[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]
DEPARTMENTS OF LABOR, HEALTH AND HUMAN
SERVICES, EDUCATION, AND RELATED AGENCIES
APPROPRIATIONS FOR 2003
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
SECOND 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, Susan Quantius, 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........ 745
Agency for Health Care Research and Quality...................... 1379
Health Resources and Services Administration..................... 1683
________
Printed for the use of the Committee on Appropriations
________
U.S. GOVERNMENT PRINTING OFFICE
80-950 WASHINGTON : 2002
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 2003
----------
Thursday, March 21, 2002.
CENTERS FOR DISEASE CONTROL AND PREVENTION
WITNESSES
DAVID W. FLEMING, M.D., DEPUTY DIRECTOR FOR SCIENCE AND PUBLIC HEALTH,
CENTERS FOR DISEASE CONTROL AND PREVENTION
WILLIAM GIMSON, ASSOCIATE DIRECTOR FOR BUDGET AND FINANCE
KERRY WEEMS, ACTING DEPUTY ASSISTANT SECRETARY, BUDGET, DHHS
Mr. Regula. Okay, we will get started. I appreciate Mr.
Obey and Mr. Wicker being here, in view of the fact that we are
recessed for a couple of weeks. So the fact that they're here
shows their dedication and interest in something that is a very
important topic.
I just thought coming down the hall, if we had a hearing on
Enron, there would be a line a mile long out there. [Laughter.]
And there was no line. Yet what you do is more important to
the people of this Nation than Enron, by a long shot.
CDC is somewhat of a well kept secret. We to some degree
discovered it as a result of September 11. We discovered it in
my district when we had a meningitis scare and everybody was
kind of panicking until CDC got on the scene and then
everything just calmed down. Likewise at the Ford plant in
Cleveland when they had a scare from Legionnaire's disease. You
are the 911, using that another way, for America in a lot of
ways. We're happy you're here, Dr. Fleming, to represent the
agency and tell us about the things that are important to the
people of this Nation.
Mr. Obey, would you like to make any comments?
Mr. Obey. No, Mr. Chairman.
Mr. Regula. Okay. Dr. Fleming, your full statement will be
made a part of the record. We'd like to have you summarize it
for us.
Introduction
Dr. Fleming. Thank you, and good morning, Mr. Chairman. I'm
David Fleming, Deputy Director for Science and Public Health
and the Centers for Disease Control and Prevention. This is my
first appropriations hearing.
Despite that fact, I am nevertheless delighted and honored
to be here today on behalf of CDC, our Nation's prevention
agency that protects the health of the American people. Mr.
Chairman, I would like to submit our written statement and I
would like to summarize that for you now.
Mr. Regula. Without objection, so ordered.
BIOTERRORISM ATTACKS
Dr. Fleming. Summarizing isn't easy, because as you may
have heard, we've had a busy year. On September 11th, life
changed for the Nation and for CDC. The horrible events of that
day and the anthrax attacks that followed brought into focus
the urgent public health challenges that we were facing like no
other event, and also the need for investing in our Nation's
public health infrastructure.
The events of September 11th precipitated the greatest
challenge in CDC's history, and resulted in an unprecedented
response. Ten minutes after that second plane crashed into the
World Trade Center, CDC's emergency operations center was up
and running.
Mr. Regula. Ten minutes?
Dr. Fleming. Ten minutes. And although we couldn't know it
at the time, Mr. Chairman, it would be running continuously, 24
hours a day, for the next 91 days. Within hours, even though
all airplanes were grounded, CDC emergency response personnel
were in the air with material from the national pharmaceutical
stockpile, on the way to Washington and New York City.
By early that afternoon, CDC's health alert network had
already started transmitting emergency messages to key public
health officials throughout the country. And that was only the
beginning. Over the next four months, CDC was a key part of the
Federal team that guided our Nation's response to the
bioterrorism events. We delivered almost 4 million doses of
antibiotics in 65 separate deployments to 10 different States
to prevent anthrax. The average time from us receiving those
requests until delivery in the field was five hours.
We coordinated laboratory testing of over 70,000 suspected
anthrax samples, from every State in the country, and tested at
CDC 6,000 of those samples, of the most critical samples using
state of the art methods. We provided through teleconferences
training to over a million and a half providers throughout this
country, and through our MMWR and health alert network,
provided key recommendations to millions of additional
providers. We provided public information every day to the
media. In October alone, CDC's web site was accessed 175
million times.
Most importantly, though, CDC deployed almost 600
professional staff into the field, and mobilized an additional
1,500 staff at our facilities throughout the country. These
individuals served by gathering critical public health
information, by investigating cases and suspect cases, by
developing new treatment and prevention guidelines, by
counseling those directly affected and providing technical
assistance to our State and local partners. They did this with
the utmost professionalism and confidence, often away from
their husbands or wives or children, and potentially at risk
themselves. We're very proud of them.
These actions by your country's public health system saved
many lives. The investment this Committee had the foresight to
make before September 11th paid off. We had made substantial
progress to developing the capacities of public health agencies
at all levels, Federal, State and local.
But the events of last fall also showed that we need to be
even better prepared. We need to correct the weaknesses that we
identified and build the capacities not yet developed.
Fortunately, though, our basic strategy is sound. The best
way to protect against any health threat is to develop and
enhance our already existing public health system andtools, not
only at the Federal level but at the State and local level as well.
Because while only a few States were involved with anthrax illness,
every State in this country was involved in this crisis. We saw so
dramatically how State and local health department partners are the
core of our public health system and how they must be ready to
responding to all public health threats.
Thanks again to your support, we have just awarded over
$900 million in funding to strengthen State and local health
departments. These resources are going to be used to plan for
this new generation of public health threats and to assure that
our responses are supported by a fully staffed, fully trained
work force, strengthened public health laboratory facilities,
enhanced surveillance and epidemiologic response capacities,
secure, up to date information systems, and an improved health
communication capability.
We are trying as hard as we can to be smart with these
investments. We are working closely with all parts of the
Department. We are building in measures of accountability. We
are preparing for those unknown threats by enhancing those
proven systems that deal with our natural, day to day threats,
like the meningitis outbreak in Ohio. And we are bolstering
State and local health department infrastructure, because it is
that infrastructure that supports every public health action.
There is one more task that is facing us. This fall, public
health was strained to the breaking point, dealing with the
challenges that were brought on by the terrorist attacks. CDC
and other public health agencies were also working around the
clock to attend to the other public health challenges that are
facing this Nation today. We must continue to attend to them in
the future.
So as we prepare for treating injuries from a terrorist
attack, we must also work to push every day injury and violence
from its rank as the leading cause of premature death in this
country. As we plan how best to respond to botulism or plague
or tularemia attack, we must also work to prevent the everyday
infections of HIV and tuberculosis and hepatitis C and e-coli,
and to assure the safety of postal workers, and we enhance our
ability to respond to a chemical terrorist attack. We must also
work to reduce the burden of existing occupational illness and
to better understand the relation between chemicals already in
our environment and illness already in our people.
As we develop adequate supplies of smallpox vaccine, we
must also assure the adequacy of our supply of standard
childhood vaccines, and work to increase the lifesaving
vaccines in adults, like pneumococcal vaccine and influenza.
And as we work to prevent anthrax hospitalizations, we must
also work to prevent hospitalizations from chronic diseases,
which are the leading cause of death and disability in this
country.
These problems are urgent. They are fixable, as fixable as
bioterrorist preparedness, by applying knowledge already gained
through research, putting it into practice on the front lines,
proven strategies, strategies that can prevent diabetes and
fire deaths, that can prevent heart disease and birth defects
as surely as antibiotics prevent anthrax.
To meet those needs, Mr. Chairman, today I am asking for a
total request for CDC of $6.6 billion. This request represents
our President's and this Administration's commitment to CDC and
our Nation's capabilities by preparing for, and responding to,
acts of bioterrorism, other terrorist attacks and public health
emergencies. Our request includes resources to continue to
improve preparedness of State and local health departments, as
well as CDC. It also supports our Nation's ongoing battles and
other health threats, the preventable causes of illness that we
deal with every day. It includes increases in breast cancer
prevention and our Secretary's initiative to healthy
communities.
In conclusion, this has been a busy year for CDC. But there
has never been a more exciting time to work in public health.
And I am doubly fortunate to be able to work during this time,
at the best public health agency in the world. Make no mistake,
this is also a tremendously challenging time to be in public
health. But as I have traveled around the country during this
crisis, I have heard a consistent message, not only CDC, but
all of this country's public health front lines are ready to do
what needs to be done. We are up to this challenge.
So in closing, I'd like to thank this Subcommittee for your
continued support in protecting and improving our country's
public health system. Rest assured, you are making a wise
investment.
Thank you very much. I would be happy to answer any
questions you may have.
Mr. Regula. Thank you.
In the interest of time, I'll defer my questions. Mr. Obey.
Mr. Obey. Thank you, Mr. Chairman.
PUBLIC HEALTH INFRASTRUCTURE
Dr. Fleming, you're in the process of distributing the $920
million that Congress gave you last year to strengthen State
and local public health departments. As many in this room may
recall, and as I certainly well recall, the Administration had
to be dragged, kicking and screaming, into accepting that
money. The President at one point told me personally that if
the Congress appropriated one additional dime above his budget
request he'd veto the bill that contained the increase.
Congress increased the President's proposal more than ten-
fold, and guess what, he didn't veto it. Thank God for small
favors. Can you tell us how that money is going to be used?
Dr. Fleming. Yes, thank you, Representative. First off, I
am delighted to report that the request for that money is
continuing in the 2003 budget that we are here to talk with you
about today. These dollars are critical to improve our Nation's
public health infrastructure. So we, with the Department, have
been working very hard to plan how best to allocate them, both
quickly but in a manner that assures accountability and in a
manner that makes us as well preparedas possible.
Working with our State and local partners, I think we've
come up with an absolutely wonderful way to do this. These
dollars have already been awarded to States. States right now
have been able to use the first 20 percent of the emergency
funding and are right now preparing their applications for that
remaining 80 percent.
What we've done here is really a new way of doing business.
These dollars are designed to fill in the holes, fill in the
gaps that people found, as a result of September 11th and the
anthrax attacks. As a result, we, the Federal Government, don't
want to be, nor should we be, absolutely prescriptive in
saying, here's exactly how these dollars need to be spent.
Rather, what we've done is, working with our State and local
partners, defined the outcomes that we want to achieve, what
are the capacities that it is we're trying to develop.
We have identified about 20 of those capacities. Health
departments are now looking at those capacities and they are
looking at how well prepared they are to attain those
capacities. They are then coming back, with the deadline being
April 15th for their grant application, to say, given their
unique circumstances at the State and local level, what the
most important piece is that they need to invest in to achieve
those capacities, we've designed it and we're hoping that as a
result, the applications that come back from States will be
different from one another. Because States have chosen to make
different investments already. There is different funding that
is available to different States.
But the bottom line is, at the end of the day, using these
dollars, we will have a public health system that is far better
prepared to deal with bioterrorism, but as importantly, far
better prepared to deal with other infectious threats that this
country faces. We are building that capacity on the underlying
or fundamental capacities that make our public health system
sound. So we will have a sound, better public health system in
this country as a result.
IN-HOUSE CAPACITY
Mr. Obey. Thank you. As you know, the supplemental
appropriation bill last year also gave you $100 million for the
agency to use to improve your in-house capacity, to deal with
bioterrorist threats and public health emergencies. Again, the
White House and OMB had to be dragged into accepting it. They
proposed an appropriation half that amount and then threatened
veto of anything over it.
