure, they look at safe use of drugs, too, but we have a number 
of projects that we have done. Our pride and joy in this area 
is a program that Carolyn leads called our Centers for 
Education and Research on Therapeutics.
    Senator Frist wrote this into law and said, AHRQ, we want 
you to run some Centers for Education and Research on 
Therapeutics.
    So, do you want to take a moment and describe it? I 
shouldn't hog the limelight here.
    Dr. Clancy. There are seven centers located around the 
country, and their focus is exactly what John said, to focus on 
safe and effective use of drugs to try to help people 
understand it, but a little more clearly so that the right 
drugs are given to the right people.
    Mr. Regula. Say an individual is contemplating using a drug 
let's say for arthritis. Can that individual go to your Website 
and gain access to what information you have about the efficacy 
of that particular drug and the possible side effects?
    Dr. Clancy. Well, that is the goal. Some of that 
information is available from what the manufacturers put out, 
but more specific information, particularly about some of the 
newer arthritis drugs, is a specific focus of a couple of these 
centers. If you have been watching TV at all or reading 
magazines, you will know that there are ever more sophisticated 
drugs for people with arthritis.
    Mr. Regula. Well, the front page sells it, and the back 
page says, here are all the problems.
    Dr. Eisenberg. That is right. We do have some of that 
information on the guideline clearinghouse, and some of those 
organizations I mentioned earlier have asked us to do evidence 
reports, for example, the comparison of drugs for depression. 
We did this report including alternative treatments like Saint 
John's Wort and how well they do. We did a report in that area, 
and to Mr. Peterson's point, not everybody was happy with that 
report. But we did do that report, and you can get the results 
of that report with just a couple of clicks.
    Mr. Regula. Mr. Istook.

                    INCREASING COSTS OF MEDICAL CARE

    Mr. Istook. Thank you, Mr. Chairman.
    Dr. Eisenberg, I appreciate hearing from you and everyone 
with you today. I just wanted to delve into one particular 
area. That is a--it relates to a growing concern I have had 
that a lot of what is being done in medicine has been a cost 
driver, not just an expansion of the ways and effectiveness of 
different treatments. There was a study that was commissioned 
by Blue Cross/Blue Shield completed recently that indicated 
that a third of the growth in medical expense is due to the 
results of medical research, and the scenario basically is that 
when people say something can be done,therefore, they say, 
well, you must provide that treatment to you, and pressures are 
created, and indeed, we want medical research to result in clinical 
treatment of people.
    But as more--I will use the term exotic--as more exotic or 
expansive treatments become possible, expenses are increased by 
it, and what I see is a deficiency in the research that we are 
devoting to finding more affordable ways to provide new 
treatments or perhaps some sort of parallel treatment that I 
see as a gap in the major funding increases that we have had 
for NIH. And I think perhaps we can develop a consensus that a, 
I will say, significant portion, whatever level that might be, 
of the research that is being devoted through NIH or that it 
uses cooperatively with you or anyone else be devoted to find 
the ways to provide these treatments at reduced costs, and I 
don't mean by imposing cost controls upon the providers. I am 
talking about actually making them less expensive to provide 
the treatment, to find the ways to do that so that the success 
in medical research can indeed be translated into availability 
of treatments without making the whole financing system more 
precarious, as we have been seeing.
    I wanted to ask you generally your feelings as to whether 
this is indeed a phenomenon that we are experiencing as far as 
elevating the cost of medical care and how research dollars can 
be devoted to bringing the costs into line with people's 
ability to pay.
    Dr. Eisenberg. Well, thank you for that question. As it 
turns out, it is one of the issues I personally feel the most 
passionate about because I think it is an issue that our Agency 
can address, and, frankly, it is an issue I used to do research 
on so----

                        TECHNOLOGICAL IMPERATIVE

    Mr. Istook. Research on research, right?
    Dr. Eisenberg. The technological imperative is the jargon 
term that we use to describe what you said. The technological 
imperative is the term that is used by people in health 
services research to describe the attitude, ``we can do it; 
therefore, we must do it''. We as physicians, we suffer from 
the technological imperative, it can be done; therefore, it 
must be done. And there are some financial incentives to that 
as well.
    But let me stick with the technology part for a minute and 
then comment on the other aspect.
    Certainly because it can be done doesn't mean it should be 
done for everybody and all the time. So the first step, I 
think, in this issue is to say for whom should it be done, when 
should it be done, at what time in a person's illness is this 
test or is this treatment appropriate, and that is our 
specialty. That is what this Agency has been doing since it 
started, since it began, is to ask the question of when should 
a service be done, for whom, and, you know, what time in the 
course of their illness and compared to what.
    The compared to what question is an awfully important 
question because there usually are alternatives. It is not just 
you should do this because it is available. It is that there 
are several alternatives, and we need to have better research 
about what the alternatives get us.
    A second way of addressing this issue is to say what is the 
value of that service, what are we getting for the money we are 
spending. You know, if the costs go up, well, maybe that is 
okay if we get tremendous value for it, and that is another of 
our specialties as an agency is to look at the value. We 
created a new unit in our Agency which we call RICE, Research 
in Cost-Effectiveness. It is an area a lot of us feel 
passionately about, that we can't just measure cost or just 
measure effectiveness. We have got to understand how they 
balance with each other, and especially if we are comparing 
different kinds of services. We need to know the cost, and we 
need to know the effectiveness of the alternative choices, and 
that is an area where we are very pleased to do research. In 
fact, some of our colleagues in other agencies have asked us to 
help them with this kind of research because it is an area we 
specialize in.
    But often even though it seems valuable, the services are 
denied, and the costs go up, and we as a country or as a 
Nation, we have to decide is that increase in quality that we 
get from that service worth the increase in cost; is it 
something that competes successfully with the others.
    But sometimes the costs will go down. There are going to be 
some savings, and, in fact, I would love to tell you about a 
study that we sponsored in southern California that looked at 
how costs can be reduced when new services are offered. An 
investigator at the Rand Corporation had a grant from us that 
looked at what happens if we provide more pharmaceutical 
benefits to people who are HIV-infected because of all the new 
drugs that we have that can do a better job.
    This was an article that was published in the New England 
Journal of Medicine about 2 weeks ago. What he showed, or his 
group showed, was if you spend more on the pharmaceuticals, in 
this case, that you will spend less on hospitalization, because 
people need to be in the hospital less, so hospitalization 
costs were down 40 percent. Overall costs of care were down 
between 10 and 20 percent.
    There are other instances where we have sponsored research 
to ask the question of are we getting more value for money, or 
are we actually saving money by providing this service, or is 
there no added value and we are spending more money. Sometimes 
that is the case, that there is no value added, which is 
spending more money, and there are incentives to physicians to 
provide those services.
    And let me just close with that. The Institute of Medicine, 
when it came out with its report a couple of weeks ago, said 
that we have a problem in quality in this country, but we have 
to remember that health care is provided in an environment that 
provides certain signals to hospitals and clinicians, and if we 
provide signals that we want them to do more, then they will do 
more. So we have a set of research projects that we are now 
sponsoring, some on the west coast, but several around the 
country, that evaluate how clinicians and how hospitals respond 
to different signals, how they respond to markets, how they 
respond to different kinds of incentives to understand better 
how, if we did want to change the incentives, how we could 
change the incentives to hospitals and physicians so that if a 
service added no value, but did cost more, then we wouldn't 
just pursue the technological imperative. We would be able to 
provide higher quality care even at a lower cost. There are 
other examples of that.
    Mr. Istook. Certainly.
    Dr. Eisenberg. I would be happy to come by and talk to you 
about them if you want.

                EFFECTIVE, LOW-COST MEDICAL ALTERNATIVES

    Mr. Istook. Certainly, and I would appreciate your 
providing my office with the information that you can see as 
pertinent to this.
    Let me ask about an area that I didn't really hearexpressly 
covered, and that is because sometimes you find, well, there is a 
certain treatment if you treat with this substance. Well, perhaps it is 
very difficult to obtain or produce that substance, maybe you--I don't 
know, maybe you precipitated out some solution, and there is some 
better way to do it. I have no idea. Maybe it is something that relates 
to skin grafts, and there is a less expensive way of doing those. In 
other words, if you take the component elements of a treatment and say 
which ones are the cost drivers, because you are purchasing it from 
someone, or it is time-consuming or whatever it may be, my question 
really is how well does the effort to find, to identify those 
components and to use research as the tool for finding more effective, 
more efficient or alternative ways of doing it, how responsive is this 
situation to directed research?
    Dr. Eisenberg. The methods are there to do the research, 
but not much of it has been done. We haven't been able to do 
much.
    Mr. Istook. And the reason is that not much has been done?
    Dr. Eisenberg. I think it is just a matter of funding 
issues. But the rest of your question is when the research is 
done, does anybody pay attention to it is the critical issue. 
That is a tough, tough question because when we get research on 
this area, the hospitals tell us there is not a business case 
for quality, and they will adopt the research if there is 
either going to be a tangible increase in quality, or they know 
that they will decrease costs. And I mentioned earlier that I 
have been frustrated that hospital managers don't always use 
the research as well as clinicians do.
    There is a study, for example, that shows that once-a-day 
antibiotics are cheaper to use than four-times-a-day 
antibiotics, and you would expect, therefore, that the hospital 
would move towards once-a-day antibiotics, and that has 
happened to some extent, but it hasn't happened to the extent 
that I wish it would happen. I think that is in part--this is 
not a study we sponsored. But I think that happens in part 
because the managers are not accustomed to reading the research 
literature, and we, as we sponsor more of this literature, are 
getting it to them. But as I mentioned earlier, we have to make 
them a more receptive site to these kinds of decisions as you 
describe, and we have to be sure that their boards understand 
that this research is available, that the managers understand 
that this research is available so that they can manage more 
effectively.

               TRANSLATION AND DISSEMINATION OF RESEARCH

    Mr. Istook. So it is not only having the research that is 
focused on this to find it, but it is, of course, also making 
sure the information is disseminated, because when you have as 
vast and as rapidly expanding a body of knowledge as you do 
possess with medical research, being able to do the data mining 
of it and organize and extract the information and get it into 
proper hands, which I know--I have got a daughter that is going 
into a doctoral program of medical informatics or 
bioinformatics on that, and so I will have a little bit of 
insight through her, I guess, on that, but I know that is a 
challenge.
    But I bring that up because I wanted to ask about what 
level of resources you believe that we are devoting to the 
ability to make sure that all this marvelous knowledge doesn't 
just get filed away on a dusty bookshelf.
    Dr. Eisenberg. Well, you picked one of my favorite topics, 
computers and hospitals. We have a grant out right now, a 
request for applications, for studies to be done on the degree 
to which computers improve patient safety in hospitals, because 
we sponsored some research in the past that shows that they do, 
because we believe that if we can show that computers do 
improve patient safety, then the purchasers will start to ask 
the hospitals, do you have a system in place, a computer system 
in place that is going to help us to reduce errors. In fact, we 
worked very closely with some of the purchaser groups so that 
they know what the literature is.
    I will give you two examples. One is the computer area, the 
so-called Leapfrog Group, which is a group of purchasers led by 
General Electric. But a number of others, including our Office 
of Personnel Management and HCFA, are now asking hospitals to 
show that they have in place systems that work before they will 
send their people to them. We have asked the National Quality 
Forum to give advice to us based on the research that we have 
either sponsored or that others have sponsored about what does 
work, just along the lines that you are describing, so that 
hospitals would have to show in a market-oriented system that 
they are doing the right thing.
    Finally, we have sponsored research about the relationship 
between the volume of care and outcomes of care. There is 
clearly relationship between volume and outcomes. We are 
starting now to do some more fine-tuned research about that, 
which says at what volume does quality start to go up, at what 
point does practice make perfect, and for what diseases, for 
what conditions. And I believe one of the people who is doing 
that research is, in fact, here, but I won't ask her to come 
up, but it is very exciting work.
    We have been asked by people like the purchasers, well, how 
much volume is enough volume as we start to look at hospitals. 
So I think my answer to your question is that as we disseminate 
the information, as you said, and as we have purchasers 
starting to ask the tough questions of hospitals and 
physicians, independent of whether the hospitals and physicians 
want to provide high-quality care, which I believe they do, but 
the more we have the purchasers asking the tough questions, 
then the more they are going to be driven to adopt those 
services that work. And I am sure that your daughter--I hope 
she applies to us for a grant because I think--I am serious, we 
have so much work that can be done on the applications of 
computers in health care, and we know so little about when they 
make the biggest difference.

                           UNIVERSITY OF UTAH

    Mr. Istook. Well, I appreciate that, and she has a 
fellowship with the University of Utah that is putting her 
through this.
    Dr. Eisenberg. Is this with Intermountain?
    Mr. Istook. Well, it is through University of Utah. I don't 
know of any involvement of the Intermountain Health Care 
System.
    Dr. Eisenberg. Well, you have to let me brag for a minute. 
The University of Utah and earlier at LDS, which is now called 
Intermountain, was one of our first grantees in the area of 
computers in health care, and we currently are working very 
closely with Intermountain System because it does have one of 
the best computers in health care systems in the country. She 
chose well.
    Mr. Istook. Okay. Well, good, because her husband's going 
to medical school, and he is in that aspect of it, too.
    Dr. Eisenberg. Good.
    Mr. Istook. I appreciate the testimony, look forward 
tohearing more, and including, of course, the--you know, the 
organizational barriers that may be a challenge to try to achieve this 
result. I thank you and look forward to the information.
    Thank you, Mr. Chairman.
    Dr. Eisenberg. Thank you so much.
    Mr. Regula. Well, thank you for your patience. The hearing 
is adjourned.
    [The following questions were submitted to be answered for 
the record:]

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                                              Tuesday, May 8, 2001.