How are you making use of that in-house capacity that we
provided?
Dr. Fleming. And thanks to the Committee once again for
that appropriation in the 2003 budget. That dollar amount has
been increased by about $20 million. Those dollars are much
needed at CDC, and we very much appreciate them being in the
President's budget.
There is a number of different activities. One, relating
back to the question that you just asked, is we need to assure
across CDC that we have the technical assistance capability to
make sure that the dollars that are going out to State and
local health departments are spent as wisely as possible. So
some of this money is going to be used to upgrade our capacity
at CDC, to provide technical assistance and to enable contracts
for technical assistance that States can directly access.
In addition, however, there are critical areas of program
and research, not only in infectious disease, infectious
disease is an important part of that, upgrading our laboratory
capacity, upgrading our epidemiologic capacity, but in other
parts of CDC. The Secretary has committed to there be an EIS
officer, or epidemic intelligence service officers, in every
State. This money will be used to make that happen.
In addition, it will be used to upgrade our ability to
prepare internally for chemical terrorist events and working
with NIOSH, make sure that workers that are involved in
responding to these threats are appropriately prepared. There
are long lists of needed activities at CDC that we need to do
internally to make sure that those front line responses are the
best as possible.
Mr. Obey. I have several other questions that I would like
to ask that you respond to in the record at this point, one
relating to the question of what more we need to be doing to
deal with public health infrastructure problems around the
country.
NIOSH
Mr. Obey. But I'd like to turn now to NIOSH, which you just
mentioned. In the years I've been on this Committee, there has
been a distinct pattern, for almost 30 years. That pattern has
been that NIOSH has been attacked by people who don't like the
idea that if NIOSH develops science that indicates that there
are problems with the health of the people in the workplace,
then somebody has to spend money to correct it. So there has
been a concerted lobby effort for over 30 years to squeeze the
NIOSH budget. And I'd like to ask you a few questions about
that.
For NIOSH, the Administration's budget proposes to cut $28
million, or 10 percent below the current year level, as I
understand it. And as I understand it, a huge portion of this
reduction would come in the extramural research program, or
NORA. That would result in a cut of more than half--from $40
million to around $15 million this year. Are those numbers
correct?
Dr. Fleming. Yes.
Mr. Obey. I understand that the NIOSH process for making
extramural grants is very similar to NIH, peer reviewed and all
that. The CDC budget justifications indicate that the proposed
budget cut would reduce the number of extramural research
grants by more than half--from 201 in fiscal year 2002 to just
88 in fiscal year 2003. What would be the impact of that cut?
Would NIOSH be able to make any newextramural grants next year?
Would you have to terminate some existing grants in mid-stream?
Dr. Fleming. Yes. We at CDC realize that we're living in an
era where our needs outstrip our resources. Therefore, very
difficult decisions have had to be made regarding priorities.
We fully support those decisions.
Mr. Obey. But the answer to my question was yes?
Dr. Fleming. Yes, that is correct.
Mr. Obey. To both questions the answer was yes?
Dr. Fleming. Yes.
Mr. Obey. Great. Wonderful. Splendid.
Mr. Chairman, I have a number of other questions that I
would like to ask also for the record, but I don't want to take
up any more time, so I'll submit them. Thank you.
Mr. Regula. We will have another round.
Mr. Wicker.
INFRASTRUCTURE
Mr. Wicker. Thank you very much, Dr. Fleming and guests,
welcome. I think you know that CDC has a lot of support in this
Subcommittee.
We were talking informally with a constituent of yours,
Congressman Linder from Georgia, I guess you're a constituent
of his and he of yours. He just wanted to stop by earlier and
express his interest in continuing to improve the
infrastructure at CDC.
I am quite fond of my minority Ranking Member on this
Subcommittee. Some of the questions that he has asked would
make it seem that the Administration is somehow hostile to
increased spending at CDC. I think you and I would both agree
that that is the farthest thing from accurate. As a matter of
fact----
Mr. Obey. I said the President was opposed----
Mr. Wicker. Mr. Chairman, I think I'm entitled----
Mr. Obey [continuing]. When we were trying hard to raise
this funding, so yes, I do think that's hostile.
Mr. Wicker. I think as a matter of courtesy I should be
able to finish my statement. I waited while the gentleman from
Wisconsin predicated his questions on a----
Mr. Obey. That's inaccurate.
Mr. Wicker. Are we on cross-fire, Mr. Chairman?
Mr. Regula. Mr. Wicker----
Mr. Wicker. I control the time, and I am quite fond of my
friend from----
Mr. Obey. You mischaracterize my words.
Mr. Wicker [continuing]. Wisconsin. I want to pursue a line
of questioning. But I think it's fair to say that the
Administration has been supportive of CDC. As a matter of fact,
has increased funding requests for CDC's budget, is that
correct?
Dr. Fleming. That's correct. Yes, Representative Wicker.
Mr. Wicker. And I do appreciate my friend from Georgia
coming in and pointing out that there may be additional
opportunities for this Subcommittee to look at the
infrastructure at CDC. I've been to Georgia twice to see the
facility, and I agree that there are needed improvements, and
it needs to be long term and we need to continue that. I would
suggest to my Chairman and to my Ranking Member that perhaps we
can tweak the budget and make improvements there.
But I am also appreciative of the Administration for its
advocacy of increased funding for CDC.
In spite of my strong support for CDC, I do have to ask a
question that has become a matter of concern to me over time.
That is, the feeling among many of us who support the Second
Amendment rights, that the CDC is violating not only the spirit
but the letter of the law as set out by Congress. Where
Congress has since 1997 provided, in the law, in appropriation
bills, the following language: provided further that none of
the funds made available for injury prevention and control at
the Centers for Disease Control and Prevention may be used to
advocate or promote gun control.
I think it is fair to say that the CDC is aware of a
firestorm of criticism that has come from time to time based on
apparent violations by the CDC of this express intent of the
Congress as set forth in the law of the land. I'll give you an
example or two, Dr. Fleming. One would be a CDC study entitled
Relationship Between Licensing, Registration and Other Gun Sale
Laws and the Source of Crime Guns. This study espouses
licensing and registration as being effective. Also, it states,
this was released at a time when the California legislature was
expressly debating adopting such legislation.
Also, as you know, in October of 2001, the CDC released a
model State emergency health powers act, which among other
things, advocated legislation to allow a Governor, without any
input or oversight in the State legislature, to control,
restrict or prohibit firearms, including the seizing of private
property. As you are aware, after a public outcry, the CDC
amended their language. But in my opinion, the message was out
there from the Centers for Disease Control and the damage was
done.
Do you agree that these examples violate either the spirit
or the letter of the law? Do you agree that the express will of
the Congress as stated in the appropriations act is what you
should follow? And when a grant application is reviewed, are
you able to tell me what procedures are in place to ensure that
the CDC is in full compliance with Federal law? And what
controls will the CDC implement to ensure that no monies in
whole or in part are spent on studies where the objectives are
to promote or advocate gun control in contravention of the
clearly stated Federal law?
Dr. Fleming. Thank you, Representative Wicker. We certainly
are aware and intend to fully comply with the language that we
have been directed to comply with. The specific examples that
you have raised are ones that I am going to need to go back in
and look into specifically. I would be happy to get back to you
on the record around those.
[The information follows]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Dr. Fleming. I would like to say that it is important, and
we do believe that it is the intent of the Committee that CDC
still take an active role in looking at issues around the
epidemiology of injury and violence. One of our best strengths
is the ability to collect information that does not take sides
on an issue one way or another, but alternatively allows policy
makers and those who are appropriately, the appropriate
individuals to make policy decisions have the best possible
information available to them.
So in that context, through our various surveillance
systems, looking at injury and violence, vital records, death
certificates, police reports, we do routinely collect
information about weapons that are used, firearms, knives,
etc., and try as hard as we can to compile that information and
make it available to you and others in as objective a way as
possible. We feel that the debate around gun control is
something that is in your hands. Our role in that is to provide
the information that you need to make that debate as
scientifically sound as possible.
Mr. Wicker. Just a follow-up and then I'll take my turn
later on, Mr. Chairman, but Doctor, you are not saying that a
study which provides, which involves surveillance and provides
data in one portion and a conclusion or advocacy in another
portion of that study would be permitted under the express
legislative language that Congress has enacted since 1997, are
you?
Dr. Fleming. Advocacy for a particular position, for a
particular policy, is not something that we would be doing in
this setting. Our role is to gather data so that the policy
makers can set policy.
Mr. Wicker. So if a study involved data in one portion and
conclusions and advocacy in another portion, then that study
should not be funded by CDC under the statute?
Dr. Fleming. Again, I would need to go back, and we will
look at the specific issues that you've raised and get back to
you on the record.
Mr. Wicker. On the record.
Dr. Fleming. I would draw a distinction between conclusions
that can be drawn from the scientific data and then the next
step, which is to advocate for a policy or legislative
decision.
Mr. Wicker. Thank you very much.
Mr. Regula. Mr. Hoyer, and if you'd like to yield a minute
to Mr. Obey.
Mr. Hoyer. I'd love to yield a minute to Mr. Obey.
Mr. Regula. Mr. Obey.
BIOTERRORISM
Mr. Obey. Thank you, Mr. Chairman.
Mr. Chairman, the reason I barked at the comments made by
the gentleman from Mississippi is because he indicated that the
questions that I had asked would lead one to the inaccurate
impression that the Administration was hostile to budget
increases for NIOSH.
Here are the facts. After September 11th, the Chairman of
the full Committee, Mr. Young, and I asked our staff to develop
a bipartisan list of additional emergency requests that had
been made to us by FBI, NSA, CIA, CDC, HHS and any other
alphabet agency you can name that had anything to do with
dealing with terrorism. The fact is, when we went down to the
White House to talk to the President about it, he said to me,
nose to nose, that if we provided one dime more than his budget
called for, he would veto the bill that contained that
increased money.
Now, if that's not a hostile response, I'd hate like hell
to see what was. In fact, we provided ten times the amount for
buttressing public health than the Administration had in terms
of an increase in its own budget proposal. Mr. Daniels, the OMB
budget director, then attacked our package as being laden with
pork. I later said to the Attorney General, if he could find a
single piece of pork in that entire package that Mr. Young and
I developed, that I'd eat his honorary degree from Bob Jones U.
[Laughter.]
Mr. Hoyer. A worthy objective in and of itself.
Mr. Regula. In defense of Bob Jones, they've changed their
policies, if you've been reading the news.
Mr. Obey. Hallelujah. All I would say is that CDC is
getting a billion dollars more today than they would have
gotten if we had listened to the President's threats. Threats
which I did consider to be not only hostile, but totally
irresponsible.
Mr. Wicker. And if I might have a minute to respond----
Mr. Regula. Well, okay, one minute.
Mr. Wicker. I could have just jumped right in and
interrupted.
If the Ranking Member, for whom I have the greatest
admiration, had a heated and pointed exchange about one
appropriation concerning CDC, I wasn't privy to that
conversation, but I think the totality of the record, and it
needed to be corrected this morning, in the face of repeated
statements by the Ranking Member, is that the President and
this Administration have been supportive of increased CDC
funding and they have not demonstrated a hostility toward
increasing this very valuable appropriation. That is the point
that I would continue to insist on.