              HEALTH RESOURCES AND SERVICES ADMINISTRATION

                               WITNESSES

ELIZABETH JAMES DUKE, Ph.D., ACTING ADMINISTRATOR, HRSA
DR. SAM SHEKAR, ASSOCIATE ADMINISTRATOR, BUREAU OF HEALTH PROFESSIONS
DR. PETER VAN DYCK, ASSOCIATE ADMINISTRATOR, MATERNAL AND CHILD HEALTH 
    BUREAU
MR. DENNIS P. WILLIAMS, ACTING ASSISTANT SECRETARY FOR MANAGEMENT AND 
    BUDGET, DEPARTMENT OF HEALTH AND HUMAN SERVICES
DR. MARILYN H. GASTON, ASSOCIATE ADMINISTRATOR, BUREAU OF PRIMARY 
    HEALTH CARE
DR. JOSEPH F. O'NEILL, ASSOCIATE ADMINISTRATOR, HIV/AIDS BUREAU

                       Introduction of Witnesses

    Mr. Regula. Well, good afternoon. Thank you all for coming 
and we look forward to your testimony. Your full statements 
will be made part of the record. You can summarize as you 
choose. Dr. Duke.
    Dr. Duke. Good afternoon, sir.
    I am happy to be here this afternoon. I would like to 
introduce the people at the table with me and then I have a 
brief opening statement. To my right is Dr. Sam Shekar, the 
Associate Administrator for the Bureau of Health Professions. 
To his right is Dr. Peter van Dyck, the Associate Administrator 
for Maternal and Child Health Bureau, and to his right is Dr. 
Dennis P. Williams, the Deputy Assistant Secretary for Budget 
at the Department of Health and Human Services. On my left is 
Dr. Marilyn Gaston, Associate Administrator of Bureau of 
Primary Health Care, and to her left is Dr. Joseph O'Neill, the 
Associate Administrator, HIV/AIDS Bureau.

                            Opening Remarks

    I am pleased to appear before you today to discuss the 
fiscal year 2002 budget request for HRSA, Health Resources and 
Services Administration.
    HRSA grantees deliver preventive and primary health care to 
needy, unemployed and underserved individuals and families. We 
work with States to ensure that babies are born healthy and 
that pregnant women and children have access to health care. We 
administer programs like Ryan White CARE Act that give low 
income people with HIV/AIDS the medication and care they need. 
We help train physicians, nurses and other health care 
providers and place them in communities where their services 
are desperately needed and we oversee the Nation's organ 
procurement and transplantation system and the bone marrow 
donor program.
    While the U.S. Census Bureau reported recently that the 
number of Americans without health insurance coverage declined 
to 42.6 million, down 1.7 million from the previous year, some 
populations, especially those who use HRSA funded services in 
large numbers, continue to fare poorly. They face a combination 
of obstacles to good health care--obstacles of cost, language 
and culture. Thus they are more vulnerable to certain diseases 
and less likely to receive services to prevent or treat them.
    HRSA programs represent the ultimate safety net, a net 
whose strength depends upon the collaboration of partners in 
each community and at all levels of government.
    At this time please allow me to briefly address three major 
initiatives, the Presidential initiatives in the 2002 budget. 
First, the President's 2002 budget includes the Health Center 
Presidential Initiative, which requests 1.3 billion dollars for 
health centers, an increase of 124 million above the 2001 
appropriation. These additional funds will allow health centers 
to create 200 new and expanded access points and serve up to 
one million additional patients, almost half of them uninsured. 
The added funds represent the first installment of the 
administration's multiyear initiative, which will eventually 
increase or expand health center access points by 1,200 over 5 
years and eventually double the number of people served.
    Health care at many of the center sites is provided by 
clinicians recruited through the National Health Service Corps. 
Since 1972 the Corps, through its scholarship and loan 
repayment programs, has placed more than 22,000 health care 
professionals in areas where we have shortages. Today, 
approximately 2,400 clinicians serve in border towns, rural 
areas, inner cities and in every State, the District of 
Columbia, Puerto Rico and the Pacific Basin. In fiscal year 
2000, 46 percent of these health care providers cared for 
patients in HRSA-supported health centers. The remaining 54 
percent worked in similar freestanding community based sites.
    Secondly, the National Health Service Corps Presidential 
Management Reform Initiative will improve the Corps, which 
serves America's neediest communities. The initiative will 
examine several issues, including the ratios of scholarship to 
loan repayments and will consider amending the health 
professionals shortage area definition to include nonphysician 
providers and J-1 and H-1C visa providers practicing in 
communities. These efforts will enable the Corps to more 
accurately define shortage areas and target our placements to 
areas of greatest need.
    And third, the President's 2002 budget includes the Healthy 
Communities Innovation Initiative, a partnership among the 
Department of Health and Human Services agencies to target 
existing resources to areas where health needs are the 
greatest. Approximately 220 million is available in HRSA for 
this initiative. Funding will also be available for it from the 
Centers for Disease Control and Prevention and the Health Care 
Financing Administration.
    HRSA activities that may contribute to the initiative's 
goals are the Maternal and Child Health Block Grant, including 
the Special Projects of Regional and National Significance, the 
Community and Integrated Services System and Healthy Start.
    The fiscal year 2002 budget includes $1.8 billion for the 
Ryan White HIV/AIDS program, the same as the 2001 level, which 
is 214 million over the 2000 level. The budget will support 
services to 500,000 persons and provide pharmaceuticals to 
72,000 persons with HIV/AIDS.
    Each day in America about 62 people receive an organ 
transplant, while another 17 on the waiting list die, about 
5,500 people annually, all because too few organs areavailable. 
Currently about 75,000 Americans are on the national waiting list for 
organ transplants. Thousands more wait for tissue transplants and more 
than 30,000 people each year are diagnosed with diseases that a bone 
marrow transplant could cure.
    The President's budget includes nearly $20 million, an 
increase of $5 million for organ procurement and 
transplantation programs. The requested level is targeted to a 
new major secretarial effort to encourage increased organ 
donation and education.
    A projected shortage of nurses threatens the quality of 
health care in communities across America. The President's 
budget will enhance the educational mix and utilization of the 
nursing workforce by adding $1.5 million for nursing workforce 
diversity and $3.5 million for basic nurse education and 
practice programs. Our nursing budget will put 15,000 nurses in 
patient care by 2004.
    Through this budget request HRSA will remain the anchor for 
the safety net, investing more than $5 billion in community 
based primary health care health systems for mothers and 
children, services for low income individuals and people with 
HIV/AIDS and targeted health professions training.
    Mr. Chairman and members of the Committee, I will be 
pleased to answer questions or comments you have on the 
specifics of this budget, and I will be assisted today by the 
associate administrators I previously introduced.
    [The statement of Dr. Duke follows:]

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    
                          PUBLIC COMMUNICATION

    Mr. Regula. I am interested in how you get information in 
the hands of people who need it. We have heard a lot of 
testimony over the last several weeks from NIH, CDC and so on 
where a lot of good things are happening and yet it is so 
important that this be made available to the public. Now we do 
have the Internet and web-sites and 800 numbers. Do you have 
something like that?
    Dr. Duke. Yes, we do. We have web-sites. We have 
publications targeted to the practitioner communities. We also 
have publications targeted to our client level. So we have a 
variety of sources of information and a variety of means of 
getting that out to the public.
    Mr. Regula. If you could what we call think outside the 
box, what would you do to add to the public information 
activities of your agency?
    Dr. Duke. I think that part of the way we do our work of 
getting information out is by targeted conference calls, and I 
think that is one of the most effective ways because you have 
got one-on-one communication or one-on-small groups of 
conversation. In several of our programs we do that on a 
regular basis. I think it is an extremely effective way. We do 
this in our HIV/AIDS program, and it is one of the ways that we 
keep people up to date on what is happening in the field. That 
is done on a regular every other week basis.

                             HEALTH CENTERS

    Mr. Regula. I was interested in your testimony on health 
centers and the addition of 200 Centers proposed in the budget. 
Are these generally partnerships? Does local government, 
volunteers, and other agencies participate in making these 
centers successful?
    Dr. Duke. The health centers are in a variety of different 
venues and we bring together the professional providers that we 
hire through the community health centers, and then we reach 
out to the community in a variety of partnerships. We have in 
our health centers projects for integrating services and we 
reach out to the communities to public hospitals, to other 
providers in the communities. And Dr. Marilyn Gaston to my left 
could add to that if you would like her to.
    Mr. Regula. Well, I would be interested and maybe you can't 
quantify all of the volunteer services and other community 
services, but I would suspect that in value they would be 
greater than what we would have in terms of the government, 
Federal participation.
    Dr. Duke. We leverage funds very well in our community 
health centers.
    Dr. Gaston. In fact, the grant dollars on average that go 
across the Nation to support the 3,200 sites that we have out 
there is only 27 percent of all of the costs that it takes to 
run that infrastructure. 32 percent is Medicaid and the rest 
come from State dollars, private dollars, othergovernment 
dollars.

                               UNINSURED

    Mr. Regula. Sounds like a very effective program of 
leveraging for the benefit of the community, and I think you 
said that almost half of the clients have no coverage.
    Dr. Duke. That is correct.
    Mr. Regula. Now what do you do? Are there nominal charges 
for those that have no coverage or are all the services free?
    Dr. Gaston. All the programs use a sliding fee scale based 
on what people are able to pay, and of course it varies across 
the patient population that they see, whether they are 
homeless, migrant farm worker, rural communities, et cetera, 
but there is no question that the sliding fee scale is tailored 
to meet the needs of the community.
    Mr. Regula. So even those that might have some minimal 
coverage could get the services and use the sliding scale for 
reimbursement purposes?
    Dr. Gaston. Absolutely. No person is turned away from the 
door.
    Mr. Regula. I think these are wonderful things in the 
communities because people don't feel uncomfortable in going 
there as they might to a physician's office in a high-rise and 
not too sure what they will do by way of compensation.
    Dr. Duke. That is one of the goals of the program--to 
ensure that we not only have a 100 percent access but that we 
have a culturally competent staff to make patients comfortable 
in order to allow them to have the maximum advantages of the 
services we provide.
    Mr. Regula. That is the impression of the one that serves 
our community. Doesn't this take a lot of pressure off the 
emergency rooms and the hospitals also?
    Dr. Duke. Indeed, our goal is to do not only primary care 
in the sense of meeting acute needs but also to take care of 
the general, to be a medical home for our constituents, so that 
they have preventive health care as well as services for 
immediate illnesses.

                          PREVENTIVE MEDICINE

    Mr. Regula. That triggers another question because I am an 
advocate of doing more in preventive medicine. What particular 
things would a health center do? For example, would they 
educate their patients about nutrition, about better habits?
    Dr. Duke. Indeed. Among the services provided are not just 
a care for a specific illness or symptom at the time but also 
counseling on such things as smoking reduction, attention to 
obesity, attention to blood pressure and control of blood 
pressure, and the health centers have a good track record of 
dealing with the kinds of symptoms which can present as having 
long-term negative effects on people's health; for example, 
ensuring that women have mammograms and pap smears. Those are 
the kinds of services that can pay off in prevention.

                             PRE-NATAL CARE

    Mr. Regula. Would you work with Planned Parenthood 
agencies? Since they oftentimes get young women who need 
nutritional advice, would there be some cross work between 
those two agencies, HRSA and Planned Parenthood?
    Dr. Duke. We have services for pregnant women. We provide 
services through our Maternal and Child Health Block Grant. We 
provide the Healthy Start program, which has a budget proposal 
of $90 million, and so we work with pregnant women around 
increasing their knowledge of nutrition and also improving 
their habits regarding tobacco, alcohol, and so forth.

                            SCHOOL PROGRAMS

    Mr. Regula. Do you get into the schools at all with these 
education programs?
    Dr. Duke. We have several programs in schools, both in our 
Bureau of Primary Health Care and our Maternal and Child Health 
program. We have programs in schools designed not only to 
provide acute care but chronic care, deal with physical 
illnesses and also mental health supports, and those programs 
are nationwide.

                            NURSING SHORTAGE

    Mr. Regula. Very interesting. One last question. We hear a 
lot about the shortage of nurses. Does your agency help to try 
to address that problem?
    Dr. Duke. Yes, we do. Our Bureau of Health Professions 
tracks the availability of health professions and also tracks 
the trends in nursing availability. In the process of doing so, 
we also help the issues concerning training and availability. 
We put in this budget a request for $5 million additional for 
nursing, nursing education, and we also have in our Bureau of 
Primary Health Care a request for $2 million to allow us to use 
the loan repayment process to put 200 additional nurses right 
now into patient care settings.
    Mr. Regula. Is the program working well?
    Dr. Duke. We think that it is working well. We think that 
the problem of nursing is that it is a challenging profession. 
It is a hard profession. I have a daughter who is a nurse, so I 
know a good deal about it.
    Mr. Regula. You hear a good deal about it, too, I am sure.
    Dr. Duke. Yes, and I think that the thing about nursing, it 
is a very hard job. It is a job that takes a heart as well as 
your physical endurance. It is a profession that is being 
honored this week actually, and it is one that we are committed 
to finding ways to attract people to, and that is one of the 
things that is being targeted by our bureaus this year. We have 
a program called ``Kids into Health Careers'', and we are going 
to be launching that as kids go back to school this year. We 
are going to be paying attention to their having the idea that 
a health profession and particularly a nursing profession is a 
worthy thing to do.
    Mr. Regula. That is great.
    Ms. DeLauro.