Mr. Regula. We'll continue this during the markup. Because
that's where the rubber hits the road.
Mr. Hoyer.
IMMUNIZATION
Mr. Hoyer. Thank you very much, Mr. Chairman.
I want to ask some specific questions and maybe go tosome
general questions, see what time I garner here in terms of the
interpretation of who yielded what when.
Immunization, I've been very involved with immunization.
Immunization is flat funded, as I understand it, at $631
million. As you know, Doctor, currently 75 percent, we went
down one point, in terms of percentages of children immunized
in America, fully immunized, from 76 I think in 2000 to 75 in
2001. It may have been 99 in 2000, I'm not sure which are the
figures. We're now flat funded.
What program, I want to know what's the consequence of this
going to be, secondly, I want to know what programmatic steps
do we need to take to raise children from the current average
of 75 percent to what I believe is a much more appropriate, and
I believe our target of 90 percent? The third question in the
immunization area, does the President's budget assume funding
for a six month stockpile of childhood vaccines?
Dr. Fleming. That last question?
Mr. Hoyer. Six month stockpile of childhood vaccines.
VACCINES FOR CHILDREN'S PROGRAM
Dr. Fleming. Thank you very much, Representative.
In the budget, in addition to the dollars that are directly
allocated to CDC, as you know, the vaccines for children's
program, which is administered under CDC, that money also comes
to us. There is an additional $824 million in the vaccine for
children's program for childhood vaccine.
That having been said, our goal is to achieve 90 percent
vaccine coverage for childhood vaccines. They are the really
public health success story of the 20th century, aren't they,
when you look at the reductions in morbidity and mortality from
diseases like measles and diphtheria and whooping cough. CDC's
MMWR today, hemophilus influenza meningitis----
Mr. Hoyer. Is that microphone on? I mean, I can hear you
fine.
Dr. Fleming. I'll speak louder.
I was going to mention that in today's MMWR, there is a
story about reductions in hemophilus influenza type B
meningitis. Twenty years ago, this was the most common cause of
bacterial meningitis in children in this country with the
significant mortality rate and long term neurologic
complications in children who survived. Today's pediatric
residents have never seen this disease, and don't even know
what it is.
Mr. Hoyer. Doctor, if I can interject, if you know, and if
you don't, I'd like you to provide it for the record, what is
the projection that CDC makes of the dollar savings as a result
of an investment in vaccines which are saved as a result of
preventing the illness?
Dr. Fleming. Vaccines are amongst the most cost effective
medical interventions. For every dollar that we spent on DTAP
vaccine, we saved $27 in health costs.
Mr. Hoyer. So there is a 1 to 27 payoff in the investment
in the fund that we have frozen?
Dr. Fleming. Yes, although it depends a little bit on the
vaccine.
Mr. Hoyer. You don't need to put it that way, I just put it
that way. You don't need to adopt my statement. I don't want
Mr. Wicker mad at you. Or Mr. Obey mad at Mr. Wicker because
he's mad at me. [Laughter.]
Dr. Fleming. I don't want to get involved in this, I don't
think.
If I may, though, let me just talk a little bit about the
activities that we can and need to do to improve childhood
immunization rates in this country. First off, we need to make
sure that there are functioning registries across this country,
so that as children come into the health care setting, their
provider knows without having to rely on their memory or the
memory of the child's parents what vaccines need to be
administered. That needs to be an electronic system so that's
available 24 hours a day.
Mr. Hoyer. I want to call to the attention, as a matter of
fact, Mr. Wicker and I have both been very involved in this,
that is a critical problem. When I talk to my local health
officials who interview parents, they can't remember when they
travel from one State to another exactly what the immunization
record of their child was and they may not have the record.
Therefore, what Dr. Fleming is now saying in terms of the
electronic record that can be accessed on the history of
immunization for children that travel readily around the
country, their parents are transferred or whatever, is a
critical element.
Go ahead, Doctor.
VACCINE SHORTAGE
Dr. Fleming. In addition, I think we need to recognize that
there is a relatively new crisis that we're facing today. That
is a shortage in available standard childhood vaccines. The
causes for this are multi-factoral, but essentially revolve
around a diminishing number of manufacturers for vaccine, such
that if one manufacturer has a production problem we're
confronted with a shortage, and difficulties that we've all had
in projecting how much vaccine is going to be used. CDC will be
participating with manufacturers and with a Department-led
initiative run by the Assistant Secretary of Health to look
over the next six to twelve months at how to improve this
problem and how to correct it both in the short term and the
long term.
Stockpiles that you mentioned may be one of the long term
solutions to this problem.
Mr. Hoyer. Doctor, my time is up. Let me ask you one last
question on this round, and I'm going to go to another hearing
on assistive technology for those with disabilities and then
I'll come back. But my question to you is this, if you know,
and if you don't know, I would like it provided for the record.
And I don't want to hear about it being an internal request.
How much did CDC request for this item to the Secretary of
Health and Human Services?
Dr. Fleming. Let me get back to you on the record for that,
Mr. Hoyer.
Mr. Hoyer. I would like that within the next 30 days, prior
to our markup.
[The information follows:]
Mr. Hoyer. How much did CDC request for childhood vaccines
to the Secretary of Health and Human Services?
Dr. Fleming. We cannot provide the specific information you
requested. Per OMB Circular A-11 and OMB memorandum M-01-17
dated April 25, 2001, Executive Branch internal deliberations
regarding the issues and options that were considered in the
process leading to the President's budget decisions are
confidential and should remain a matter of internal record.
Because--and this is not partisan, but when we can devote
$1 and save $27, or some figure thereabout, and keep children
healthy, there is absolutely no excuse for the wealthiest
nation on the face of the earth not to invest that money in
reaching at least 90 percent. Getting 100 percent is difficult
for reasons unrelated to expenditures of money. But there is no
excuse for us not making the requisite investment in making
sure that every child in America is vaccinated against
absolutely, totally preventable diseases.
Doctor, I thank you for the effort you're making. I'll ask
some questions on the next round.
Thank you, Mr. Chairman.
IMMUNIZATION RECORDS
Mr. Regula. I'd just like to ask a question. The only
record of immunization would be what your own doctor keeps, is
that correct?
Dr. Fleming. That in many instances is correct. What people
are trying to do is to have a dual record, so that in addition
to the physicians having a record, that the child and the
parents will have a record. I think many of us grew up in an
era that we had a shot card that we would take around and show
to our provider. That is something we have not paid as much
attention to in recent years. But having patient-held record of
immunizations, where the patient themselves, where the parents
can hold onto, is another way of making sure that information
can be communicated.
Mr. Hoyer. Mr. Chairman?
Mr. Regula. Yes.
PUBLIC HEALTH
Mr. Hoyer. One of the problems is, particularly with, we
tend to know our doctor. People of means and people that have
insurance and all that, they have a doctor. They know how to
contact the doctor.
But a lot of people access public health and access others.
They may not have as good a communication. One of the problems,
in talking to some of my rural area public health clinics, when
new families move into the area, their parents just are not
aware. They may say, well, yes, he or she has had a vaccination
shot, but they're not exactly sure what it was and how
extensive it was, when it was last given, whether it's up to
date. I think that's what Dr. Fleming is talking about and
trying to get some sort of central registry, so that public
health in particular can access what Sally's status is that
relates to vaccination.
Dr. Fleming. If I may add one comment. This problem is
getting worse, not better, because of the success that we've
had, and as progressively more childhood vaccines become
available and can be administered, it becomes even more complex
to keep track of which shots an individual child has received.
Mr. Kennedy. If I could ask, in Rhode Island, we have a
thing called Kids Net. It tracks all the kids and their
immunizations up to age three. I don't know whether that's
national or not.
Mr. Regula. Let me suggest, you might suggest a program
that we could look at. I think this is a very important point
that's been raised here.
We're going to have to move on. Ms. Pelosi.
WORK-RELATED DEATHS
Ms. Pelosi. Thank you, Mr. Chairman. Thank you, Dr.
Fleming, for your testimony. I hope you will convey my own
thanks and appreciation to Dr. Koplan. I want to wish much
success to him in his future endeavors. We will miss him and
appreciate the testimony you have presented here today.
I have some concerns. I'm reading from the Department of
Health and Human Services, CDC, your own book. It says here,
each day 16 workers die from an injury sustained at work, and
137 workers die from work-related diseases. The annual costs of
occupational injuries and diseases are estimated to be over
$171 billion. The annual costs of occupational injuries and
diseases are estimated to be over $171 billion, annual, per
year.
For that reason, I have very serious concerns about the
cut, $28 million cut, in NIOSH. We have all agreed here that
any initiatives or proposed solutions to the challenges we face
should be scientifically based. You referenced it as
scientifically sound as possible in another reference here
earlier. But basing how we proceed, whether it's prevention,
whatever it is, has to be scientifically based.
I guess we are in another meeting of the flat earth society
here when the Administration has decided to cut off the
science. How are we going to make the decisions if we insist,
and correctly so, that to be scientifically based, and then we
take $28 million out of the science that would enable us to go
forward and make those decisions, in an area that costs us $171
billion to our economy, not to mention what it means in those
people's lives each year? So I would put that as my opening
salvo to you.
I had hoped that we could talk more about my next question,
which is, yesterday I introduced a bill to create a nationwide
health tracking network--following up on just tracking and
networks, not the immunization side of it, though--that will
identify the links between chronic disease and exposure to
environmental pollutants. Last year I worked with my colleagues
to include $17.5 million in the public health improvements
account for a pilot project to explore the development of such
a network.
Can you provide the Subcommittee with an update on the
status of those pilot projects?
Dr. Fleming. Yes, thank you, Representative Pelosi. We
appreciate your support over the years. I will convey to Dr.
Koplan your message.
Ms. Pelosi. Thank you.
ENVIRONMENTAL ISSUES
Dr. Fleming. The environmental health tracking system that
we're working on is a critical system to better understand the
environmental health that this country is facing. The short
answer to this is that a lot of information is being collected
at the State and local level about environmental issues. But
we've done not as good as job as we should in linking that
information.
So in one place, people may be collecting information about
where toxic sites are, or what kind of chemicals may be in the
environment. In another place there may be measures of the
extent to which those toxic chemicals are getting into people.
In yet a third place, there may be registries of illnesses that
are potentially caused by environmental agents like cancer or
asthma. Then in a fourth place, there may be prevention
programs targeted.
The basic thing that needs to happen here is to invest the
resources that this Committee has allocated to allow the
linking of those different sets of information that are out
there, so that we have a coherent loop of information that
ranges from where chemicals are in the environment to how much
they are getting into people to what potential illnesses are to
what the prevention programs are, and then that feeds back on
our basis.
The dollars that we are using are dollars that will be
going to States, a small number of States around the country,to
begin to explore the best methodology for, number one, linking the
already existing information that we do have, and then second,
identifying whether or not after information is linked there are still
any gaps in our information for which we need to invest in additional
programs.
The environmental issues certainly are national issues. But
having worked at a State health department for about 15 years,
I can also assure you that they are State and more importantly
local issues. And for that reason, the information that we
gather cannot be a representative sample only that allows us to
garner national estimates. But we need to have sufficient
information such that every community in this country, to the
extent they are concerned about environmental issues, has
information that directly relates back to their community.
Ms. Pelosi. I don't remember ever having a hearing in this
Committee, except in our oversight hearings, but Chairman
Porter, when he was Chairman, did have a hearing on
environmental health. We were very grateful, that was before
our new distinguished Chairman came on board. It was an
exception, in all the years I have been on the Committee. It is
a very important issue, as acknowledged by our previous
Chairman.
I want to just say that I was pleased to see the release of
the National Exposure Report last year that provided the
detailed information on human exposure to 27 toxic chemical
substances. What is the time line for expanding the number of
toxic substances? If you have that information you could submit
it for the record, because my time is blinking away here.
Dr. Fleming. Sure.
[The information follows:]
Ms. Pelosi. The National Exposure Report last year provided
the detailed information on human exposure to 27 toxic chemical
substances. What is the timeline for expanding the number of
toxic substances?
Dr. Fleming. The National Report on Human Exposure to
Environmental Chemicals will be released in late fall of 2002
and will provide detailed information on at least 75 chemicals,
including additional data on the 27 chemicals that appeared in
last year's Report. New categories or classes of chemicals that
will be in this next Report include polycyclic aromatic
hydrocarbons (PAHs), polychlorinated biphenyls (PCBs),
persistent organochlorine pesticides, organophosphate
pesticides, dioxins, and furans.
CANCER SCREENING PROGRAM
Ms. Pelosi. And I also wanted to express my concern about
the fact of the meager resources that are put to the National
Breast and Cervical Cancer Screening Program. Congresswoman
DeLauro, Congresswoman Lowey and I have worked on this for
years and years and years. It took us a long time to get it
over $100 million, we were hoping to get it over $200 million.
But only 15 percent of eligible women are served through
the screening program. We think we could reach up to 70 percent
but we certainly can't do that with the $9 million that the
Administration has put into the program. So I want to register
my concern about that.
And I have some questions about the more difficult and more
expensive challenges we have in treating the declining rate of
TB and some questions about AIDS, which I will submit to the
record, both domestic and international. The red light is
blinking, I will submit those for the record.
Ms. Pelosi. Thank you, Dr. Fleming. Thank you, Mr.
Chairman.
Mr. Regula. Thank you. Mr. Miller.
ORGAN DONATION AND LIVER ISSUES
Mr. Miller. Good morning. I want to convey my thanks to Dr.
Koplan for the great job he's done. He will be missed. Tough
shoes to follow here.
I have a couple of questions. An area that I've developed a
special area of interest in is organ donation and liver issues.
My daughter donated half her liver to our son last October. So
all of a sudden, it becomes personal, certain things.
I'm curious what CDC does in the area of--I know there's
work being done in organ promotion donations and living donor
donations. I don't know if it's in CDC or not, so I'm curious
about that. And then would you comment what, in the liver area
in particular, in hepatitis, what the CDC does?
Dr. Fleming. Sure. CDC does participate with the Department
in developing recommendations for donor transplantation. Our
particular expertise is more in the infectious disease arena.
So what we bring to the table are recommendations around
standards and practices that can be used to minimize or
eliminate the risk of transmission of infectious disease in the
process of donor transplantation.
We also have a major technical role in looking at issues
around blood safety, blood transfusion. People oftentimesdon't
think of that as organ donation, but in some way it is. And we have a
role there.
You're absolutely right, though, that one of the most
concerning and to a large extent silent epidemics that we're
facing right now is epidemic liver disease, liver disease in
particular caused by hepatitis C. There was information even on
the Today show this morning about that. But probably close to 2
million Americans in this country have hepatitis C infection.
Approximately 20 percent of those individuals are going to go
on and develop chronic cirrhosis. Many of them may well wind up
needing liver transplantation.
CDC has an aggressive program to try to deal with this
problem. First, many of the people who are infected with
hepatitis C in this country don't know that they're infected.
So we are working as hard as we can to encourage hepatitis C
testing. In particular, implement it in health departments
around the country in settings where testing for other
conditions like HIV is being done, to have this test also be
available. We fund hepatitis C coordinators in every State to
try to make this increase in testing happen, and also to work
with the private sector.
A second aspect of control of hepatitis C has to do with
prevention to chronic liver disease in people who have that.
CDC is active with NIH and other Department agencies to try to
define what's the best treatment for hepatitis C. Because in
fact, there has been substantial improvements in our ability to
treat hepatitis C, even over the last year or two, such that
now, individuals, if they're diagnosed, have a reasonable
chance with medical therapy, of being able to clear that
infection.
So we're working to try to increase public awareness of
hepatitis, particularly hepatitis C, increased testing and then
increase the likelihood that people that test positive can be
connected with the medical system.
COLORECTAL CANCER AND HEPATITIS TREATMENT
Mr. Miller. It's been brought to my attention that
something you all have is a national colorectal cancer
roundtable that has been very effective at bringing all the
different parties together on that subject. Would you describe
that and see whether this would be applicable in the whole
issue of hepatitis, to have CDC help organize all the different
parties involved in the issue, for communications of prevention
and treatment of hepatitis?
Dr. Fleming. Right. What we've learned with cancer in
general, and colorectal cancer in particular, is that it's
important not only to deliver programs that are specific for an
individual cancer, but to mobilize community and mobilize
providers around the general issue of cancer prevention. So CDC
is currently funding approximately 20 States around this
country to develop comprehensive cancer programs that include
colorectal cancer and colorectal cancer screening, where you
can engage the community and you can engage providers.
I think it is possible that that same kind of methodology
could be used effectively for hepatitis.
Mr. Miller. When they have the cancer roundtable, is that
in each State or one that's national?
Dr. Fleming. My understanding of this is that there is a
national group, but that in addition, we encourage at the State
and local level a similar kind of activity, such that people
who are involved, be it providers or patients or advocates, can
get together at the same place at the same time and work
together. That kind of strategy really is what drives all
public health. It will be a good strategy, I think, to think
about for hepatitis C as well.
When you think about it, hepatitis C in many ways from a
prevention standpoint and a testing standpoint, and linking to
cure standpoint, is not dissimilar to HIV. We can and are
working on better ways to integrate those programs and engage a
larger cross section of the community.
HEMOPHILIA
Mr. Miller. I would be interested in learning about this,
to encourage that type of roundtable for the whole area of
hepatitis, mainly C, because that's the large one.
One brief last question is, hemophilia. I don't know if you
know much about the program. Are you at all familiar? It's not
a big part of CDC, I know, but they really do a lot of good
work, for a long number of years. Their treatment centers and
funding, I don't know if you know much about them, I don't mean
to put you on the spot.
Dr. Fleming. That's fine. I do know that CDC has a close
association with the Hemophilia Foundation and we work
collaboratively with them to develop educational programs.
Mr. Miller. They've been flat funding their treatment
programs ever since I've been on this Committee, which is not
still a big program, but I know the work they've done in
different States has been very productive, mainly in medical
institutions and schools where they have them around the
country. So thank you, thank you for the good work and thank
you for standing in for Dr. Koplan.
Dr. Fleming. Thank you.
Mr. Regula. Mr. Kennedy.
Mr. Kennedy. Thank you, Mr. Chairman.
Welcome. I have a number of questions and a short amount of
time to fit them all in, spanning from oral health to asthma to
diabetes to heart disease and a whole host of things. So I'll
try to get through what I can.
Mr. Regula. We'll have another round.
CHRONIC CHILDHOOD DISEASE
Mr. Kennedy. That will be great. The Surgeon's General's
Report on Oral Health states that the dental decay is the most
prevalent chronic childhood disease, five times greater than
asthma. Furthermore, it also reports that dental decay is the
most frequently named unmet health need of children. It is my
understanding that generally speaking, pediatric dentists treat
the most severe cases.
But there are only 3,800 pediatric dentists in the country.
In my State, there are fewer than 10 pediatric dentists for
25,000 children who lack basic dental care. We literally have
kids in the Blackstone Valley whose mouths are rotting out.
Your budget justification says that the CDC is the Federal
agency with the primary responsibility for supporting State and
community efforts to prevent oral disease. It also mentions
that five States receive core funding and seven additional will
be added. I'd like to know what you are planning to do to do
more about this real crisis in child health in the area of oral
health care.
Dr. Fleming. Thank you, Representative Kennedy. I
appreciate very much your bringing this issue up.
Mr. Kennedy. You can comment briefly and then I can get
more for the record.
DENTAL CARE
Dr. Fleming. Okay. What I'd like to just mention then is
that we are going to be funding 12 States and one territory,
focusing on not only provision of dental care, but also from a
prevention standpoint, more importantly, fluoridation,
sealants, so that our children can be prevented from getting
into the position where they need dental care in the first
place.
Mr. Kennedy. Super. I look forward to working with you on
that. My State has a particularly critical problem there, and I
want to work with you there to get that problem addressed.
Given that many of our negative health behaviors escalate
in times of stress, could you comment on what the CDC is doing
to increase potential increase of chronic health problems
related to stress and negative health behaviors?
Dr. Fleming. This is an area that is one that we're just
moving into. You're absolutely right, mental health and
physical health are very closely correlated with each other at
all stages of life, particularly in the elderly. It's important
to recognize that mental health is an important aspect of
overall health. We're working primarily within the context of
our chronic disease programs in diabetes and cancer control and
heart disease to assure that as people work to attend to their
physical problems that they're also attending to the very
important issues that you're raising.
Mr. Kennedy. I'd like to get a detailed brief from you in
terms of what you're actually doing and where it is in the
budget and what programs you have out there to address this
area.
Dr. Fleming. I'd be happy to give that to you for the
record.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
CHRONIC DISEASE
Mr. Kennedy. I also want to comment on your bringing up the
subject of the chronic health, because as you know, the chronic
health disease prevention and health promotion line is cut by
$57 million in your budget. This is the line that deals with
such things as nutrition, physical activity, obesity, etc., all
things which are key to dealing with the epidemic unmet needs
around chronic diseases. So I just ask you also to comment
briefly about how you plan to make up for this unmet need of
chronic disease prevention by cutting the $57 million that
you're cutting in the chronic disease prevention line.
Dr. Fleming. The primary reason for that cut is the youth
media campaign. The President's budget does propose almost $700
million for chronic disease control, and that includes very
active and vigorous programs in diabetes prevention,
cardiovascular disease, obesity and nutrition. So we can do a
great deal with the resources that we're asking for.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
ASTHMA
Mr. Kennedy. Well, super. I look forward to seeing some of
those ads in Rhode Island. We'd like to see the media budget
when you put it together.
Asthma is of course growing at epidemic proportions,
particularly within the inner cities. It's becoming a very
serious health problem. So I'd like to ask you what it is that
you're doing to address this treatable chronic condition, which
is really just a question of getting the resources to where
there's the least insurance, I guess.
Dr. Fleming. Asthma is an epidemic disease in this country.
Its incidence has increased markedly in the past several
decades. We have cooperative agreements with approximately 30
States currently to work on asthma prevention strategies.
Asthma is preventable, you can't prevent someone from
carrying a diagnosis, but what you can do is control the
disease through environmental modifications in their home and
through assuring that they're educated on how to treat
exacerbations. We are working in these cooperative agreements
to do that, particularly in poorly served inner city areas.
DIABETES
Mr. Kennedy. Again, I look forward to getting into more
detail with you on it.
Finally, about the diabetes, do you think that there ought
to be a diabetes comprehensive program in every State, because
of the growing epidemic in diabetes, particularly as it relates
to the obesity question that you talked about earlier?