                                  AHEC

    Ms. DeLauro. Thank you very much, Mr. Chairman. Thank you 
all for being here today.
    Dr. Duke, this Thursday I am meeting with the directors of 
the national Area Health Education Training Centers, AHECs, and 
the Health Education and Training Centers, HETCs. As I read 
this, the health professions budget proposes a severe cut, from 
$33.3 million to $7.5 million for the Area Health Education and 
Training Centers and from $4.4 million to zero for HETCs. I 
think they could be categorized as severe cuts.
    I need your help. What rationale should I give these folks 
on Thursday for the administration's proposal?
    Dr. Duke. The problem with budgeting is, as you all know 
better than I, are so many good things are competing for 
available funding. We feel that the AHEC program is a well-
established program, and our goal in both of these is to target 
our funds toward those who produce the support for integrated 
health care as much as we possibly can, so we have targeted our 
resources toward the programs that can provide a diverse 
population for our health care providers and provide continuing 
education as we can. We recognize that our programs are seed 
programs, that we are not the only providers of these services, and it 
is for these reasons that the administration has made a decision to put 
its emphasis in this budget on direct provision of health care for 
people. This budget is focused on funding patient care, and perhaps Dr. 
Shekar to my right could add to that. He heads the Bureau of Health 
Professions.
    Dr. Shekar. The administration believes that these programs 
have successfully established community-based partnerships 
which are well positioned at this point in these areas to 
encourage community service and academic collaborations with 
less need for Federal funds and increased use of funds from 
other institutions.
    Ms. DeLauro. So we are going to hope that other 
institutions pick up some of the responsibility for this 
program, is that correct?
    Dr. Duke. These programs are already in partnerships with 
others who are deeply involved in these activities. So it isn't 
that we have been carrying these alone already. So we would 
assume that some of that would be picked up by them.
    Ms. DeLauro. I will be happy to report to you from my 
meeting on Thursday, and I will provide them with the response 
that I received here to let them know where the emphasis is, 
and maybe can get back with what they view as the result or the 
potential result of their ability to continue. They apparently 
play a role and we may find that if they are not able to 
continue that we may have more to do in patient care since we 
are doing less in terms of the training aspects. So I will be 
happy to provide that kind of response to you.
    Dr. Duke. We will appreciate the feedback.

                        Nursing Workplace Issues

    Ms. DeLauro. Let me just ask a nursing question because the 
Chairman asked a question and the nursing shortage is something 
that is widespread across the country. Let me just ask you your 
view about HRSA's role in the retention of nurses, but 
specifically by addressing the workplace issues that nurses are 
really concerned about these days, which is leading a lot of 
folks to leave the profession, 3,200 I might mention in 
Connecticut have left the profession. This is a serious problem 
everywhere. I represent Connecticut so I can talk about our 
circumstances more intimately, but part of it is attraction, 
which I commend the effort to get the schools to encourage 
young men and women to join the profession, but a lot of it is 
the workplace conditions that I hear about from the nurses. And 
again my question is, do you think that HRSA's role should be 
expanded in that effort at retention to specifically address 
workplace issues that nurses are concerned about?
    Dr. Duke. The workplace issues that are reported in many of 
the studies are probably somewhat beyond HRSA's realm, but they 
are areas in which our ability to do studies and produce 
information back to the community is worthy. A recent study 
that I just read last night suggested that problems in the 
workplace are leading to a level of discontent, which is very 
worrisome. Not only are two in 10 nurses thinking of leaving 
the profession within the year, but that is particularly marked 
in nurses who are between 20 and 30 years of age.
    Ms. DeLauro. Right.
    Dr. Duke. And that is a very big worry. We are aware of the 
problems. The nursing profession is becoming more complex. It 
is requiring more problem solving skills. It is a profession 
that works in an interdisciplinary team to provide health care, 
and so these things we are aware of from our studies and we do 
work with advisory committees who represent the field of 
nursing, and through them the Bureau of Health Professions has 
an ability to influence but we don't control.
    Ms. DeLauro. A lot of what I hear about it are the back-to-
back shifts. Thes are often women who have responsibilities to 
a profession and to a family and can't always turn on a dime 
and deal with child care. Also, more importantly, is when you 
are working back-to-back shifts you get tired and when you get 
tired you make mistakes. When you make mistakes in that 
profession, it is different, and a more serious--to make a 
mistake in the nursing profession, sometimes there are life and 
death consequences. So I would love to be able to work with 
you, and something I hope that we could work on in the future 
is the workplace conditions that nurses are facing.
    Dr. Shekar. I would like to mention that we actually in the 
President's budget will continue to support programs that in 
fact address some work-related issues, such as career ladders, 
which will allow nurses to move up in their educational 
training as well as nurse-managed centers that allow them to 
have more opportunities to run clinics.

                      Health Professions Programs

    Ms. DeLauro. I have a comment to make related to my prior 
question, the health professions programs, as I understand, it 
would be cut by about 60 percent. I think that is troublesome. 
The budget cuts by about 58 percent assistance for minority 
students undertaking health careers, as I read the 
documentation. I think this is particularly troubling, given 
the patient loads, given the kinds of issues around diversity 
that we are trying to address, and so forth, so just let me 
leave that there.

                           Newborn Screening

    Last August there was a HRSA-sponsored task force on 
newborn screening and it talked about a patchwork quilt of 
State newborn screening qualities. My State of Connecticut 
fortunately is one of the 18 or so States that tests for at 
least seven heritable disorders. By contrast, over one-half of 
all States test for only about five or fewer of those 
disorders, and there have been some tragic stories about 
youngsters dying from certain disorders that the State newborn 
screening program did not test for because it is not on the 
list. But if that child had been in another State they might 
have been tested for that and, they could have been treated, et 
cetera. The task force report called for the Federal Government 
to step up its involvement in this issue and with bipartisan 
support, I might add, we took a step toward addressing that 
problem with the Children's Health Act of 2000. Title 26 of the 
act authorizes HHS, specifically HRSA, to provide grants to 
States to expand State and local programs for screening.
    I happen to believe that this is one of the most important 
investments that we can be engaged in. This is the most 
prosperous country in the world, and I view this about a lot of 
things, but particularly the health of our kids shouldn't be 
depend on what your particular ZIP code is.
    I just think that is not the way to address health issues. 
So I would hope that we could work together on the funding for 
Title 26 in the Labor-HHS appropriation bill so that we again 
afford States the ability to increase that list of heritable 
disorders that can be tested for. I don'tknow what your intent 
or plans are in this area, but I would like to work with you on it.
    Dr. Duke. We do recognize that that is a problem. The 
heritable disease screening is a very mixed picture. It is a 
State responsibility, but it is one in which our Maternal and 
Child Health Bureau has tried to look at convening a work group 
around the idea of finding some common minimums and at least in 
making sure that parents are informed what has been screened 
for and what hasn't so they have informed choices as to what 
other screening they might need.

                           Wise Woman Program

    Ms. DeLauro. I would just say this. I have worked long and 
hard on the area of breast and cervical cancer, and now we have 
these clinics around the country where women are screened and 
now we are trying to expand that program to something called 
the WiseWoman Program, where if people are coming in you can 
screen also for osteoporosis or cardiovascular diseases. But 
the long and the short of it, there again, it is patchwork. 
Some States have it, some States do not have it. That is the 
issue here.
    It would just seem to me that we ought to have the will and 
the resources to extend what we know works in terms of saving 
lives. If we have got it in 18 States, then we have some 
measures on which to determine that this is a valuable program. 
We then ought to avoid the continued patchwork of programs that 
we have, and that we know work. Again, I have always been of 
the view that geography should not be the determinant of 
whether or not you sustain your life or the lives of your 
families.
    Thank you very much.
    Mr. Regula. Mr. Sherwood.
    Ms. DeLauro. Thank you, Mr. Chairman, sorry.
    Mr. Regula. That is all right.

                        Underserved Rural Areas

    Mr. Sherwood. Thank you, Mr. Chairman. Doctor, I appreciate 
very much your coming to talk with us today on these very 
important issues, and I appreciate your agency's mission to 
improve the Nation's health care by assuring equal access and 
comprehensive and culturally competent quality health care for 
all, and I also appreciate the fact that in your testimony you 
address rural areas and particularly underserved rural areas. 
But I was very disappointed in February to learn that the 
National Health Service Corps, which falls under HRSA of 
course, put notice out that they will withdraw their 
commissioned officer from the only health facility in rural 
Laporte in Sullivan County, Pennsylvania, which is a very 
underserved, very rural area that I happen to represent, and I 
know that there is about a 11 percent cut in this budget from 
2001, but it is maybe a percent better than 2000. But this, 
when notice was put out before the budget and the proposal for 
the use of a commissioned officer was submitted by the 
Philadelphia College of Osteopathic Medicine, and they tell me 
that they would like to remain in the clinic but they have to 
have this doctor to do it and they use it as a teaching 
mechanism and they have run this for several years. It has been 
very successful, and I would like to ask your help in meeting 
the health care needs of this medically underserved area and 
see if you have any comments on really how can we help. What 
can we do?
    Dr. Duke. I don't know the specifics of that case, but I 
will look into it and get back to you on that matter. The 
problem we have in the--as a general statement, but I can't 
respond specifically to that instance, as a general phenomenon 
there are definitions which undergird our ability to place a 
provider in the definition of an underserved area, medically 
underserved group. So that would be one piece of it. A second 
piece is that we unfortunately always have more need than we 
can fill. We can fill only about 40 percent of the requests we 
have. So I don't know the specifics of that case, but I will 
look into it and get back to you with precisely what is going 
on and look at it in more detail.
    [The information follows:]

    CDR Calvin Vermiere, a National Health Service Corps (NHSC) 
physician, is scheduled to transfer from Laporte to a new assignment in 
Cleveland, Ohio, no later than September 2001. This has raised concerns 
about continued care for the residents of Sullivan County.
    Sullivan County did not submit an application for Federal 
assignment during the required time period, to replace CDR Vermiere, 
and therefore was not included on the initial list of approved sites. 
When the Philadelphia College of Osteopathic Medicine (PCOM) called on 
behalf of the Sullivan County Medical Center (SCMC), the NHSC agreed to 
allow the site to submit an application, even though the deadline had 
passed. This application was reviewed in the same manner as the others, 
and scored a 55. The scores of sites that were included on the list for 
family practice physicians ranged from 107 to 82.
    The PCOM and the SCMC have been aware for some time that eventually 
the placement of a NHSC Federal physician would end. The PCOM has 
tried, unsuccessfully to date, to find alternatives. The PCOM has 
formally notified the County that they will terminate their contract 
with the County as of September 2001.
    The PCOM has indicated that, in light of what has occurred, CDR 
Vermiere's remaining at the site is not a viable option. Given this 
position, the following option may be considered:
    Provide technical assistance--The PCOM has explored partnership 
options with the major hospital systems in the contiguous areas 
(Geisinger, Guthrie, and others), but, to date, none have been 
interested due to the potential financial liability of subsidizing the 
practice. If an assessment of the long-term viability of the practice 
without a Federal subsidy is positive, the assignment of a non-Federal 
NHSC clinician could be considered. In the short term, that could 
include physicians coming out of default or transfers who are available 
off-cycle. In the longer term, assignment could include scholars in 
future placement cycles. Absent partners to assist the PCOM in 
subsidizing the practice, financial viability must be established 
before the program could consider ``back-filling'' this position with 
an NHSC clinician.

    Mr. Sherwood. But it strikes me that a great portion of the 
general budgets in Washington are administration, and I might 
say fluff, but this is the muscle. I mean when you remove the 
single physician from a one-physician operation, then it 
closes. And that seems to me a very, very unusual situation and 
this is an ongoing relationship that has been there for several 
years serving this community, and that decision was made last 
February and we were notified, and of course I have been 
talking with the College of Osteopathic Medicine. We are trying 
to figure out a way to keep it going, but I think this is 
certainly muscle, not overhead.
    Dr. Duke. That is one of the convictions we have also, 
which is that we are looking to put the muscle, as you put it, 
not overhead. We are committed to the provision of more patient 
care. I honestly don't know the specifics, and Dr. Gaston, who 
runs that program, doesn't know the specific instance, but we 
will get on it and get right back to you about what is going on 
and see what we can do.
    Mr. Sherwood. Thank you very much. I look forward to 
chatting with you about it.
    Dr. Duke. Thank you.

                           GERIATRIC PROGRAMS

    Mr. Regula. I note that you have eliminated the funds for 
the geriatric programs. It seems to me with an aging population 
that these programs would be more important than ever. 
Demographically and percentagewise, we are getting older. I 
have always felt that geriatric medicine should start almost at 
birth, because ultimately the habits and the nutritional 
dimensions of youth are going to affect your health in your 
senior years, and I have always felt that part of the basic 
course for a physician should include some geriatric medicine. 
I was surprised that you seem to eliminate the emphasis even 
under those circumstances.
    Dr. Duke. The program we have is a relatively small 
program, but it doesn't mean that we have turned our back on 
geriatrics or on geriatric medicine. We are a relatively small 
player in that field. HCFA is of course much bigger, and so is 
the Veterans Administration. We also look at our program as a 
total program and the fact that a specifically targeted program 
does not show in the budget doesn't mean that a geriatric 
program could not apply for some of the other programs and be 
successful in that, so our commitment is still there because we 
are also aging.

                             MENTAL HEALTH

    Mr. Regula. We talked about the community health centers 
before and one thing I did not mention was mental health 
services. I would be interested in what they offer. Do 
community health centers focus on mental health at all and 
treat it as one of the ongoing needs equal to other types of 
illnesses?
    Dr. Duke. We do have a commitment to mental health in our 
health centers, and part of the President's initiative this 
year is not only to provide new points of access but also to 
have expanded points of access and expanded centers so we will 
be providing more providers in the existing centers as well as 
satellites for those centers, and in those we have a commitment 
to increase the mental health providers in our centers as well 
because we do feel it is an important component of our program 
and one that needs to be increased.
    Mr. Regula. Do you work through the public health agencies 
at all in the States and local communities?
    Dr. Duke. We work with the public health agencies in the 
States and communities along with a variety of partners.

                              RURAL HEALTH

    Mr. Regula. What programs have you found the most effective 
in reaching out to rural areas? I think Mr. Sherwood talked 
about that a little bit and that is an area that I think needs 
to have some attention.
    Dr. Duke. We have an Office of Rural Health that has a 
series of rural health policy centers that do research around 
the areas of the impact of the changes in the market and the 
changes in the health care needs of the rural area in order to 
help us focus and to give information to us and to the local 
providers about the changing world of health care for rural 
communities. So we have had a very active program. We have a 
series of outreach grants in the rural communities. We work 
with rural hospitals particularly to stabilize them financially 
and to provide opportunities for them to serve the needs of 
their population. As I said in the case of geriatrics, we also 
make all of our grants available, not just to the big hospitals 
but also to rural hospitals as well.

                             CROSS-CUTTING

    Mr. Regula. Do you in any way coordinate with NIH and/or 
CDC?
    Dr. Duke. Yes, we work with the sister agencies in the 
Department quite a bit. We work on a lot of programs together; 
that is to say, as their research comes on line, then how can 
we translate that research into treatments. We work with CDC, 
for example, on TB along the borders. We have a project along 
the border where we are doing surveillance and treatment. So we 
work with the sister agencies in the Department quite a bit.
    Mr. Regula. Well, it makes a lot of sense because all of 
you are serving the public. You want to avoid duplication of 
services, but in turn I assume you want to utilize that 
information base to transmit it to the public?
    Dr. Duke. Absolutely right, absolutely right. We work with 
CDC on our poison control program as well. That is a very nice 
partnership with them.

                     ORGAN TRANSPLANTATION-DONATION

    Mr. Regula. You mentioned organ transplants. I think this 
is a program that your agency is responsible for. I would be 
interested in what your experience is and what you think can be 
done to further implement this. It came home to me recently. 
The secretary of the Committee I previously chaired just had a 
lung transplant. She is conversing with the staff, not a lot 
because she is still in intensive care, but what a miraculous 
thing. She would not have lived much longer had the transplant 
not taken place, and it brought home certainly on a one-on-one 
for me how important this is, and I know Chairman Young has 
been very much involved in bone marrow transplants. So I would 
be interested in your comments on this program.
    Dr. Duke. This is a very important program. It is one of 
the programs in which we are seeking an increase of $5 million 
this year, and our focus is on increasing donation. The 
Secretary announced on April 17 a major program to increase 
donations of organs because every single day while 65 people 
are saved every day through organ transplants, 17 people die 
every day because there aren't enough transplants to go around, 
and so the Secretary has a major initiative to increase the 
donations, and that involves such things as teaching people in 
their driver's ed courses about the value of becoming a donor, 
providing cards that will allow people to make their intention 
to donate their organs clear to their families so that when 
their families are facing a dreadful situation of loss that 
they are aware that that loved one wanted those organs to be 
shared.
    So there is a big initiative along this line and it isone 
that the Secretary feels passionately about and has a major workforce 
initiative here as well to get people in their work life to focus on, 
hey, you know you have an opportunity to do something worthwhile, so 
this is a big deal for us.
    Mr. Regula. Would you comment on the improvement in 
technology or procedures in making transplants more effective?
    Dr. Duke. There are two or three pieces but one of them is 
as mundane as we have more ability to travel organs further 
distances, is one piece, so that we have some control in that 
sense to have the organ vital for a longer period of time, and 
then we have also made progress in terms of the drug therapies 
that will help the transplant be successful, and that is 
suppressing the resistance of the body toward a strange, what 
it sees as a strange item.
    Mr. Regula. I agree. It seems to me one of the keys is to 
have the ability for the body to adjust to the new organ.
    Dr. Duke. That is correct. That is correct, and this is a 
very delicate process.

                          PERFORMANCE MEASURES

    Mr. Regula. Many of your performance measurements are 
dependent on data gathered from grantees at the State and local 
level. Do you have some standards so that this measurement has 
uniformity to measure Ohio versus Michigan? You would have to 
assume that it was being gathered on the same basis.
    Dr. Duke. I think since the passage of the government 
performance act, the GPRA has allowed us to work on the idea of 
improving our statement of objectives and also the data that we 
gather to evaluate how well we are doing. We have done that, 
for example, in our Bureau of Primary Health Care. We have 
identified certain performance levels that we expect our 
community health centers to achieve; for example, in dealing 
with hypertension, in dealing with ensuring that people have 
mammograms and in order to achieve better outcomes, also in the 
care of pregnant women and newborns, trying to work with our 
health centers to bring up the level of birth weight, which is 
an indicator of good health.
    So we have done that and our Bureau of Maternal and Child 
Health has an extraordinarily good program that they have 
worked out, which has 18 indicators on which all States must 
report, and they put this information on the Internet and so 
they also have a provision that allows the States to choose 
things that they will measure themselves on with the idea that 
it is not a cookie cutter thing; that we have universal 
standards but we also have some specific standards, and Dr. van 
Dyck can speak more on that if you wish.

                            INFORMATION AGE

    Mr. Regula. The proliferation of information must change 
the way you operate almost on a daily basis, and I assume you 
keep up to speed on the Information Age.
    Dr. Duke. The Information Age is a joy, but it is also a 
challenge.
    Mr. Regula. I believe that.
    Dr. Duke. And each of our major bureaus has major 
commitments to understanding as best we can what is the 
effectiveness of our programs, and so that is the challenge of 
our time.
    Mr. Regula. Mr. Sherwood, do you have any more questions 
you would like to ask?

                            RURAL HEALTH CUT

    Mr. Sherwood. Well, I feel compelled maybe to get back to 
the budgeting aspect. It would be easy for me to understand if 
we had a 10 percent reduction in the budget, if someone said 
that the doctor for the rural health clinic, the local 
government, the local community had to come up with a 10 
percent share. I would understand that as being the theory of 
when you have austere times you share the pain equally. But I 
am having a hard time understanding the decision that was made 
in February to cut this out because I think it is such a vital 
program and it goes to the very essence of what you do.
    Dr. Duke. I wish I understood that issue, sir. I just don't 
know the specific instance. I am not sure whether it was a 
budgetary decision. There are definitions that allow us to have 
health providers in areas. I don't know whether it was an issue 
of the definition or an issue of budgeting. I just don't know 
that specific case, but I am certainly going to absolutely get 
on that first thing I get back to the office this afternoon.
    Mr. Sherwood. Well, thank you very much. Rural health care, 
you know, when you talk about the underserved, there are two or 
three categories which stand out and the inner cities is one 
and very rural areas are another, and we sort of have an 
obligation in the country to try and, as my colleague Ms. 
DeLauro said, not let geography get in the way and we often do 
that and communities will help themselves to a great extent, 
but I think the money that we put in our national programs I am 
very interested in seeing that it is on the delivery of 
services rather than on the bureaucracy, and I think that is 
one reason I am driving this one home so hard.
    Dr. Duke. That is the whole thesis behind our approach to 
this budget. The principle that formed this budget was the 
principle that the investment should be in direct care to 
patients and the services that actually put that service, that 
access out there for patients. So that is the principle that 
formed it, and I just don't know the answer on your particular 
situation.
    Mr. Sherwood. Thank you very much.
    Dr. Duke. Thank you. You are welcome.
    Mr. Regula. Ms. Pelosi.

                            NURSING SHORTAGE

    Ms. Pelosi. Thank you very much, Mr. Chairman. Dr. Duke, 
welcome. I am sorry I wasn't here for your fuller presentation, 
but I have some questions nonetheless and I know I want to 
associate myself with the questions asked by Congresswoman 
DeLauro regarding the growing shortage of nurses, dentists, 
pharmacists, public health professionals and allied 
professionals. So I wanted to associate myself, as I say, with 
that concern.

                                  ADAP

    But I want to ask you first of all about the National ADAP 
Monitoring Report. The most recent one, released in March 2001, 
reports that budget shortfalls will cause 17 States to restrict 
access to AIDS drug assistance programs. President Bush's 
budget says the number of people served by ADAP will be 
increased this year, but despite this the only important 
program in the Ryan White CARE Act is flat funded. As you know, 
there are 40,000 new HIV infections each year. How will the 
current unmet need and the additional need created by 40,000 
new infections be addressed without any additional funds?
    Dr. Duke. The ADAP program will continue at the level that 
it was this year. Certain changes in the protocols mean that 
some of the cases do not move into the ADAP, into the drug 
phase as early as they used to and we have some additional 
relief on the drug budget on that side.
    Ms. Pelosi. Ten States have had to put people in need of 
life-saving medications on waiting lists already. Additional 
restrictions include lowering financial eligibility, limiting 
the drugs covered by the program and restricting access to 
protease inhibitors. I don't know if they are some of the 
considerations that you said were going to contribute to 
lowering the costs. According to the National Association of 
State and Territorial AIDS Directors, nearly nine out of 10 
States, 88 percent, have indicated that flat funding for ADAP 
will negatively impact client services.
    Dr. Duke. I will ask Dr. O'Neill to address that.
    Dr. O'Neill. These are, I think, very difficult questions. 
With the number of changes both within the CARE Act as well as 
within the clinical guidelines--the administration's position 
would be that the equal number of people would be served in 
2002 as 2001 with the ADAP program, with a hope that, or an 
intent that, there may be some additional relief, as Dr. Duke 
pointed out, with the beginning of antiretroviral therapy at 
350 rather than 500 T cells. I think that is a fair statement 
of the administration's position.
    Ms. Pelosi. Mr. Chairman, at the risk of sounding 
repetitive, because, as you may recall, I brought this subject 
up with the Secretary of Health and Human Services, and 
basically the response that I got was that we should be 
focusing on prevention and a vaccine rather than Ryan White 
care. As much respect as I have for him, and he made a 
beautiful statement of commitment on the AIDS issue, and I 
respect that and I look forward to working with him, it is 
simply not possible for us to meet the needs to say that this 
is a priority that we are going to increase the number of 
people who have access to these drugs with the presentation 
that I am hearing now. With all due respect to your 
presentation, this makes the multiplication of the loaves and 
the fishes look like a minor league miracle for you to be able 
to meet the needs that you describe, forgetting any 
additionality. I mean Dr. Duke said that we are going to be 
able to treat the same number of people in 2002 as we did in 
2001. That is simply completely inadequate, completely 
inadequate. It doesn't begin to be considered in any way, shape 
or form a priority if that is the--I mean that is talking the 
talk but it's certainly not walking the walk in terms of--Dr. 
O'Neill, would this have been your professional judgment, 
recommendation?
    Dr. O'Neill. I have given a lot of thought to the entire 
budget that has been presented. Looking beyond the ADAP 
program, the increases that have been requested in the 
community health centers as well as in substance abuse 
treatment would certainly make an important contribution to the 
care needs of people living with HIV and AIDS. The 
administration's position is that looking at the entire HIV 
package that has been brought forward and in making the 
difficult decisions between research and care and prevention, 
the administration feels that this is a way that they have had 
to make their priority choices.
    Ms. Pelosi. So therefore the care is not a priority?
    Dr. O'Neill. I think the administration would make the 
point that this would still be the largest program at HRSA and 
that there is still a very, very significant increase over the 
last 2 years in the program. I think those of us that are 
managing the program feel doubly and triply committed to making 
sure that with the resources that this committee sees fit to 
give us that we will make sure that we stretch these as far as 
possible.
    Ms. Pelosi. If I may, Mr. Chairman, to comment on that, 
this committee has been magnificent in a bipartisan way in 
putting resources toward doubling the funding for the NIH and 
where the research is done, as you know. If we are committing 
the funds to the research and then when we have an opportunity 
with some of the breakthroughs to provide care and then we say, 
well, that is not as high a priority as prevention and, believe 
me, prevention, prevention, prevention, prevention vaccine. I 
have a bill on the vaccine. I don't have to be impressed on how 
important that is. But really we invested in this with some 
expectation out there that if and when there were some 
breakthroughs and hopefully one day a cure, but at the moment a 
holding pattern with the protease inhibitors, et cetera, that 
this would be available to people; that we would not invest in 
the research and then limit the access to that and there is a 
business case to be made for it. It costs us less to invest in 
these interventions than it does to not to.
    My time is up so I can't go overly into it, but the 
recommendation for an increase of $124 million to serve those 
who are eligible, you know this falls very far short of that.

                        COMMUNITY ACCESS PROGRAM

    And I just want to make one other comment. You state in the 
budget justification that community health centers are the 
foundation for the health care safety net, and we are all 
worshippers at the shrine of the community health centers. 
However, the President's budget, it does include a $124 million 
increase for community health centers, but it cuts $125 million 
from the Community Access Program, which has helped communities 
improve access to care for uninsured children in many ways that 
weren't known. Wouldn't the elimination of that undermine the 
ability of community health centers to provide care to the 
Nation's uninsured? And all of this is of course related.
    Dr. Duke. The Community Access Program is a 1-year program 
which has grants for building some synergy. The Community 
Health Program that we discussed is a 5-yearprogram that the 
administration is proposing to increase the number of health centers 
over that period by 1,200 sites. They are really not a--it is not one 
or the other but rather that the Community Health Center Program is a 
long-term project that will have significant growth involved.
    Ms. Pelosi. Well, all I can say, Mr. Chairman, is I hope we 
can fight for a bigger pie here because again it is lamb eat 
lamb. Everything is good in the budget and again it is all good 
investments that ultimately save the taxpayer money, and I find 
the President's budget woefully inadequate, but that is a set 
of priorities. What I find woefully regretful is that they say 
one thing is a priority and the funding doesn't match. That 
inconsistency I find problematic in light of the budget debate 
that is going on now.
    Thank you, Mr. Chairman. Thank you, Dr. Duke, Dr. O'Neill.
    Mr. Regula. Mr. Obey.