Dr. Fleming. Diabetes is epidemic in this country. The
cooperative agreements that we currently have in States that
have comprehensive care are showing unbelievable results with
as much as 35 percent reductions in hospitalizations for
diabetes, 30 percent reductions in incidence of amputation.
These are highly cost effective programs.
Mr. Kennedy. So if you had additional money, could you roll
it right out to the States for their comprehensive diabetes
control programs?
Dr. Fleming. There are additional States that do not have
comprehensive programs who are ready to do them.
Mr. Kennedy. So we'll look forward to working with you on
that.
Thank you, Mr. Chairman.
Mr. Regula. Thank you. Mr. Istook.
Mr. Istook. Thank you, Mr. Chairman.
Dr. Fleming, happy to have you here this morning.
Dr. Fleming. Good morning.
Mr. Istook. One of the things mentioned in the budget
justification for CDC talks about the problems of the emergency
personnel, the first responders at the World Trade Center
attack. And the challenge with having protective breathing gear
for them, certainly that's something we saw with the attack on
the Federal building in Oklahoma City. We've seen it in the
terrorist attacks. We see it in the concerns regarding
potential anthrax or other chemical or biological agents that
could be used in an attack, the need for respiratory
protection.
Your budget justification, of course, talks about NIOSH
becoming a part of trying to make sure that protective gearis
supplied. I'm concerned, however, that NIOSH for some years has been
the source of the problem, rather than the source of the solution.
Efforts to get them to certify the protective masks and separately the
variable filters that can be involved in different types of masks seem
to have gone nowhere. I guess they want a perfect scheme and the
perfect becomes the enemy of the good. Even emergency funding,
directions from Congress seem to have done no good.
Our first responders, police, fire and other emergency
personnel, as well as people doing everyday jobs where they
might be subjected to some other airborne agent, their lives
are at risk, their health is at risk. And NIOSH is dragging its
feet.
My question is very simple. Would you please tell us who at
NIOSH is responsible for this blockage and how do we get them
out of their positions?
Dr. Fleming. Thank you, Representative Istook. The
responsibility is CDC's, and we will work very hard, I'd be
happy to work with you individually to address your concerns. I
couldn't agree more with you that there is a critical need to
assure that our front line responders are protected as they are
protecting the health of others. We need to make sure that part
of that is effective respirators.
NIOSH has, over the last two years, as you know, created a
special part of the institute to deal with this issue. There is
substantial progress that is being made today, and I'd like to
get back to you on the record for that progress. I think you'd
be pleasantly surprised.
Mr. Istook. Well, I'm not, excuse me for interrupting, but
I'm not pleasantly surprised, because I hear they're saying,
well, we'll have something by the end of the year. That's not
the satisfactory time frame in my book. Even if they want
something that may have a longer time span, I would think they
could do some things on a provisional or emergency basis,
rather than saying by the end of the year.
Now, perhaps you're talking about a different time frame
than I've heard.
Dr. Fleming. We certainly will be working to speed that up.
In addition, there is substantial work right now looking at
collaborating with the Department of Defense, so that we can
take advantage of the mutual expertise that exists in both
places, to make sure that the process is as efficient, as
speedy as possible.
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ANTHRAX
Mr. Istook. I appreciate that, and I appreciate your
sharing the concern with the people that are on the front lines
of these situations and the risks that they face. Let me ask
one other question that relates to the overall airborne
contamination issue on this. I chair, for example, the Postal
Service Subcommittee. Certainly we're both familiar and CDC has
been very cooperative in working with the Postal Service on the
anthrax threats.
Part of the challenge that we have in trying to allocate
resources is assessing the level of that threat. You can talk
about the number of deaths, that each one was unfortunate and
horrible. Nevertheless, when we look at a perspective with what
percentage of the mail is contaminated, what sort of threat is
there, what are the vectors whereby somebody might obtain
anthrax or any other substance, part of the challenge we have
is in correctly assessing the level of the threat, so that we
can allocate resources to where the threats are the greatest.
Can you give us your best estimation of just how severe is
the threat or absence of threat of any future anthrax
contamination instances? I know you don't have a crystal ball,
but your best assessment is valuable to us.
Dr. Fleming. I'm not going to be able to do as good a job
on that as I would like, or as I'm sure you would like. I think
what we learned from these anthrax attacks is that mail is a
very efficient way to disrupt a system. The spores that got
sent through the letters, when you look, were very effectively
distributed. That's a great concern to us as far as threat is
concerned. Until the people or person, the people who did this
are caught and brought to justice, I think we need to be
prepared for them to do it again.
We are working closely with the Postal Service, given that
that's what we need to be planning for, to try to address the
issues that you're raising, what are the most appropriate
places to invest to provide the best possible protection for
the most people.
Mr. Istook. How much knowledge and control do you believe
that we now have over the places in the United States or with
access to the United States that have access to anthrax spores?
Dr. Fleming. I think through select agent and through
activities that many of the regulatory and law enforcement
agencies are taking, that we're doing close to as good a job as
can be done. But we need to recognize that with agents of
bioterrorism, and anthrax is an example, that these bacteria
exist in the environment. So there is never going to be a way
for us to absolutely preclude someone from obtaining these
agents and working in laboratories to make potential
bioterrorism agents. We can work as hard as we can, but that
threat unfortunately just cannot be eliminated.
Mr. Istook. Right. And it's tough to evaluate, as we both
know. Thank you, Dr. Fleming.
Mr. Regula. Mr. Sherwood.
FLUORIDATION
Mr. Sherwood. Thank you, Mr. Chairman.
I have two thoughts I'd like to get into today. One is a
follow-up on your discussion with my colleague Mr. Kennedy on
dental care, oral care. And you talked about the veryobvious
value of fluoridation.
I had an experience a couple of years ago of being in the
bush in northern South Africa for about two weeks. We had some
Zulu trackers and spotters and guides working with us,
remarkable men who had never lived anywhere where there was
running water, never been to a dentist, lived in a society that
by everything we would think was very, very primitive. These
men were in their 30s and 40s and early 50s, and they had
absolutely perfect teeth. White, sparkling, and they had never
been to a dentist, they had never owned a toothbrush. They had
never done any of the things we do, and they didn't have any of
the problems we have.
So fluoridation, unless there's naturally occurring
fluoridation in northern South Africa, wasn't their answer.
Dr. Fleming. I don't know whether there is naturally
occurring fluoridation in South Africa. There are many water
systems that do contain fluoride naturally. So that may be an
explanation.
In addition, though, I would point out that maybe what you
didn't see were the children or adults who did not have teeth
in that condition, and as a result of illness or infection had
died. In some ways, many of the health conditions that we're
seeing, we don't want to let natural selection be the process
by which we see healthy adults. I know that you weren't
implying that by any means. But there are differences, I think,
between the circumstances in South Africa and the circumstances
in this country.
Fluoridation in particular is one where it may not be
appropriate in every community. It needs to be a decision
that's made by community values. We need to assess the level of
natural fluoride in the water. But it's just one of those
things we need to have in our tool box.
Mr. Sherwood. And of course, you're correct, I was
interacting with the ones who had come through the system very
well. But I think a great deal of the problem, or the answer,
is diet. I don't think that they drank three Cokes a day or ate
all the sugar. So I think health care in this country and
dental care is to a large extent public information, changing
public behavior. I don't think with all our wonderful
discoveries, the thread we've had in these hearings the last
few days is that it takes 15 or 20 years to get out new
discoveries into the market place and being practiced. I just
wanted to emphasize that fact, that I think public health is
public education.
The other thing I'd like to ask you about, I represent a
community, a nice residential community that lives alongside a
huge landfill. They've asked your office, the Borough of Old
Forge, Pennsylvania, the officials of the Borough of Old Forge
have petitioned the Centers for Disease Control for a public
health assessment. Could you describe this process for the
Subcommittee, and maybe provide me with a little information on
the time frame for such a study?
Dr. Fleming. Sure, thank you, Representative Sherwood. I'm
aware of the request. We received it in the first week of March
of this year. This is a process that is actually done by CDC's
sister agency, ATSDR. The Director of CDC is also the director
of ATSDR. Dr. Henry Falk is the administrator there and is
currently reviewing the request.
Basically what it involves is first an assessment by ATSDR
of the specifics and then depending on what those specifics
are, working with appropriate members of the community and the
health community to take the appropriate steps. I'm being
vague, because without knowing the results of that initial,
preliminary assessment, what subsequently may happen could take
a whole wide range of different avenues. But we will make sure
to keep your office apprised of how that request is proceeding.
Mr. Sherwood. I would appreciate that, if you would get
back to me about it.
Dr. Fleming. Absolutely.
Mr. Sherwood. Thank you.
Mr. Regula. Ms. DeLauro.
Ms. DeLauro. Thanks very much, Mr. Chairman.
Thank you, Dr. Fleming. I'm sorry that I didn't hear your
testimony. The Subcommittee on Ag is meeting as well this
morning, so I'm kind of going back and forth.
If I can, I'd like to pick up on something that my
colleague just mentioned, and that is, public health is public
education. I think there has been some discussion of the
obesity epidemic in this Nation. In 1999-2000, 71 percent of
African-Americans, 59 percent Hispanic, 53 percent of whites in
the State of Connecticut were overweight. Long and the short of
it, and we know what the risk factors are involved,
cardiovascular, diabetes, cancer, to name a few.
We also know that this is a problem particularly among
youngsters. Let me just make a couple of points. The former
Chair of the Appropriations Committee, John Porter, said, ``If
advertising can influence decisions about what cars we drive
and what cereal we eat, why can't it persuade children to make
healthy lifestyle choices? Just as corporate advertising sways
young people to drink a particular brand of soda, it makes
perfect sense to harness the power of the media to convince
kids to eat right, to stay physically fit and drug free.''
OBESITY
When Dr. Koplan was here a while ago in response to the
testimony on the epidemic of obesity among children, which he
said was the obesity rate has increased by 100 percent since
1986, Chairman Porter allocated resources to the CDC for a
youth media campaign. He talked about unleashing the magic of
Madison Avenue to increase kids looking at healthy lifestyles.
In any case, that campaign was a partnership between CDC,
SAMSHA, HRSA, the NIH. Healthy diet, exercise, dangers of
tobacco use. Every day, 3,000 young people take up smoking.
Participation in high school in physical education programs
dropped from 42 percent in 1991 to 27 percent in 1997. Almost
three-fourths of young people do not eat the recommended number
of servings of fruits and vegetables. As many as 15 percent of
our young people age 6 to 17 years are considered overweight.
The youth media campaign, getting to my point, price tag,
no more than what Mattel spends on marketing the Barbie doll,
about $125 million. Not a high price to pay to curb an obesity
epidemic which costs this Nation every single year $100 billion
annually. That program, and I ask how can it be justified to
eliminate a campaign, even though when the odds are stacked
against our kids.
Let me just give you another point. We had, I think it was
the Department of Education, the physical activity program in
our schools has just been dropped. It's eliminated from the
budget. Physical activity dropped for kids, no campaign to deal
with lifestyles about the three Cokes a day, the candy bar with
the vending machine right there. Why are we pulling back on
those things that we thought would be responsive?
So again, why has this program been dropped from the CDC?
Dr. Fleming. Let me talk a little bit about the youth media
campaign. Thank you for raising it. I know at the last
appropriations hearing, we went through those charts showing
the obesity epidemic in this country. The only little point I
would take would be to say that it definitely is a problem in
children, but it's also a problem in adults. So we need to make
sure that we're attacking this across the board.