                               UNINSURED

    Mr. Obey. Thank you, Mr. Chairman. Just two points. First 
of all, with respect to one specific program. As you know, this 
committee provided $15 million in the budget last year and 2 
years ago and provided additional funding in last year's budget 
in order to allow States to apply for grants in order to try to 
develop, first of all, the identity of the uninsured people in 
their jurisdictions and, secondly, a strategy for getting the 
rate of uninsured and under-insured people in their States down 
to zero. I would simply like to observe that I think this has 
the potential to change the nature of the health care debate in 
this country because in my view there are going to be a number 
of States who have strong convictions that they can get that 
uninsured rate down to zero. I think it is going to be up to 
the Federal Government to decide whether or not we are going to 
be sufficiently forthcoming with respect to matching resources 
in order to allow these States to experiment so that we can get 
the number of uninsured down to zero without the country 
joining hands and jumping off the same cliff together before we 
are absolutely sure that the approach that is going to be 
followed nationally is the right one.
    So if we make mistakes they will be confined to smaller 
areas. And it will be less expensive to test ideas that could 
demonstrate real imagination in dealing with the problem. So I 
simply look forward to working with your agency to see as these 
State proposals come in, that they are met with something other 
than stony silence.
    Dr. Duke. Sir, they are supposed to come in two waves and 
we will be sharing those with you as they come in.

                              UNDERSERVED

    Mr. Obey. Secondly, I know you folks didn't make the final 
funding decisions on the budget but I would simply like to 
observe there are a number of different appropriation bills and 
those appropriation bills each are targeted at somewhat 
different kinds of problems. We have, for instance, the Energy 
Department appropriation, which in many ways tests our 
technical abilities to get to certain points in the technical 
field. We have the Commerce Department budget, which gets to 
the question of how economically shrewd and sensible we are. We 
get to the Interior Department budget, which simply decides 
what kind of commitment we want to make to the beauty of the 
natural surroundings that we have all been blessed with. Then 
you get to this bill, and I tell you what I think this bill is. 
We have an awful lot of people in this society who are used to 
being at the head of the line whenever goodies are passed out, 
whenever problems are addressed. This is the one bill that is 
supposed to go to help people who are so often just pounded 
down by the realities of life, that had no expectations except 
to be put at the end of the line, and your agency certainly is 
an agency that deals in the main with those kinds of people. 
They are people in this society that often unfortunately are 
looked at as being, quote, the leftovers in society, and I 
think morally we have to do better than this budget would have 
us do. The people who this agency's budget are designed to help 
aren't the people you are likely to run into at the local 
Rotary Club or the local Kiwanis or the local collection of 
people at the country club or even the media elites. They are 
some of the kids who interview me for the local news outlets in 
my district, who work for companies who don't themselves 
provide health insurance. They are homeless people. They are 
migrant workers, not exactly people who are going to wind up on 
America's best dressed list. But when I look at what this 
budget provides for them, I am frankly appalled. The proposal 
provides for the elimination of the Community Access Program. 
It calls for termination of support for training in primary 
health care, family dentistry and geriatric medicine.

                            FAMILY DENTISTRY

    When you talk about family dentistry, I told a story before 
but I will tell again. I will tell it a hundred times because I 
am so haunted by this woman. I walked into a town in my 
district about a month ago to announce the creation of a mobile 
dental unit. In that four county area there are 64 dentists, 31 
of whom take Medicaid, or take Medicaid patients I should say. 
Of those who do take Medicaid patients, they don't take any new 
Medicaid patients because the reimbursement rates are so low 
and they are so buried in patients that there is no room in the 
inn for anybody else. And this woman came up to me and told me 
that her husband had been sick for a number of years. She was 
on Medicaid. Her oldest son was also sick, and she looked for 
months to find one dentist who would take the braces off her 
son's teeth and could find none, and so finally she held the 
kid down while the husband took the braces off with a pair of 
pliers.
    Now these are the kinds of people we are shortchanging when 
we knock down some of the items that you have in this agency's 
budget in order to provide huge tax cuts for the most well off, 
the most fortunate, the most privileged people in this society. 
When I see that this terminates support for training in family 
dentistry, I just about want to strangle somebody, and then 
when I see the 5 percent cut in the scholarship program for 
disadvantaged students studying medicine, who the hell is going 
to take care of the people in the poverty census tracks in this 
country if it isn't people who are born there, grew up there, 
have some sense of commitment to those people and who just 
might return if they get a little help for training? You are 
not going to get somebody from a classy suburb in Maple Bluff, 
Wisconsin to go up to Maple, Wisconsin, where people are a 
whole lot poorer, and practice medicine or dentistry there. You 
have got to go to the people with the roots in the community, 
and I am just absolutely appalled when I see all of these 
little nicks that are taken that escape attention because they 
appear to be so small but in cumulative effect really affect 
our ability to do anything except deliver status quo medicine 
to people in this country. And then I see that most of what 
isn't cut is frozen.
    There are a couple of bright spots. You do have the 
increasefor community health centers, which I welcome, but even 
that increase is smaller than the increase this committee provided last 
year. So it is nothing for anybody to brag about. I don't in any way 
question any of you because I know that you folks didn't make the final 
decision about where the really big bucks in this budget go but, my 
God, we can do better.
    Thank you, Mr. Chairman.
    Mr. Regula. Mr. Wicker.

                           DENTISTRY PROGRAM

    Mr. Wicker. Thank you very much. Let me agree in part, in 
large part, with what Mr. Obey had to say, but first I would 
have to imagine that with regard to the story about the little 
boy who couldn't find a single dentist or orthodontist to 
perform pro bono work to take his braces off, I would have to 
think that is the exception to the rule. I know that in my 
local community there is a free clinic paid for by the 
community to take care of needs just such as this, and I just 
can't imagine that in any of my home counties we couldn't have 
found one dentist to get the braces off the little boy. Maybe I 
am wrong, maybe I am being naive. That is not to say that the 
need is not there for the dentistry program.

                        COMMUNITY HEALTH CENTERS

    I do want to commend you, I want to commend the 
administration for what I think is a very fine proposal on 
community health centers, 3,200 access points now nationwide, 
and if the President's recommendation is enacted, that will be 
increased by some 1,200, and I think that is one of the best 
and most cost effective ways for us to provide care for the 
types of individuals that the ranking member has just been very 
capably describing, and I think we all have the concerns for 
that type of care being expanded. So I hope we can do that and 
perhaps do better over the long haul with community health 
centers.
                        TRAINING IN PRIMARY CARE

    Now, let me pick up where Mr. Obey left off, though, on the 
program entitled Training in Primary Care Medicine and 
Dentistry that the administration is asking the Congress zero 
out. I just don't see how we can say that we are cost 
effectively taking this action when there is such a need out 
there. The administration's justification says in Fiscal Year 
2002 no funding is requested for this program, primarily 
because the number of primary care physicians and physician 
assistants has grown significantly over the past decade. In 
addition, salaries and economic incentives for primary care 
providers increased.

                      MEDICALLY UNDERSERVED AREAS

    Well, there may be more professionals someplace but there 
are still hugely underserved areas, many of them in my State. 
The justification goes on to say the Federal Health Professions 
Program needs to continue to incentivize and address two 
remaining problems; I will say, number one, more effective 
distribution of practitioners to underserved populations and, 
number two, improved race, ethnic makeup of the health care 
work force. I just don't think we are there yet in the area of 
underserved areas, and I really don't see how the 
recommendation could be made in light of the statement made on 
the previous page, that this program is designed to provide 
professionals that are qualified and likely to practice in 
underserved areas. The Federal support for these grant programs 
serves as a catalyst, not as a source of maintenance funds. And 
then it goes on to say that the program has funded projects 
that have a proven track record, a proven track record of 
producing graduates who are more likely to practice in 
underserved areas. I wonder if you agree with that statement, 
Dr. Duke. What is your response to the zeroing out of this 
program?
    Dr. Duke. The issues, as you correctly point out, are 
issues of distribution and diversity. The number of primary 
health care providers as a whole has increased as economic 
factors have made it more attractive to enter that area of the 
profession. The issue of distribution of that more available 
core of skilled workers is still with us, and that is part of 
what we have been concerned with as we look at the reform of 
the National Health Service Corps, is looking at how we can 
better distribute that workforce to needed areas.
    In that sense, the proposal that is in one of the 
presidential initiatives I discussed earlier is to look at how 
we can get more providers into the medically underserved areas 
more rapidly; and that has to do with more, for example, 
looking at the ratio of the loan repayment program to the 
scholarship program. The scholarship program has a long 
pipeline. The loan repayment program gets professionals into 
underserved areas quickly. That is one of the things we are 
looking at as a reform in the National Health Service Corps.
    Mr. Wicker. Well, let me interject. It is more effective 
than this proven program, which your very own words say has 
been highly effective.
    Dr. Duke. The point that we have taken here is that our 
population is--could be effective in competing for grants for 
medical and dental education more broadly than just those that 
are provided in this budget. There is an increase in 
postsecondary education in the Education Department budget, and 
there are other sources of scholarship aid to assist primary 
care providers in getting that specialization.
    What we have tried to do is look at how can we get them 
where they need to be and improve the diversity of that 
workforce. So that has been the emphasis in the budget we have 
submitted.
    Mr. Wicker. Well, if there is a better way to do it that is 
demonstrably effective, then I am interested in looking at it. 
But, if not, it does seem to me that this subcommittee may want 
to revisit this particular recommendation.

                            RURAL HOSPITALS

    Also, with respect to rural hospitals under 50 beds, there 
was a program in the Balanced Budget Refinement Act of 1999 to 
authorize a grant program through the Medicare Rural Hospital 
Flexibility Program, and I note that the administration has not 
requested funding for this program. I know the administration 
shares my concern for rural health care and for the small rural 
hospitals, and I just wondered why the administration didn't 
request funds for this program and what in general can you tell 
me we are going to be trying to do. What will be our push for 
assisting rural hospitals under 50 beds?
    Dr. Duke. The budget that the administration isproposing 
today includes $25 million for flex grants for the rural hospitals, and 
we believe that that is a very good investment in the sense that it is 
a service to rural communities. That is one that needs to be honed and 
protected. So it is with a good deal of enthusiasm that we present that 
piece of our budget.
    Mr. Wicker. So you agree that there is a role for the very 
small rural hospital in the health care mix for rural America.
    Dr. Duke. The advantage that we have been able to produce 
over the last 2 years has been the conversion of small 
hospitals to critical access hospitals that have allowed them 
to work with the emergency medical services to provide 
emergency care and care in the community as well as small in-
house beds as well. So we think that we have done much in the 
last 2 years to stabilize or begin the stabilization of those 
small rural health hospitals.
    Mr. Wicker. Thank you, Mr. Chairman.
    Mr. Regula. Mr. Istook.
    Mr. Istook. Thank you, Mr. Chairman.
    Good afternoon. I appreciate your testimony and the desire 
to make sure that things penetrate where they are--the need is 
existing.

                         INNOVATIVE HEALTH CARE

    I notice in your testimony it is mentioned that about $400 
million may be available through existing DHHS grants and grant 
programs to fund innovative health care solutions at the State 
and local level. When you mention that $400 million may be 
available, are we speaking of unexpended funds that carry over 
or are we speaking of things that have been used for other 
purposes in those programs, that you desire to have funding be 
State and local innovative programs?
    Dr. Duke. The initiative that you are referring to has 
identified $400 million of funding in the Department that we 
intend to use in a coordinated way across components of the 
Department to work on targeted areas of health needs. Part of 
that money is targeted from our budget, and other parts come 
from HCFA's budget and CDC's budget, and the goal is to have a 
coordinated approach to some of the illnesses that plague us 
such as heart disease, obesity, blood pressure issues, so that 
we can get some more bang for the buck by some synergy.
    Mr. Istook. Are you trying to correlate those with the 
diseases that you find have been most costly or most prevalent 
in the general population? Or how are you determining where you 
want to apply that focus?
    Dr. Duke. The diseases that were identified so far in this 
project were diabetes and heart disease, which are prevalent 
and are costly.
    Mr. Istook. Okay, but that is the criteria, the prevalence 
and cost, which is driving that.
    Now you mention, of course, that this cuts across different 
funding streams. And to what--how would you characterize how 
those funding streams were being applied before that instead 
you intend to apply in this manner?
    Dr. Duke. The issue here is the coordinated approach. The 
funding, for example from HRSA, is funding that comes largely 
from our Maternal and Child Health Bureau, and we have programs 
that have addressed these diseases, but this is a focused 
project. I don't at this point have a blueprint of exactly how 
this is going to look.
    Mr. Istook. It is still being formulated.
    Dr. Duke. Yes, sir, it is.
    Mr. Istook. And the funds that are being worked through 
this, these are not formula grants? These are based upon 
applications that are sent in by Departments?
    Dr. Duke. At this point, I don't have a plan on how this is 
going to work. This is something that all three agencies are 
just at the beginning of how to work out, how it is going to 
operate across the Department.
    Mr. Istook. Can you give us some insight into how you are 
trying to make that decision? Obviously, it is important to 
people to understand whether these might be applied according 
to some formula or according to yet-to-be-developed criteria 
for grants. What is the process by which you are trying to make 
those decisions?
    Dr. Duke. This is an initiative that is really at the 
beginning, in the formulation stage; and we have not put 
together a work group on this.
    I just checked with Peter. We are really beginning to think 
this through. We do believe that synergy across the Department 
is something that we should be seeking in order to try to make 
a difference on some important problems.
    Mr. Istook. The funds--and, I mean, obviously, you have 
identified some funding streams to be able to arrive at the 
$400 million figure. Previously, you know, in the last fiscal 
year and the current fiscal year and the prior fiscal year 
those were funding streams that were going by formula or by 
application?
    Dr. Duke. By application.
    Mr. Istook. By application. Okay.
    And you don't know--I mean, there is not--those are not 
multiyear grants, so they are 1 year at a time to be able to 
tap into that stream, I presume.
    Dr. Duke. That has to be my assumption, but I really don't 
have a plan on that at this point.
    Mr. Istook. I understood you. I think you made that clear.
    Dr. Duke. I am sorry about that.
    Mr. Istook. I understand the importance of that. You don't 
want to have someone get the wrong opinion when you haven't 
really established things. I really appreciate that.

                        UNDERSERVED RURAL AREAS

    There is--of course, you talk about the rural areas and 
underserved areas and so forth. Can you tell me whether, when 
you look at areas that tend to be underserved and you look at 
the Medicare and Medicaid reimbursement rates for those 
particular areas, do they tend to coincide? And can you say 
which is kind of the leading or the trailing indicator?
    There is a lot of concern that some areas are being 
underserved because the reimbursement rates are set at--so low 
that they are actually below the cost of delivering the 
services. Therefore, providers avoid those areas; and they 
become underserved. Do you have any information regarding 
potential relationships between these factors?
    Dr. Duke. I will ask Dr. Gaston to address that.
    Mr. Istook. Certainly.
    Dr. Gaston. I think I am understanding your question. We do 
know that it varies State by State in terms of Medicaid 
reimbursement rate and that in some States it is very, very 
low. And so, of course, with our safety net providers that are 
having a major growth in terms of uninsured at the same time 
having a decrease in reimbursement rates, they are really in a 
very tenuous situation.

                          TRACKING UNDERSERVED

    Mr. Istook. I presume you track underserved areas year to 
year. In other words, what areas that were underservedhopefully 
no longer are underserved or what areas that were properly served have 
gotten into that category. That you track those areas I presume over 
time, and you can do an overlay with other factors to try to determine 
what is at work here.
    Dr. Duke. We have a process for identifying medically 
underserved areas in the health profession's shortage areas. 
That is one of the points I made earlier, that one of the 
things we are looking at in terms of ensuring access to care is 
how we go about getting providers into underserved areas has to 
do with the way we define those. We do track those annually, 
and we do have a picture of what they are.
    One of the things that the President is offering in this 
budget is taking a look at how we define those areas so that we 
can address the issues of adequate service to ensure access to 
care for all.
    Mr. Istook. Sure, and I appreciate that. I would appreciate 
further information showing over time and presupposing static 
definitions. I know if definitions change that varies the 
result, but I think that would be useful information to myself 
and other members.
    Dr. Duke. Be happy to provide it.
    Mr. Istook. Thank you. Thank you, Mr. Chairman.
    [The information follows:]

    In comparing the number and type of primary medical care 
HPSAs in 1990 and 2000, some trends can be identified. First, 
the total number of primary medical care HPSAs increased from 
2,049 in 1990 to 2,787 (all numbers as of December 31). This 
represents an increase of 36 percent during the period.
    The population in designated primary care HPSAs rose from 
34,358,000 to 48,770,000 between 1990 and 2000, an increase of 
42 percent.
    The types of HPSA designations include geographic areas, 
population groups and facilities, and the statistics show a 
significant trend in terms of population group HPSAs. The 
number of primary care population group HPSAs increased from 
272 to 829 between 1990 and 2000, while the number of 
geographic HPSAs declined slightly, from 1,674 to 1,647. This 
205 percent increase in population group HPSAs can be 
attributed to several factors. First, HPSAs more than three 
years old are reevaluated as part of the annual review of 
HPSAs. Many areas that no longer qualified for geographic HPSA 
status did show a shortage of primary care for the low-income 
population residing in the area.
    Second, in some areas that were not previously designated 
as HPSAs, shortages of primary care services for persons 
dependent on Medicaid reimbursed or sliding fee scale care were 
identified, resulting in new population group HPSAs.

    Mr. Regula. Mr. Jackson.
    Mr. Jackson. Thank you, Mr. Chairman; and let me apologize 
for being a little bit late.
    I want to welcome Administrator Duke and my friend Dr. 
Gaston to our subcommittee and all members of the panel. I 
thank all of you for your testimony.

                           FUNDING PRIORITIES

    Dr. Duke, I am a little bit confused about the President's 
budget and its funding priorities. The Bible says where your 
treasure is is where your heart shall be. If that is so, then I 
am confused why the President decreased funding for your agency 
by $557 million when HRSA's mission is to improve the access to 
health care for low income, uninsured people, rural residents 
and other underserved populations and areas.

                        COMMUNITY ACCESS PROGRAM

    For example, I am thankful about his increase in the 
community health centers budget, but I am not sure that it is 
enough, and it appears that his increase came at the expense of 
eliminating the Community Access Program which, as you know, 
makes grants to assist providers of health care for low income 
and uninsured people in an area to form integrated service 
delivery networks.
    Dr. Duke, when the HRSA administrator testified before this 
subcommittee last year, he stated that the agency's health 
professions' training programs were highly effective, 
particularly in increasing the number of minority health 
professions. I completely agreed with that view and, in 
addition, believe that these programs play a critical role 
inexpanding health care services to minority and underserved 
communities. Consequently, I am very concerned at the President's 
proposed cuts in this area. Could you explain to the committee and 
explain to all of us the rationale for slashing health professions' 
programs by more than 60 percent?
    Dr. Duke. The principle that formed this budget was the 
view that the most important thing was to get more health care 
available to patients in the field now; and, therefore, the 
emphasis in this budget is on the first installment of a long-
term program to increase the number of health care--of health 
centers by 1,200 and to double the number of patients seen in 
those health centers. That was the most--that was the forming 
principle, is health care now.
    In terms of the reasoning in some of the reductions in 
health professions, the view was that the health professions' 
budget is only one source of funding for disadvantaged students 
to enter these professions, we have maintained some funding to 
particularly address the issue of minority and disadvantaged 
students but we also recognize that the population also can 
compete extremely well for grants that come out of the 
Department of Education as well. We also believe that the 
institutions that provide the health care providers who are the 
backbone of our services to minority communities can compete 
well for grants not only in HRSA but elsewhere, and we provide 
technical assistance for them to do so.
    So our view is that we can make a difference in the health 
care of individuals today by providing more access now and that 
we can also provide some support ourselves, some seed money 
ourselves and also support that clientele in accessing other 
sources of income.

                          MINORITY UNDERSERVED

    Mr. Jackson. You are aware that your view is fundamentally 
different than the HRSA administrator who testified before this 
committee just 1 year ago who claimed that this was one of the 
most effective HRSA programs for providing minority underserved 
populations with those health training professionals? You are 
aware of that?
    Dr. Duke. We believe these are extremely effective 
programs. We believe that budgets are made of hard choices, and 
these were hard choices that were made by this administration.
    Mr. Jackson. But HRSA's primary mission is to serve 
medically underserved, uninsured, rural areas, and it is a 
known fact that when you have minorities who are willing to 
reach out to other minorities that they are more likely than 
the majority of populations to end up in these medically 
underserved areas. So some of the hard choices that HRSA made 
this time include a 60 percent reduction in the program that 
allows more minorities to work in minority communities on these 
questions. You are aware of that? That is a fundamentally 
different view than the last HRSA administrator.
    Dr. Duke. The administration's position is that they wanted 
to put more health care available to the populations that we 
serve that are largely poor and minority rural and urban and 
that in order to do that they had to make hard choices, and 
these are the choices they have made.
    Mr. Jackson. Thank you, Dr. Duke.

                         CENTERS FOR EXCELLENCE

    I am also particularly concerned about the proposed cuts in 
the health professions' training and diversity programs. For 
example, I understand the Minority Centers for Excellence 
Program has been cut from $30.6 million to $12.8 million. In 
your budget justification it states that the requested $12 
million would provide support for four Centers of Excellence at 
historically black colleges and institutions and one additional 
project. My concern, Dr. Duke, is for the numerous other HBCU, 
Hispanic-serving and Native American institutions that are 
currently designated as Centers for Excellence. What happens to 
those programs under this budget? The President continues to 
claim that the administration is committed to supporting 
Minority Serving institutions. Unfortunately, that commitment 
is sorely lacking in your budget--in the budget of your agency.
    Dr. Duke. The Centers for Excellence budget will fund the 
programs that we have with the historically black colleges and 
universities and provide a small amount that can be provided to 
Spanish-serving, Hispanic-serving institutions, leaving a small 
amount for other programs as well.
    Again, we believe that those institutions are capable of 
successfully competing for our grants in other areas as well as 
for other provisions, and we make technical assistance 
available to institutions to compete for grants. We have a 
Technical Assistance Project in Silver Spring, Maryland, that 
runs nationwide, a consultation under our Office of Minority 
Health, to help people compete for grants across the board; and 
we believe that it is a program that will prove to be very 
helpful in this situation.
    Mr. Jackson. Well, you keep using the word ``compete'' for 
grants as if the minority-serving institutions are not 
competing for grants in the minority Centers of Excellence 
program. But what we have here is a program that is 
specifically designed to help Hispanic-serving, Native American 
institutions as well as African American institutions. It 
appears that $30.6 million, which was last year's 
appropriation--and they have only requested, I understand, a 
modest increase this year in the program--so that those 
institutions are not just limited to HBCUs but also Hispanic 
and Native American institutions, that this appears to be a cut 
that can undermine the quality of care for health profession 
training and diversity programs across the country.

              HISTORICALLY BLACK COLLEGES AND UNIVERSITIES

    Now to this day, Mr. Chairman, the historically black 
colleges and universities graduate more baccalaureate degrees, 
112 of them, than all major land grant white institutions in 
America combined. The 112 historically black colleges provide 
more baccalaureate graduates than any institutions in the 
country combined. And when we cut programs in these 
institutions along with Hispanic and native American serving 
institutions, that greatly impacts the pool of people that will 
be available to work in these institutions in the future.
    I do plan to work along with members of the committee to do 
our very best to restore those funds, because the available 
pool that ultimately will help these diversity programs greatly 
comes from the institutions that have been cut under this 
budget.
    Thank you, Mr. Chairman; and, Ms. Duke, if you have any 
responses to that, I would be more than appreciative to hear 
them.
    Dr. Duke. The programs that we have identified represent 
tough choices and a tough budgetary situation. We believe that 
we have provided opportunities for institutions to provide--to 
access funding from other sources in our budget, but we 
recognize that these are difficult times.
    Mr. Jackson. Thank you, Mr. Chairman.
    Mr. Regula. Just a couple of things before we adjourn.

                     EDUCATION FOR HEALTH MANAGERS

    We have all these community health care facilities. Do you 
have any type of education program for those who manage these 
facilities? It seems to me it requires skills to utilize the 
talents of volunteers, of all the people that participate in 
community health programs to really meet the needs of a very 
diverse clientele.
    Dr. Duke. Dr. Gaston.
    Dr. Gaston. Yes, we have any number of technical assistance 
programs that target the leadership of the health centers.
    Mr. Regula. Do you bring them together at all for some type 
of an education program?
    Dr. Gaston. All the time. So they receive technical 
assistance on site. We bring them together at meetings for 
special training. We have outstanding clinical training 
programs in conjunction with academic institutions, other 
health centers that are models in particular areas as it 
relates to management of a center, being a medical director of 
a center. So there is all kinds of technical assistance.
    It depends also on the environment. For instance, when 
managed care became prominent, we had major training that went 
on across the country for--and we still have sessions that go 
on in this arena. We have sessions on networking and how to 
form integrated networks and systems.
    So, yes, there is a lot of technical assistance that we do.

                       GRADUATE MEDICAL EDUCATION

    Mr. Regula. You have the medical education for program 
pediatric specialists.
    Dr. Duke. The medical education?
    Mr. Regula. Yes, through the universities. Do you feel we 
have an adequate program to meet the needs in the field of 
children's medicine?
    Dr. Duke. The budget we proposed this year we believe is an 
adequate budget. We recognize that the whole subject of 
graduate medical education, not just for children but for 
adults, is a subject for review and consideration; and we would 
certainly see that our program could be considered within that.
    Mr. Regula. As I understand it, under Medicare they have 
graduate medical educator programs for the physicians in the 
non-children field, but the program you have addresses the need 
for assistance to individuals dealing with children. Am I 
correct?
    Dr. Duke. Our program on graduate medical education 
includes a GME for about 60 freestanding childrens hospitals. 
That is a small subset of a large number of hospitals that do 
training for physicians, but the small subset that we are 
talking about does a disproportionate share of the training for 
pediatricians, with over 30 percent of them doing their 
residencies in the hospitals we are talking about.
    Mr. Regula. Is the demand greater than the resources? Do 
you feel that you can pretty much meet the requirements of the 
children's hospitals that offer this skilled training?
    Dr. Duke. I am not sure that I can answer the supply and 
demand question in that instance, but I will get back to you on 
that.
    [The information follows:]

    Funding of graduate medical education in children's hospitals is 
not driven by supply and demand. These funds were designed to address 
the disparity between Federal support for graduate medical education 
taking place in freestanding children's hospitals and other teaching 
hospitals. Medicare is a major source of support for graduate medical 
education in teaching hospitals. Freestanding children's hospitals 
qualify for almost no support from Medicare because they serve very few 
Medicare patients. Funds from the Children's Hospitals Graduate Medical 
Education Payment Program subsidize the training of physicians at 
Children's Hospitals. The Children's Hospitals Graduate Medical 
Education Payment Program has grown from $40 million in 2000 to $235 
million in 2001. The administration is trying to moderate the growth of 
the program so it becomes sustainable. The demand for funds and support 
will always be greater than the resources and there are funders of 
graduate medical education in children's hospitals other than the 
federal government. The Children's Hospitals Graduate Medical Education 
Payment Program makes a very significant contribution to assuring the 
training of a future pediatric workforce that will care for children in 
the U.S.
    The question about meeting the requirements of the children's 
hospitals that offer this skilled training is complex and points to the 
fact that as part of reform considerations for the Medicare program, 
there is need to assess how graduate medical education is financed in 
this country, not only for teaching children's hospitals but for all 
teaching hospitals. In that context, the assessment of financing 
graduate medical education should include an examination of supply and 
demand for resources to assure that there is a qualified health 
workforce to care for the health care needs of the U.S. population.