Ms. DeLauro. Amen. I concur with you.
TWEENS
Dr. Fleming. The youth media campaign is a program that's
designed to target behaviors in our kids, and particularly what
we call ``tweens,'' children between the ages of 9 and 13, of
which I have two.
Ms. DeLauro. Middle school kids.
Dr. Fleming. That's right. It's the formative years, that's
the point at which we can make the most difference.
And you're absolutely right, that there's a lot of
expertise out there on how to do this. What we've tried to do
with the youth media dollars is to take advantage of that
expertise and not have this be a Government program, but have
this be a program that represents the best of what the private
sector can contribute, not have it be a program that
immediately starts sending messages out that may or may not be
effective, but to take the 12 to 18 months that the private
sector takes to develop messages and make sure those messages
are message kids will respond to, and make sure that those
messages are integrated with community events. Because the
public media campaign alone can only be so effective. The
community needs to be involved as well.
That's what it is we're trying to do with the youth media
campaign, it's going to be launched in June of 2002. It will
get to full gear in October of this year, and it will continue
through the 2003 cycle.
Ms. DeLauro. It's going to be a private program versus any
kind of Federal resources?
Dr. Fleming. It will be paid for by the dollars that this
Committee has appropriated, but we're taking advantage of the
private sector expertise that exists out there to make the
efforts as effective as possible. Because of the fact that we
have taken this industry standard of 18 months to gear up to
figure out exactly what is going to be most effective, the
dollars that the Committee has already allocated will allow us
to continue the activities of this campaign in 2003.
Ms. DeLauro. How much money are we talking about?
Dr. Fleming. The first year's appropriation I believe was
about $125 million, and last year was $68 million.
Ms. DeLauro. So that $125 million is going to pay or to get
the private sector to develop a program?
Dr. Fleming. It is going already to get them to develop the
program. But then it also is going to be used in the coming
months to pay for the commercial air time to add the media part
of this and also to pay for the community involvement in the
cities that this program will be visiting.
Ms. DeLauro. How will that work? I don't understand. Tell
me how that is going to work and what will be our connection
with it. We've appropriated the money for the program, it's
going to go to, and I think we ought to think out of the box on
these things. If you've got commercial advertising, they know,
all of us like to think in our own efforts that we can design
the jingle, design the slogan, but we can't do that. I believe
in looking at it.
Just explain to me how this works and what our efforts
continue to be with it, and how does it get to the community
involvement piece. What's that process about?
Dr. Fleming. I'd be happy to provide you with a more
detailed answer on the record.
Ms. DeLauro. Please.
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Dr. Fleming. Basically, we are approaching this just as any
media campaign in the private sector. So the way that folks get
you to eat Cheerios in the morning or to buy a refrigerator of
a given brand, we are tapping into that expertise and into that
methodology to make these behavior messages get to our kids. As
a result, there is going to be a combination of innovative
media messages in venues that ``tweens'' watch, Nickelodeon,
for example, taking advantage of the private sector. There are
many in the private sector who know this is a problem and are
anxious to work with us.
Ms. DeLauro. Are they going to contribute dollars to the
programs?
Dr. Fleming. There will be in-kind contributions.
Ms. DeLauro. Is that in terms of buying the time and doing
things like that?
Dr. Fleming. I can get back to you.
Ms. DeLauro. If you can, right. If you can just lay out,
because I also am anxious to find out how you deal with the
community involvement in this local area, what is that going to
include. So if you could just lay all that out and when it will
start, what's your sense of its duration, so that we can be
thinking about what our obligations and responsibilities are.
Dr. Fleming. Absolutely. I'd be happy to.
One last point is that the key audience here are kids. So a
key part of our development process has been accessing those
kids in ways that are friendly to find out from them what are
the messages that are going to work. So kids to a large extent
are helping us design the effective messages.
Ms. DeLauro. That's great. I believe that kids can lead us
to adults. I think our kids did that on the environmental
issues, I think they'll do that on the smoking issue. If you
could just pass on to Dr. Koplan our regards, thank him for his
very, very good work. It was really a pleasure to work with him
over the years. Thanks so much.
Dr. Fleming. You're welcome, thank you.
Mr. Regula. Ms. DeLauro, you'd be interested to know that
two of our staff have looked at the media campaign and came
back very impressed.
Ms. DeLauro. That's great.
Mr. Regula. So I think you're off on the right track, and
of course, my staff has five teenagers or thereabouts. If she
thinks it will work for them, it must be good. [Laughter.]
Not that they necessarily need it, but she knows kids, what
they respond to.
I yield two quick minutes to Mr. Wicker.
Mr. Wicker. Thank you, Mr. Chairman, for your indulgence.
Just to echo what Mr. Sherwood and Ms. DeLauro have said, I
think you are going to find bipartisan support in
thisSubcommittee for this campaign. And I appreciate your answer to Ms.
DeLauro's question about doing it right and taking the time and
involving everybody. There is the other model, and I asked the director
of CMS about this yesterday. He decided that they needed an education
program about Medicare and Medicaid and found some money in his budget
and came up with a program in a matter of months which he feels is
effective.
So I just want to ask you and point out that this is taking
an awful long time. We're ready to go with it and I think we're
ready to support you on this. Ms. DeLauro is right, and you are
right, it is the children and it's also the adults,
particularly in this obesity question. It sounds so touchy-
feely for me to be saying the Government ought to be helping
people get the weight off. But it is an epidemic health
problem, all across the country. And I've seen the charts about
where it started and where it's expanded. It causes so many
other problems that we've just got to get a handle on it.
So I would urge you to speed up the process if you can.
Maybe get back to me on the record about the different
approaches that you took and that your agency took as compared
to CMS, where they got a program up and running real quick and
where we've taken a whole lot of time, maybe it is a little
frustrating to some of us on the Subcommittee.
Dr. Fleming. Thank you. I'd be happy to do that.
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Dr. Fleming. We are as anxious, I think, if not more
anxious than you are, to get this out. We want to make sure
that we're doing it right.
Mr. Regula. Mr. Obey.
NIOSH
Mr. Obey. Mr. Chairman, let me return to NIOSH. I was
observing earlier that yesterday we passed a brigadoon budget
under which our ability to meet all of our obligations in the
health area, education, DOD, science and the rest, under the
discretionary dollar limit imposed by the budget resolution
yesterday, disappeared into the mist as soon as it was voted
on. We're going to be left with the reality on this
Subcommittee and others that health education and worker
protection and a number of other areas are going to get
crunched. It seems to me that NIOSH is as good an example as
any.
My understanding of your responses, I should say my
understanding of the budget that the President submitted, is
that NIOSH would not be able to make any new extramural grants
under the NORA operation and that they would have to terminate
some existing grants in mid-stream. I'd simply like to note for
the record three examples of the kind of research that's done
under NORA.
There's research at the Washington State Department of
Health on improving the quality of data used in tracking
pesticide illnesses. Coming from a farm area, that's very
important to somebody like me. The research at the University
of Louisville on fertility problems in men working in polymer
production may not be very important to somebody who puts the
budget together at OMB, but it's pretty important to somebody
who is exposed to the problem.
Another example is research done by an organization called
Technological Systems Research on developing a device
preventing electrocution by mobile cranes. My grandfather died
of an electrocution. So I think that could be fairly important
to people who work around those things. I just think it's
important for us to understand what some of these numbers mean.
And then I would simply like to note again for the record,
in light of the discussion that occurred between Mr. Wicker and
me a few minutes ago, here's the record. On bioterrorism
preparedness funding, Congress provided $2.5 billion in fiscal
year 2002 in the emergency supplemental for bioterrorism
preparedness at HHS. That was in the DOD appropriations act and
was carried by that vehicle.
That was $1 billion more than requested by the
Administration. It was $250 million less than the amendment
that I had originally offered and had hoped to provide. And
here are some of the differences. In funding for State and
local health departments, we wound up providing $865 million
for grants to upgrade those capacities, as opposed to $65
million in the Administration's budget. For grants to upgrade
hospital planning and preparedness, this Committee provided
$135 million in comparison to the $50 million requested by the
Administration and the $200 million which we had wanted in our
original amendment.
For funds to upgrade in-house CDC capacity, $100 million
was provided by this Committee as opposed to the $50 million
requested by the Administration. For accelerated NIH research
on vaccines and treatments, $85 million was provided. The
President requested no supplemental funding for that purpose.
We had wanted to provide $115 million, so $85 million wasn't a
bad compromise.
In addition, that supplemental provided $70 million for
construction of high biosafety level labs at NIH to do that
kind of research, compared to zero requested by the President.
I simply wanted that in the record to again make clear what the
story was last year in terms of the resistance that we received
from the White House budget office and the President himself to
our efforts to react to what we had been told were emergency
needs by CDC, by HHS, by the FBI.
The FBI would still be clunking along with computers half
of which couldn't even send to another city a picture of a
suspected terrorist. We've now got the FBI up and running so
that their new computer system will be up and running
thissummer, rather than waiting the years we would have had to wait if
the White House had had its way.
So if I keep beating a dead horse, it's because I think if
we make enough noise about the nature of the disagreement last
year, maybe we won't have a disagreement this year, because
everybody will recognize the necessity for these kinds of
expenditures. So I'm really not asking you to comment, but I
wanted that spelled out in the record.
And I simply also would like to say, it will be interesting
to see who will in fact be appointed to fill the vacancy at
NIOSH. It is often possible to frustrate the ability of any
agency to defend the public interest by appointing a fox to
guard the henhouse. I recall years ago when Ray Bliss was the
Republican National Chairman under Eisenhower. I don't actually
recall it, I'm not that old, but I certainly read about it at
the time. There was that famous remark where he told the
members of the caucus, he said, look, fellows, you don't have
to vote against this stuff, we can just administer it to death.
And that was true, unfortunately. I think that I would hope
that whoever is appointed to run NIOSH will be someone who is
not seen as having been resistant to the past efforts of NIOSH
or OSHA to protect workers. That would be a prescription for a
lot of nasty fights and that would be a prescription that would
not be in the public interest. I don't have a whole lot to say
about that, but I think it's worth noting.
Mr. Chairman, thank you for the time.
Mr. Regula. Thank you. I have a couple of questions, then
we'll go to you, Mr. Jackson.
What's the status of your management reforms? Are you
making any progress?
Dr. Fleming. Yes.
Mr. Regula. I think the Secretary is very interested in
that.
Dr. Fleming. Absolutely. You know, effective management and
administration are a key part of any agency. I think being in
the Government both at the State and Federal level, it's
impressed me that for our trust and credibility, we just
absolutely have to have as effective management and
administration as possible. In that context, we are fully
supportive of both the President's and the Secretary's
initiatives on increasing management efficiencies. We're
working closely with the Department. Currently they've been
down, we've had really good discussions with them for how to
begin these changes, and we're excited about them.
IMMUNIZATION
Mr. Regula. Last year we provided over $85 million increase
for immunization. You've heard the discussion here. What are
you doing with that money, the increase and the money on
immunization? Are you trying to promote using it to get more
vaccines out?
Dr. Fleming. Yes. As we've talked, because of our success
in immunizations reducing disease, people have forgotten how
horrible these illnesses are. It's becoming harder and harder
to make sure that kids get the vaccines that they need. We need
to therefore work to implement a more systematic approach
through the registries that we talked about, through providing
increased dollars to State and local health departments to do
work at the local level.