    Mr. Regula. Any further questions?
    Mr. Jackson. Mr. Chairman, I just have one.
    Mr. Regula. Mr. Jackson.
    Mr. Jackson. Dr. Duke, our Nation is presently experiencing 
the largest economic expansion in the Nation's history. We have 
here in Washington the largest projected surpluses in the 
Nation's history. The census confirms that African Americans 
and Hispanics are largely the uninsured amongst those who are 
uninsured and also the medically underserved.
    Today the Congress is going to begin debating the budget. A 
few moments ago, when I asked you questions about these budget 
cuts, you said that you had to make hard choices because these 
are hard times. In light of the economic expansion, in light of 
the surpluses that we are experiencing, projected surpluses we 
are experiencing here in Washington, how are you defining hard 
times?
    Dr. Duke. I should have said hard choices, which is what I 
intended to say, that hard choices were made. The 
administration's position is that they have made a choice to 
put more health care available to people on the ground now, and 
that has been their commitment rather than to invest in other 
areas, all of which are worthy of support but all of which are 
competing for resources.

                     COMMUNITY HEALTH CARE CENTERS

    Mr. Jackson. When you say health care on the ground now, 
which is obviously HRSA's mission, how are you defining health 
care--and I don't have many more questions, Mr. Chairman. How 
are you defining health care on the ground now in light of 
these community health centers? I have always seen community 
health centers and some of these programs as on the ground now 
health care programs because they reach people who wouldn't 
have access to care but for the programs.
    How is the administration defining on the ground now?
    Dr. Duke. The effort is to increase the access to our 
health centers by increasing the number, by increasing the 
services, by increasing the hours of service, by increasing the 
kinds of providers and the number of providers that are 
available now and to continue to increase both the sites and 
the services over the next 5 years, such that we will have more 
health centers serving ultimately double the population that 
they are serving now.
    Mr. Jackson. So the cuts are justified in expanding 
facilities--I am having a problem how the cuts expand the 
facilities you are talking about. You are saying you are 
creating more on-the-ground coverage, more providers, but how 
do you do that by cutting funds?
    Dr. Duke. In the case of the health centers, we have not 
cut the funds. We are putting in a budget for health centers at 
a $1.3 billion, which is an increase in order to allow us a 
$124 million increase this year and over the next 5 years, 
investments each year ultimately rising to $180 million in the 
fifth year such that we will have a significant increase in the 
access that people will have to health centers and that we will 
ultimately serve twice as many people as we serve today.
    Mr. Jackson. Thank you, Dr. Duke.
    Thank you, Mr. Chairman.
    Mr. Regula. Mr. Istook.
    Mr. Istook. Thank you, Mr. Chairman. I will be brief.
    Just a couple of things I wanted to bring up, Dr. Duke; and 
I want to express my appreciation to Dr. van Dyck.

                          ABSTINENCE EDUCATION

    I wrote to you recently, of course; and we appreciate very 
much the cooperation and effort regarding the abstinence 
education programs that are becoming more established and I 
think have not only good results, already showed, but terrific 
potential to try to help young people not to get involved in 
certain risky behaviors. We do that in other cases of drugs and 
tobacco, and yet one of the strongest indicators of the path 
that may be a very difficult path for a young person is if they 
become involved in sex at an early age in a premarital 
situation, that it traps them sometimes into cycles of poverty 
and many other problems, so I am very appreciative of the 
cooperation regarding that effort.
    I know Secretary Thompson had some very positive comments 
when he testified last week, and I just wanted to not really 
pose any questions at this hearing on it, but I thought it was 
important to say that I appreciate the effort in keeping this 
program expanding to meet the very great need.
    Dr. Duke. Thank you.

                      ORGAN DONATION AND EDUCATION

    Mr. Istook. I did want to ask one thing, going back to some 
of the testimony, Ms. Duke. You indicated that when it comes to 
organ donation and education--and I certainly applaud the 
stress on encouraging increased organ donation and education. 
We have had a challenge before with different parts of the 
country that have a stronger organ donation program--Oklahoma 
being one of them--feeling that States where they did not have 
as many donors participating wanted to grab those and different 
controversies over where is the need greatest and what factor 
should be considered. But, again, you are looking at trying to 
encourage more people to participate in the program and 
therefore expand the number that is available.
    But I had a question, though, about something that is in 
your testimony, and perhaps this is being done elsewhere but I 
am not familiar with it. Your testimony reads that in the 
coming year HRSA will establish a program to give every 
adolescent an hour of education on organ tissue donation prior 
to receiving a driver's license.
    I think we both recognize that this is something where you 
want people to be informed and to have an opportunity but not 
to feel pressured. It is very important that no one should ever 
be pressured to participate in a program here. And to say that 
a young person, before they get their driver's license, has to 
have a focused and I presume isolated hour of stress upon this 
concerns me. Where did this come from? Is it being done 
elsewhere? And at what point would that be done? As a 
mandatory--a Federal mandate as part of a driver's education 
course, Federal mandate before somebody actually is tested for 
their license, how would this actually be done, as reflected in 
your testimony?
    Dr. Duke. This would not be a Federal mandate. This is part 
of a major initiative that the Secretary announced on April 
17th to increase donation. It grows out of a program that has 
been operated successfully in the State of Wisconsin, and it is 
not mandatory for States.
    The organ donation initiative that the Secretary announced 
included several pieces. One was a donor card that is designed 
to encourage folks not only to be willing to be donors but to 
make sure that their families know they are willing to be 
donors.
    Mr. Istook. And perhaps marked on the driver's license, as 
is very standard?
    Dr. Duke. Exactly. That there would be information and 
education about donation through workplaces, second initiative 
which is in the Secretary's plan. And anotherelement of that 
plan was an idea to look at the possibility of replicating this, a 
model curriculum that States could adopt for the possibility of 
including an hour or two of instruction in the driver's ed courses that 
the students take.
    There is certainly no intention that this be a pressurized 
situation but rather one that is an education for students 
about the possibility of organ donation. The whole idea of the 
Secretary's organ donation is to bring more attention to the 
fact that, every day, 17 people die because there are not 
enough organs available to do all the transplants that we 
could, and lives are saved because we have organs to 
transplant. But not to make it an issue of pressure on people 
but an education.
    For example, another piece of that program is to have real 
recognition of the families who do make those donations. It is 
really hard at the time of the death to think beyond grief, but 
it is an opportunity for all of us in that situation to take a 
step back and, if we know that the loved ones would have wanted 
to contribute, to follow through on that wish at that difficult 
time. That is what this is all about. But it is not about 
making pressure and making life more difficult for teens, who 
already have great difficulties to begin with.
    Mr. Istook. Certainly I appreciate that, but it is just 
that particular aspect, frankly, when I was in the State 
legislature--and I know other States have had similar things--
knowing how hotly debated it is when you talk about teenagers, 
for example, not having their driver's license if they are 
school dropouts or not having it if they have some sort of 
alcohol offense and so forth. Those seem to stir up a lot of 
people. And I could just imagine--because that is linked with 
mandatory behavior. And I could only imagine the repercussions 
if we were try to say a young person cannot get their driver's 
license unless they had an hour that someone is going over 
organ donations with them and the pressures they might feel, 
whether they are intended or not. But I just think that is 
something we ought to be very sensitive to on that.
    Thank you very much.
    Dr. Duke. Thank you.
    Mr. Regula. Well, thank you, Dr. Duke, and all of your 
team. I think we have had a very productive hearing. You have 
some interesting challenges ahead, and we will try be helpful.
    Dr. Duke. Thank you very much, sir.
    Mr. Regula. Committee's adjourned.
    The following questions were submitted to be answered for 
the record:]

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                           W I T N E S S E S

                              ----------                              
                                                                   Page
Arons, B.S.......................................................   535
Autry, J.H., III.................................................   535
Clancy, Carolyn..................................................   839
Clark, H.W.......................................................   535
Duke, E.J........................................................  1175
Eisenberg, J.M...................................................   839
Gaston, Dr. M.H..................................................  1175
Gimson, William..................................................     1
Goldstone, Donald................................................   535
Klink, J.M.......................................................   535
Koch, Rita.......................................................   839
Koplan, J.P......................................................     1
O'Neill, Dr. J.F.................................................  1175
Sanchez-Way, Ruth................................................   535
Shekar, Dr. Sam..................................................  1175
van Dyck, Dr. Peter..............................................  1175
Williams, D.P.........................................1, 535, 839, 1175

 
                               I N D E X

                              ----------                              

               Centers for Disease Control and Prevention

                                                                   Page
2002 Olympic Games...............................................   171
AIDS and HIV Surveillance Systems................................   228
Arthritis.......................................................43, 226
Assessment of the Immunization Program...........................   147
ATSDR............................................................    33
Attention-Deficit and Hyperactivity Disorder Initiative..........   153
Autism in Brick Township, New Jersey.............................   136
Behavorial risk Factor Surveillance Survey on Asthma.............   120
Biomechanics.....................................................   171
Biomonitoring Program............................................   217
Bioterrorism.....................................................    51
Bioterrorism and Biowarfare......................................   214
Bioterrorism Funding.............................................   143
Birth Defects Research and Prevention............................   215
Birth Defects Surveillance.......................................   135
Birth Defects, Developmental Disabilities, Disability and Health.   153
Bouvine Spongiform Encephalitis..................................    55
Breast and Cervical Cancer.......................................    22
Breast and Cervical Cancer Early Detection Program...............   184
Buildings and Facilities Master Plan.............................   194
Buildings and Facilities.........................................    21
Bunker Hill, Idaho Medical Monitoring Program....................   128
Cancer:
    Control Programs.............................................   133
    Prevention and Control.......................................    36
    Registries...................................................    32
Cardiovascular Disease...........................................    30
CDC Facility Repair and Improvements Table.......................   124
CDC Web-Site.....................................................    55
CDC, FDA and HRSA Coordination on Genetic Programs...............    70
CDC's State-Based Chronic Disease Prevention and Health Promotion 
  Programs.......................................................    36
Center on Birth Defects and Development Disabilities.............   206
Centers for Genomics and Public Health...........................    69
Centers for Public Health Preparedness...........................    67
Cervical Cancer..................................................    33
Changing Behavior................................................     3
Childhood Obesity................................................   211
Chronic Disease Prevention...................................19, 28, 30
Chronic Disease Prevention and Health Promotion..................   176
Comprehensive Programs for Chronic Diseases......................   119
Comprehensive Tobacco Control Programs...........................   186
Confidentiality..................................................   215
Cooley's Anemia Surveillance Program.............................    25
Coordinated Genetic Testing Information System...................    69
Creutzfeld Jacob Disease.........................................    55
Crohn's Disease..................................................   152
Diabetes......................................................2, 39, 46
Dissemination of Health Information..............................    25
Emerging Infectious Diseases Laboratory..........................   171
Environmental Health.............................................   221
Evaluation.......................................................    45
Expired Program Authorizations...................................   136
Extramural Prevention Research Grants............................   167
Food Safety......................................................    55
Formula-Based Immunization Funding...............................   146
Funding Reduction to CDC's Chronic Disease Prevention and Health 
  Promotion Program.......................................225, 231, 234
Funding Table for the National Electronic Disease Surveillance 
  Systems and the Health Alert Network...........................   139
Future Public Health Challenges..................................     4
FY 2001 Unobligated Balance......................................   130
FY 2002 CDC Congressional Justification..........................   239
Genetics.........................................................    53
Genetics and Chronic and Environmental Disease Prevention Efforts    70
Global Alliance for Vaccines and Immunization....................   164
Global HIV/AIDS Initiative.......................................   161
Global Immunization Activities...................................   166
Global Polio Eradication.........................................   204
Health Alert Network.......................................52, 127, 216
Health Information Dissemination.................................    54
Heart Disease and Stroke.........................................    39
Hemophilia.......................................................   206
Hemophilia Gene Therapy..........................................   206
Hemophilia Treatment Centers.....................................   206
Hepatitis C......................................................    33
Hepatitis C Prevention...........................................   209
HIV Strategic Plan...............................................   228
HIV/AIDS Prevention Activities...................................   237
HIV/AIDS Strategic Plan.........................................22, 237
HIV/AIDS Surveillance Systems....................................   237
HPV Sentinel Surveillance........................................   161
Immunizations for Foreign Travel.................................   223
Infectious Disease Control Activities............................   168
Infectious Diseases..............................................   223
Influenza Vaccine Shortage.......................................    27
Information Dissemination........................................    56
Injury Control Research Centers..................................   172
Injury Prevention Practitioners..................................    65
International Communication......................................    53
IOM Report on Immunization.......................................   221
IOM Report on TB Elimination.....................................   219
Liver Disease....................................................   207
Medial Campaigns to Promote HIV Testing..........................   163
Minority Health Professions Foundation...........................    33
Minority HIV/AIDS Initiative.....................................   132
National Human Genome Research Institute.........................    70
National Campaign to Change Children's Health Behaviors..........    60
National Center for Complementary and Alternative Medicine at NIH   152
National Center on Birth Defects and Developmental Disabilities..   172
National Centers of Excellence on Youth Violence.................   142
National Exposure Report Card....................................   139
National Institute on Occupational Safety and Health.............   200
National Program of Cancer Registries............................   127
National Stroke Association......................................   230
National Youth Prevention Resource Center........................   142
New Born Screening Program.......................................   155
NHANES...........................................................   173
Nutrition, Physical Activity and Obesity.........................    40
Obesity.........................................................46, 224
Opening Statement................................................     1
Oral Health Programs.............................................    44
Organ Donors.....................................................   209
Ovarian Cancer...................................................    32
Paul Coverdell Stroke Registry Pilot Program.....................   230
Paul Coverdell National Acute Stroke Registry..................175, 220
Pediatric Environmental Health Specialty Unit....................   129
Physical Activity................................................    47
Pilot Testing of Aberration Detection Techniques.................   157
Plans for Bioterrorism Threats or Incidents......................    68
Pneumococcal Conjugate Vaccine.................................152, 201
Pregnancy Risk Assessment Monitoring System (PRAMS)..............    20
Prevention Centers...............................................   154
Prevention Health Outcomes.......................................   119
Prevention Program Health Specialists............................   158
Prevention Research..............................................     2
Prevention Research Centers......................................   190
Preventive Health and Health Services Block Grant Funding........    63
Primary Immunodeficiency Disease...............................232, 235
Prion Disease....................................................   167
Program on Violence Related Injuries.............................    64
Prostate-Specific Antigen Testing................................    26
Public Education.................................................    59
Public Health Challenges.........................................     1
Public Health Departments and Community-Based Organizations 
  Funding........................................................    71
Public Health Genetics...........................................    68
Public Health Infrastructure.....................................   196
Public Health Interventions......................................   190
Public Health Professions........................................    60
Public Health Response to Bioterrorism...........................    66
Public Health Threats and Emergencies Act........................   196
Public Health Threats and Emergencies Act of 2000................   217
Rapid Toxic Screen...............................................   127
Reducation in Chronic Disease Prevention and Health Promotion 
  Funding........................................................   155
Reducing Rates of Chlamydia and Gonorrhea Infections.............   160
Reduction in Abortion Rates......................................   159
Regional Centers of Excellence on Autism.........................   154
Reimbursements...................................................   170
Respiratory Protection Equipment Standards.......................    66
Safe Motherhood..................................................    19
Safe Motherhood/Infant Health Programs...........................    42
School Health....................................................    26
School Health Programs...........................................    41
School Nutrition Programs........................................    47
Sentinel Patient Safety Network..................................   169
Smoke Alarms.....................................................     2
Spongiform.......................................................    56
State Based Programs.............................................    34
Stroke.........................................................175, 229
Studies for Heart Disease and Stroke Activities..................   155
Sudden Infant Death Syndrome Protocols...........................   146
Suicide Prevention Evaluation Projects...........................   123
Suicide Prevention Research Center...............................   123
Syphilis.........................................................     4
TB Elimination...................................................   160
TB Surveillance System...........................................   132
Teen Smoking.....................................................   213
Testimony........................................................     6
The Contribution of Soft Drinks to the Energy Intake of U.S. 
  Children.......................................................    49
Tobacco Prevention and Control Program...........................    41
Tobacco Use......................................................     3
Toms River Cancer cluster........................................   122
Toxic Exposure Study.............................................   134
Translating Research Into Action for Diabetes Project............   134
Translating Research of Prevention...............................   225
Tuberculosis.....................................................   197
Universal Data Collection Surveillance System for Blood Safety...   130
Urban Research Centers...........................................   121
Vaccine Adverse Events...........................................   164
Vaccine Preventable Diseases.....................................   165
Vaccine Purchase.................................................   221
Vaccine Purchase Grant Programs..................................   202
Vaccines for Children Program....................................    62
Vaccines Tables..................................................   126
Violence Against Women Survey....................................   146
Violence Prevention Intervention Programs........................   143
Violence Prevention Programs for High Risk Youth.................    64
Wisewoman Program................................................   139
Women at Risk of Alcohol-Exposed Pregnancies.....................   135
Youth Media......................................................    27
Youth Media Campaign.............................................    28
Youth Violence Prevention Activities.............................    63