In addition, we cannot forget that many of the vaccine
preventable diseases that have been eliminated in this country
are still causing devastating illness overseas. So for example,
$25 million of the dollars that the Committee allocated last
year went for the eradication of polio worldwide. I'm pleased
to report that we've made dramatic improvements in reaching
that goal.
There are only now about, as I recall, 10 countries in the
world in which polio exists. The number of cases has dropped
well over 99 percent since the 1980s. We're in that last mop-up
phase with polio eradication. But we need to make sure that we
have the resources to finish the job. The places where polio is
right now in the world, in places like Sudan and Afghanistan,
are going to be the most difficult places to finally, to
finally eliminate it.
Mr. Regula. It's remarkable what's been accomplished, when
you read the history of even our own society here, back a
couple of hundred years ago. My case in point, President
William McKinley used to represent the 16th district prior to
being Governor, then President. He and his wife had two
daughters, one was two and one was four, that died, I don't
know, some type of fever, both of them. Obviously with
vaccines, they would have survived. That's just a good example
of how that was, it was about 100 years ago.
POLIO
Dr. Fleming. Even in the early part of this century, the
leading cause of disability in this country was polio. And we
haven't had a case of polio in the U.S. for several decades.
Mr. Regula. We are so fortunate. Are you doing anything on
the registry? I'm intrigued by this idea. We are such a mobile
population, and people change doctors, we don't have the old
family doctor any more. It isn't part of our life as it used to
be, where you could call up and find out, gee, did I get a
vaccine when I was 10 or whatever. And the schools used to,
well, I guess they still do, it's very useful information.
There ought to be some way to have a data base on this.
Dr. Fleming. CDC, and we'd be happy to get that information
back to you on the record, in detail. But it is working with
many States to do this. The State that I used to work in, in
Oregon, in the old days, people would only have a single
doctor. But in the 1990s, the average kid had three, over three
providers that gave them immunizations at some point during
their first three years of life. It's that switching of health
care systems that makes it almost impossible to track, in the
absence of a select----
Mr. Regula. My granddaughter is seven weeks old, she's had
three doctors already. It's just a changing world. I think it
is something that would be very useful to pursue.
VACCINES FOR CHILDHOOD DISEASES
Dr. Fleming. Let me just mention one other point, which is
that as some of these new vaccines have become available, for
example, vaccines to prevent chicken pox or more recently, a
vaccine to prevent what's called pneumococcal disease, which is
a major cause of pneumonia and meningitis in children. The
costs of the vaccine themselves, of the routine vaccine series,
are going up.
So one of the things also that we've done with the money
that the Committee has provided us is use that money to
immunize the same number of kids, but those kids are now
costing more per child to immunize because of the fact that
there are these new vaccines out there.
Mr. Regula. Mr. Jackson.
Mr. Jackson. Thank you, Mr. Chairman.
And welcome, Deputy Director Fleming. I want to thank you
for your testimony and apologize for being a bit tardy.
Yesterday, the Institute of Medicine released a report that
this Subcommittee commissioned entitled UnequalTreatment. The
study found wide discrepancies in the health care received by whites
and by members of minority groups in this country. The report says that
health care gaps persist even when different racial groups have similar
incomes and insurance coverage.
For example, while 71 percent of white patients received
breast cancer screening, only 63 percent of black patients did.
For every 100 white patients who had a procedure to clear an
artery, only 74 black patients did. Black patients are over
three and a half times more likely to have a limb amputated as
a result of diabetes.
Director Fleming, on page 199 of your justification, at the
very bottom, you acknowledge many of these facts. Nowhere are
these interventions needed more than among our Nation's
communities of color. You cite several facts with respect to
cardiovascular disease and with respect to diabetes.
But on page 207, where it really matters--you've got the
facts on 199--but where it matters on 207--fiscal year 2001--
the request was at $37,810,000, for 2002, essentially level
funding. There is a small cut in 2003, if not level funding. In
light of the report by the IOM, my question to you, Dr.
Fleming, is why is the REACH program, that is, eliminating
racial and ethnic disparities, cut slightly from $37.81 million
to $37.55 million?
Constituents of mine, like Access Community Health Care
received a REACH grant two years ago and are working to
eliminate these disparities in my district and in Chicago. We
obviously need more organizations like this to do this kind of
work. But how can they do it when the program is essentially
flat funded and even experiencing some reductions in light of
the facts?
REACH FUNDING
Dr. Fleming. Thank you very much, Representative Jackson.
The specific answer to that remedy question about REACH funding
is that management deficiencies are the reason for that modest
reduction, and should not affect the amount of dollars that are
going out from CDC to your constituent groups.
Having said that, I could not agree more with you about the
need in this country to more directly attack health
disparities. The IOM report was only one part of that. That
said, holding level access, holding level cultural differences,
even when somebody gets into the system, we still have a
problem in this country where your race or your ethnicity in
fact predicts the level of care that you're getting. CDC I
think can contribute in that area, in the role that we do best,
which is providing more data to say, are there best practices
that will prevent that, are there areas in the country that are
doing a better job, are there health plans that are doing a
better job.
But that's only a part of the problem. Access to health
care is a second important part. And the third perhaps, from a
public health perspective, most important part, is making sure
that in our community program, independent of whether they're
REACH or HIV or diabetes or asthma, that we have programs that
reach those individuals that are affected, regardless of their
race or ethnicity, that we've taken the time to make sure that
those programs are culturally appropriate. We know that the
people who are delivering the messages to those communities are
respected by the communities and they oftentimes are perceived
as peers.
So I would not want you to take away from this that the
only part of CDC that is attending to the issue of health
disparities is the REACH program. That's a critical program,
but we are as hard as we can trying to make this issue of
health disparities in minority communities in this country one
that all of our programs are directly addressing with the
resources that are allocated to those programs.
MANAGEMENT EFFICIENCIES
Mr. Jackson. Would you care to explain to the Committee
what you mean by management efficiencies? The IOM study is
pretty clear in terms of what their recommendations are. We
need broader participation in terms of minorities participating
in health professions. Minority schools obviously need broader
participation from both Federal and State governments. They've
given a number of very, very important recommendations.
But you talk about management efficiencies. What does that
mean in terms of level funding? In light of the facts, which
your own report suggests are clear, that cardiovascular disease
is responsible for coronary disease and that death rates are 40
percent higher among African-Americans than the white
population, that the diabetes issue is 1.7 times greater among
African-Americans, 1.9 times greater among Hispanics, 2.8 times
greater among Native Americans.
I mean, I understand the rhetoric of, we're all for health
disparities. But on page 207, it's real specific. Eliminating
racial and ethnic disparities, 2001, $37.8 million, 2002, $37.8
million, 2003, $37.5 million a reduction of $259,000, when in
fact I believe this program, and I'm making it clear to the
Chairman, because I obviously plan in light of the IOM study to
fight for significant increases in light of the facts, what a
management efficiency is. What does that mean?
Dr. Fleming. I appreciate your comments. If you look at
across all the budget categories at CDC, not by any means
singling out the REACH program, you will see that there are
similar reductions in programs for reducing administrative
layers. So this is a Presidential initiative that we will fully
support that says we can do our job better than we're doing by
across the board, not just in REACH, but all the CDC programs,
look at ways to more efficiently manage and administer our
programs. Again, it's not something that's specifically
targeted at the REACH program. But it is across all the CDC
programs.
REACH PROGRAM
Mr. Jackson. Mr. Chairman, I know my time has just about
expired. I'm not suggesting that the REACH program isn't one
that's obviously worthy and deserving because of the facts. The
Nation's top scientists and doctors have come together in their
report and said that treatment is unequal. But it appears that
the President's approach for efficiencies across all of CDC is
running contrary to what the medical community is suggesting.
It is a significant problem that requires investment by the
Federal Government and the State to address a profound problem
in a way that it has not addressed it before.
So in the name of efficiencies, what you're suggesting to
me is that there will be less funds available to address the
profound problem that the medical community is suggesting needs
to be addressed in a forthright and very aggressive way. Is
that kind of what I'm hearing?
Dr. Fleming. We are going to work as hard as possible to
make it so that the dollars that go out from CDC are not
changed as a result of these changes. These are internal
efficiencies that we're going to effect within CDC.
Mr. Jackson. Thank you, Dr. Fleming. Thank you, Mr.
Chairman.
Mr. Regula. Mr. Hoyer.
Mr. Hoyer. Thank you.
Doctor, I presume what you're referring to in the
management efficiencies, I forget, what's the three word--we're
going to find out pretty soon, because I've been asking
agencies about it, in effect, what the Administration has done
is ascribed to all the agencies across the board a percentage
of savings that they are expected to accomplish. Is that what
you're referring to?
Dr. Fleming. That's correct, yes.
BSA
Mr. Hoyer. We'll get the phrase in just a second, but Mr.
Chairman, I think you've probably been hearing it as well.
As I understand it, when I asked the agencies on the
Treasury Postal Committee on this, these are assigned to you
and to the agencies across the board, business strategy
adjustment is what they call it, BSA.
But that it is essentially saying, look, we don't have
enough money so we're just going to take an arbitrary figure
of, I don't know what percentage it is, and ascribe that to a
savings. I think we obviously need to reinvent, Gore wanted to
reinvent, do more with less, I think businesses need to do
that, Government needs to do it. And we need to do it, frankly,
so we have more resources to help those people who are eligible
for programs but we don't have resources for.
As I understand it, those are not yet identified. Those are
simply targets given to you. I wont' ask you to write them as
arbitrary, but a number that you're supposed to get to.
Dr. Fleming. Our share of the amount is $27 million across
CDC and 125 FTEs.
Mr. Hoyer. And Jesse, that's referred to as business
strategy adjustment. Essentially what it means is, we've got X
number of dollars, we're going to effect savings, and you find
it in your budget. Most businesses do that, and I understand
that. But from our standpoint, the problem with that is, again,
it doesn't say, if we give you an objective, what it costs to
get that objective. It's an arbitrary savings.
Let me go to the continuation of my questions . I
understand somebody, Congressman Kennedy may have mentioned it,
but the National Center for Health Statistics, obviously
located in my district and therefore I have an interest in it,
but also I think critically important, because it is the agency
on which we rely to give us statistical framework within which
to make decisions, figure out what's going on. We reduced it by
$1 million. Now, is that a business strategy adjustment or is
that a judgment that has been made that we can save $1 million
because we found some better way of doing something?
Dr. Fleming. That's in the business strategy adjustment.
INFRASTRUCTURE
Mr. Hoyer. I would like, without going into detail on that,
when you answer my question on the overall CDC request, matter
of fact, I don't think I asked that. I'd like your overall
request for CDC, then the particular request for the
immunization.
By the way, when you talked about the children's, that
money does not provide for help with States' infrastructure,
does it?
Dr. Fleming. The children's--I'm sorry?
Mr. Hoyer. You referenced----
Dr. Fleming. No, that's money that goes directly to
purchase vaccine.
Mr. Hoyer. Right. So the infrastructure, which is part of
the problem, part of the challenge in getting immunization, the
State's infrastructure?
Dr. Fleming. That is correct. Now, just to be clear, the
other monies that go to the immunization program in fact do go
out to support State and local immunization programs.
Mr. Hoyer. I understand that. But my point is, you
referenced that in answer to the question, but those funds are,
we've got a freeze on the 631, they're not available for the
infrastructure.
Dr. Fleming. That's right.
CHRONIC DISEASE
Mr. Hoyer. If you could provide me with both the CDC, the
immunization and also for the health statistics fund.