        Substance Abuse and Mental Health Service Administration

Abuse, Neglect, and Civil Rights Violations Reported.............   624
Accreditation-based Opioid Treatment Program.....................   609
Addiction Technology Transfer Centers..........................609, 610
Adolescents Treatment Efforts....................................   578
Agency Plan to Address Homelessness..............................   638
Budget Request, Justification of Estimates for Appropriations 
  Committees.....................................................   668
Block Grant Set-aside Funding....................................   614
Children and Violence............................................   567
Children's Mental Health Servcices.............................654, 664
Closing Services Gaps............................................   549
Collections from Other Federal Sources...........................   625
Collaboration with Bureau of Indian Affairs......................   562
Community Mental Health Block Grant.......................566, 659, 666
Co-occurring Mental and Addictive Disorders......................   652
Coordination with Other Agencies.................................   574
Cost Savings with Conversion of DAWN.............................   634
Costs of the Longitudinal Survey of Youth........................   634
Creating Healthy Communities.....................................   546
Data Collection (NHSDA)..........................................   634
Data Collection of Core Client Outcome Measures..................   616
Decision Support System..........................................   603
Drug Abuse Treatment Protocols...................................   604
Employment Intervention Demonstation Program.....................   617
Evidence-Based Tool Kits (Mental Health).........................   599
Expenditures on Alcohol and Other Abuse Treatment................   609
Expired Appropriations...........................................   627
Faith-Based Organizations......................................635, 651
Funding of Surveys and Reports...................................   627
Hard to Serve Populations........................................   649
Help Children Cope with Trauma (insert)..........................   569
High Risk Youth Grant Programs (insert)..........................   589
HIV Risk in At-Risk Populations..................................   595
Homelessness..............................................572, 643, 662
Impact of Alcohol Advertising on Youth...........................   600
Impact of Intravenous Drug Use...................................   583
Implementing Best Practices......................................   543
Improving Data Systems and Management............................   551
Information Dissemination........................................   601
Jail Diversion Program...........................................   599
KDA and Targeted Capacity Expansion Programs.....................   619
Knowledge Exchange Netework (KEN)................................   596
Knowledge Development and Capacity Expansion.....................   661
Medicare.........................................................   577
Mental Health Community-Based Care...............................   598
Mental Health Insurance Benefits.................................   656
Mental Health (Senior)...........................................   576
Mental Health Services.........................................591, 666
Mental Health State Pilot Program..............................593, 598
Mental Health Symnposium.........................................   598
Minority Fellowship Program......................................   594
National Technical Assistance Center.............................   597
National Treatment Outcomes Monitoring Systems (NTOMS)...........   615
National Treatment Plan..........................................   611
Needle Exchange Program..........................................   664
Opening Statement................................................   540
Parity for Mental Health.........................................   563
PATH Program...................................................571, 572
Performance-based Block Grant Partnerships.......................   637
Primary Care for the Elderly.....................................   635
Program Authorities in the Children's Health Act.................   629
Risk Factors--Early Childhood....................................   589
Recidivism.......................................................   562
School Testing...................................................   581
Seclusion and Restraint Initiative...............................   597
Services for American Indians/Native Alaskans....................   610
Smoking Among College Students...................................   652
Staff Supported on the Block Grant Set-asides....................   634
Starting Smart/Starting Earlier Initiative.......................   624
State Data Infrastructure Systems................................   636
Suicide Prevention Programs......................................   592
Substance Abuse Block Grant and the Children's Health Act........   612
Substance Abuse Prevention Grants................................   584
Substance Abuse Treatment for Adolescents........................   605
Substance Abuse Treatment Gap....................................   660
Synar Amendment..................................................   603
Training Protocols for Mental Health Professionals...............   592
Treatment Effectiveness..........................................   564
Treatment for Adolescents Returning from Detention...............   608
Treatment Models.................................................   580
Treatment Programs for Children..................................   574
Treatment on Demand (What works).................................   581
Web Training Sessions............................................   596
War with Drugs.................................................572, 579
Workforce Planning Analysis......................................   633
Witnesses........................................................   535

               Agency for Healthcare Research and Quality

Advise Drug Events in Nursing Homes..............................   899
Agency for Healthcare Quality and Research.......................   839
AHRQ's Mission.................................................839, 840
AHRQ's Research................................................840, 841
AHRQ's Research Pipeline..................................876, 877, 878
AHRQ's Website...................................................   866
Antimicrobial Drug Resistance....................................   902
Biographies...............................................854, 855, 856
Centers for Education and Research Therapeutics......870, 891, 901, 902
Changing Physician Behavior....................................860, 861
Child Health Insurance...........................................   899
Chronic Fatigue Syndrome Evidence Report.........................   905
Closing the Gaps...............................................843, 844
Competition Between Hospitals..................................863, 964
Congressional Justification......................................   913
Coordination of Infrastructure Programs..........................   884
Coordination with NIH............................................   887
Dissemination of Managed Care Grants.............................   889
Domestic Violence..............................................910, 912
Effective, Low-Cost Medical Alternatives.......................873, 874
Evidence-Based Practice..........................................   868
Evidence-Based Practice Centers.......881, 892, 893, 894, 895, 896, 897
Evidence Reports..........................................866, 867, 868
Excellence Centers to Eliminate Ethnic/Racial Disparities.884, 885, 886
Federal Programs and Dissemination.............................878, 879
FY 2002 Request......................................841, 842, 843, 844
Geographic Distribution..........................................   892
GSA Rental Costs.................................................   900
Health Disparities and the Rural Poor............................   906
Healthcare Workplace/Medical Errors/Quality of Care..............   903
HIV/AIDS.......................................................889, 890
HIV Data Coordinating Center..............................898, 899, 908
Increasing Costs of Medical Care.................................   871
Information From Other Countries.................................   866
Integrated Delivery System Research Network...............903, 904, 905
Introduction.....................................................   839
Investigator-Initiated Research................................886, 887
Long Term Care.......................................882, 883, 906, 907
Managed Care...................................................862, 863
Medical Errors.......................................857, 858, 910, 911
Medical Expenditure Panel Survey.................................   843
National Healthcare Disparities Report...........................   843
National Healthcare Quality Report...............................   842
National Guideline Clearinghouse Survey..........................   897
Nursing Facilities...............................................   907
Patient Safety.................................................880, 881
Patient Safety Data Development................................842, 843
Patient Safety Task Force......................................865, 866
PHS Evaluation Funds......................................890, 908, 909
Pre- and Post-Doctoral Training Award............................   905
Private Sector Use of AHRQ Research..............................   869
Quality and Costs of Care for Specific Conditions................   888
Racial and Health Disparities Initiative.........................   887
Research on Health Costs, Quality and Outcomes.................841, 842
Research Training..............................................882, 888
Rural Health.....................................................   879
Schizophrenia PORT.............................................891, 892
State of Medical Care Worldwide................................868, 869
Strategic Plan...................................................   900
Technological Imperative..................................871, 872, 873
Translation and Dissemination of Research......................874, 875
Translating Research into Practice.............................897, 898
U.S. Preventive Services Task Force..............................   901
University of Pittsburgh Information System...............859, 860, 863
University of Utah...............................................   875
User Liaison Program.............................................   900
Witness List.....................................................   845

              Health Resources and Services Administration

Administrative Expenses..........................................  1255
Advisory Committees, Councils....................................  1268
Abstinence Education.............................................  1223
ADAP.............................................................  1209
Adoption Awareness Program...................................1285, 1294
Advisory Committees, Councils, etc...............................  1269
AHEC.............................................................  1200
Area Health Education Centers....................................  1282
Centers for Excellence.......................................1220, 1280
Children's EMS...................................................  1286
Children's Hospitals GME.........................................  1284
Community Access Program.....................................1211, 1219
Community and Migrant Health Centers.............................  1321
Community Health Centers.........................1214, 1223, 1296, 1305
Community Health Centers Funding--Rural Communities..............  1304
Council on Graduate Medical Education............................  1272
Cross-Cutting....................................................  1206
Dentistry Program................................................  1213
Education for Health Managers....................................  1221
Epilepsy.........................................................  1322
Family Dentistry.................................................  1212
Federal Credentialing Program....................................  1258
Funding Priorities...............................................  1218
Geographical Maldistribution.....................................  1280
Geriatric Programs...............................................  1205
Graduate Medical Education.......................................  1221
Grant Awards.....................................................  1259
Health Care Professional Shortage in Rural Areas.................  1302
Health Careers Opportunity Program...............................  1251
Health Centers...................................................  1198
Healthy Communities Innovation Initiative....................1309, 1315
Health Education Assistance Loan Program.........................  1275
Health Education and Training Centers............................  1296
Health Professionals Training....................................  1310
Health Professions Programs..................................1202, 1308
Health Professions Shortage Areas................................  1309
Health Systems Development In Child Care.........................  1245
Healthy Start National Resource Center...........................  1258
Historically Black Colleges and Universities.....................  1221
HIV/AIDS--Title II...............................................  1323
Homelessness...........................................1287, 1290, 1318
Homelessness Planning............................................  1326
HRSA and HUD Coordination........................................  1288
Information Age..................................................  1208
Innovative Health Care...........................................  1216
Introduction of Witnesses........................................  1175
Impact of Elimination of Funding.................................  1314
Impact of Program Reductions.....................................  1226
Kids Into Healthy Careers........................................  1249
Language Barriers................................................  1297
Maternal and Child Health Block Grants...........1288, 1316, 1329, 1336
MCHB/CDC--Epidemiologists........................................  1271
MCHB-FTE.........................................................  1271
Medically Underserved Areas......................................  1214
Mental Health....................................................  1205
Minority Underserved.............................................  1219
National Hansen's Disease Program................................  1246
National Practitioner Data Bank--Section 5.......................  1258
National Vaccine Injury Compensation Program.....................  1285
Newborn Screening............................................1202, 1299
Nursing Shortage.......................................1200, 1209, 1299
Nursing Workplace Issues.........................................  1201
Opening Remarks..................................................  1175
Opening Statement................................................  1179
Organ Donation and Education.....................................  1224
Organ Transplantation--Donation..................................  1206
Performance Measures.............................................  1207
Poison Control Centers--Patient Guidelines.......................  1259
Preschool Vision Screening Projection............................  1271
Public Communication.............................................  1198
Pre-Natal Care...................................................  1199
Preventative Medicine............................................  1199
Ricky Ray Hemophilia Relief Fund Program.........................  1295
Rural Health.....................................................  1206
Rural Health Cut.................................................  1208
Rural Hospital Flexibility Grant Program.........................  1267
Rural Hospitals..................................................  1215
Ryan White...................................................1226, 1290
Scholarships for Disadvantaged Students..........................  1281
School Programs..................................................  1200
SPRANS--Best Examples............................................  1332
Status of Project--Increase Provider Screening...................  1244
Telehealth Resource Centers......................................  1284
Tracking Underserved.............................................  1217
Training In Primary Care.........................................  1214
Trauma/EMS Assessment............................................  1279
Underserved......................................................  1212
Underserved Rural Areas......................................1203, 1217
Uninsured....................................................1198, 1211
Unobligated Balances.............................................  1273
Wise Woman Program...............................................  1203

                                
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