Now, let me talk briefly, or ask you questions briefly
about chronic diseases. Essentially, Mr. Jackson has been
referring to that, and he's referring to it in the disparities
between the racial disparities and health consequences and
health research. Mr. Stokes, who was one of the finest members
that has ever served on this Committee and I in particular were
very concerned about the disparities at NIH, in terms of
cohorts, when we left our minorities and women. Jesse, in a lot
of instances, we had cohorts that we were doing research on
which did not include at least the percentages of women or
minorities that were necessary to get valid results for those
minority and women cohorts.
But chronic diseases. I want to focus on what you think CDC
is doing to ensure that we address chronic disease as
effectively as we can in light of the high proportion of
morbidity that relates to chronic diseases. In addition, if you
could reference obesity as it relates to the onset of so many
different chronic diseases, and what we're doing on that area.
If you travel in Europe, I presume you've been to Europe,
at conferences and things of that nature, the discrepancy
between obesity in the United States and in Europe is stark. I
don't have any study on that, there have been a lot of studies
on it, I know. But you just have to walk down the street and
see that to be the case. I'd appreciate your comment on that.
Dr. Fleming. Thank you. In this 2003 request, we're
requesting almost $700 million to effect chronic disease
control in this program. Chronic diseases account for about 75
percent of our $1 trillion national health care expenditure. So
in addition to it being a huge cause of illness and death, and
they are very expensive as well, and as all of us in this room
are getting older each day, those expenses are going to do
nothing but go up.
Mr. Hoyer. That's a vicious attack. [Laughter.]
Dr. Fleming. But you know, there's good news. Let me just
respond to that. With effective prevention programs, none of us
need to be looking at our old age as a place where we are going
to fall infirm and have many years of disability. In fact,
there are a number of studies that have shown that with
strategies that we already know and are already implementing
that we can significantly compress that window of morbidity
that maybe many of our parents have faced before they died.
That's a major goal of our chronic disease program. We
basically have two strategies. One is to directly attack the
diseases themselves, be it cancer, through our breast
andcervical cancer program, as an example, or diabetes, through the
programs I mentioned before, that are wonderfully effective, or heart
disease and the steps we can take there.
But in addition, we need to take a step back and look at,
what are the underlying risk factors that are present in us, in
this country, that we can influence so that people never get
that heart attack or that amputation from diabetes. So many of
our programs are also directed at issues like tobacco
reduction, improved nutrition, physical activity. The latter
two in particular are the strategies that relate to obesity.
You're right, we have an epidemic in this country.
I was just at a conference in Europe, however, that was
addressing this issue. And we are not alone. We're just leading
the charge here. The same transitions that have occurred in
this country with respect to obesity are now occurring in many
other parts of the world as well.
So programs that we're doing today to figure out how to
address this problem in this country will be programs that
we're going to need to do the technology transfer in the future
overseas. Having said that, we have pilot programs in a number
of States specifically targeting research and surveillance and
best practices to reduce obesity. There are proven programs out
there that represent a combination of improving diet and
nutrition, so people get the nutrition they need without the
calories, and increasing physical activity through school-based
programs, through urban design that makes it conducive for you
to go out and walk or ride your bike, through programs on the
work site and schools, that kind of thing.
Mr. Hoyer. Thank you. Thank you, Mr. Chairman.
Mr. Regula. Ms. DeLauro and Mr. Jackson would like to get
some----
Mr. Jackson. I don't have any more. I'll provide mine for
the record, Mr. Chairman.
Mr. Regula. Okay, Ms. DeLauro.
WISE WOMAN PROGRAM
Ms. DeLauro. Thank you, Mr. Chairman.
I just have really two questions. One has to do actually
with the breast and cervical cancer program and its extension,
if you will, to the Wise Woman program. Some women are very
interested in that. With that extension of Wise Woman is an
opportunity to look at a whole variety of other illnesses and
risk factors, if you will.
My understanding is that CDC currently funds ten ongoing
and two new Wise Woman projects in twelve States, tribes and
territories. How much would it take to fully fund the Wise
Woman program, so that all States and the women who live in
them will benefit? I have always been of the view that
geography shouldn't be the determinant of whether you live or
die, with some of these illnesses that they do uncover.
Dr. Fleming. The Wise Woman program, as you've said, is a
program that's designed to take advantage of the breast and
cervical cancer screening program, having women come into their
provider and then extending to them a range of other needed
health services that they need. And yes, there are 10 programs
currently where we are learning how best to do this.
In that context, they are almost demonstration projects. We
are right now, right now in the phase of evaluating how
effective those programs are and understanding the elements of
the program that would be amenable to a broader implementation.
So we will get back to you for the record on what that looks
like.
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Dr. Fleming. But it may in fact be, oh, six months to a
year's worth of additional evaluation of what's working and
what's not working with this program before we would be
prepared to say, here's the model that we think would be able
to be mass produced everywhere.
Ms. DeLauro. But it's six months to a year before you have
the information that you need to be able to make a----
Dr. Fleming. That's correct, yes.
BREAST AND CERVICAL CANCER PROGRAM
Ms. DeLauro. And the breast and cervical cancer program is
in every State?
Dr. Fleming. Yes, that is correct.
Ms. DeLauro. How long did it take us to get those programs
across the country?
Dr. Fleming. That was before my time at CDC, but I was in a
State at the time, and I think it was on the order of three to
five years, with the gradual implementation, each year, as you
remember, of the program into additional States.
Ms. DeLauro. What I'm saying is, I understand, my hope is
that we would, with understanding the success of the breast and
cervical cancer program in every single State, we've now just
expanded the capacity to deal with the cardiovascular and the
heart disease, high blood pressure, cholesterol efforts, it
would just seem to me, my hope is that we don't have to take
the same amount of time to do what we did.
We do have a model, it's working, we've added these
otherpieces. We ought to be able to pretty quickly tell whether or not
we're succeeding at this and be able to implement this statewide much
more quickly than we were as if this were just a brand new startup. It
is not a brand new startup, I think you would agree with me on that.
Dr. Fleming. Absolutely.
OVARIAN CANCER
Ms. DeLauro. So if there is something that we can do just
to make sure that we move more quickly on this follow-up. Thank
you.
And if I could just ask, on ovarian cancer, if you could
just tell me about the work that's being done through the
ovarian cancer control initiative, and where you go from here,
what kinds of additional funding do you need to help move this
effort. We don't have an effective screening tool yet.
I just left the Ag Committee where they talked about, the
FDA has talked about their work with NCI, and looking at new
potential tests and so forth and so on. So I just want to get a
sense of where you are.
Dr. Fleming. Sure. Well, as you've said, there is no
primary prevention strategy for ovarian cancer. So the
intervention rests on us identifying earlier women who have the
disease so they can be appropriately medically treated.
Currently, we have projects funded at about $4.6 million, and
they're designed to enable us to figure out how better to do
that targeting, by looking at the characteristics for example,
of women with ovarian cancer who've been diagnosed early and
diagnosed late, and say, what's the difference here? What was
the critical, in retrospect, element that allowed for that
early diagnosis?
Then second, working with, I believe it's Battelle,
conducting a study looking at, what are some of the best
practices out there for physicians? What kind of training is
needed to enable better diagnostic procedures, ultrasound,
pelvic exams, that kind of thing. Then third, we're working
with our cancer registry system to make sure that the
information that we have about ovarian cancer in individual
localities and the country as a whole is being made as quickly
and as easily accessible to the researchers who need to have
it.
Ms. DeLauro. Because the research is proceeding. There are
some very new discoveries, obviously, there's not any date
certain. But I had ovarian cancer 16 years ago, 16 years ago
this month I was diagnosed with ovarian cancer. But we still
have yet to find a screening for ovarian cancer. The research
is getting better and better and better. And what we need to do
is get the information to physicians, etc., and women about
what to look for. Maybe that's the new piece we can add on
these clinics that we're getting across the country.
Another piece, my point is, that that kind of public
education, so that those signs are looked at as quickly as
possible is critical to life and death, particularly with the
new developments. So again, what kind of additional funding do
you need for this effort?
Dr. Fleming. Thank you. I'd be happy to get back to you on
that.
Ms. DeLauro. Okay, please. Thank you.
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IMMUNIZATION INFRASTRUCTURE ISSUES
Mr. Regula. Just a couple of quick questions. To what
extent will the funding provided for State and local capacity
help with the immunization infrastructure issues?
Dr. Fleming. The bioterrorism dollars?
Mr. Regula. Yes.
Dr. Fleming. The dollars will not be used for directly
giving immunizations to children.
Mr. Regula. No, but it will create an infrastructure.
Dr. Fleming. Absolutely. The immunization program in every
State is only part of the health department and relies on that
health department for many of its critical, underlying
services, be it health communication or information technology
or connectivity. These dollars that are being used for
bioterrorism are designed to improve directly bioterrorism
capacity, but also those key underlying critical capacities to
make any health department effective. That will be the payoff.
Mr. Regula. Are State and local health departments getting
beefed up over the past months, working with CDC?
Dr. Fleming. Absolutely.
Mr. Regula. It seems like that was somewhat of a soft spot
in this whole thing, prior to 9/11.
Dr. Fleming. I agree. State and local health departments
responded wonderfully to 9/11 and to anthrax. But what we
learned is that what they had been saying all along is true,
that part of the problem here is just the inadequate
infrastructure and resources to do their job right. These
dollars that have already gone out to them and are in the 2003
budget are going to go a long way.
I can't tell you, Mr. Chairman, how excited State and local
health department directors are right now. It's fun to go out
now and visit.
Mr. Regula. They've been in the wilderness a long time, and
suddenly they're pleased that they're being recognized as an
important element.
Dr. Fleming. Exactly right.
ENVIRONMENTAL IMPACT ON HEALTH
Mr. Regula. I think it's vital we continue to strengthen
them. They're on the firing line.
One last one. Environmental impact on health. We had $17
million, I think. Are you working in that field?
Dr. Fleming. Yes. This is the program to improve, again,
State and local departments' ability to track environmental
figures.
Mr. Regula. Mr. Hoyer raised the question of asthma. That's
got to be an outgrowth of environmental impacts, am I correct?
Dr. Fleming. Right. One of the things that this $17 million
is going to go for is to say, okay, we know something about
where asthma is. But that information has never been linked
with where are the environmental problems in thecommunity----
Mr. Regula. Yes, where they go together.
Dr. Fleming. Exactly right.
Mr. Regula. Any last question?
Mr. Hoyer. Mr. Chairman, if I could, I know you want to get
them out of here----
Mr. Regula. You have two minutes.
CHRONIC DISEASE
Mr. Hoyer. In my two minutes, therefore, there has been in
the chronic disease, there's a $57 million cut, as I understand
it, in the chronic disease area. In Maryland, we don't have a
program for arthritis, we don't have one for cardiovascular
disease, nutrition, physical activity or school health. Maybe
others, but at least those, in terms of CDC's involvement.
Without a $350 million increase to the disease prevention
program at CDC, how will Maryland or other States that are not
included meet the demands of chronic disease? I will ask you to
submit for the record, along with the other issues, a detailed
breakdown of the cuts to these and all other chronic disease
programs that will result from the $57 million cut.
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Mr. Hoyer. If you want to have a general answer----
YOUTH MEDIA PROGRAM
Dr. Fleming. The $57 million is primarily for the youth
media program. So the funding for our programs in arthritis and
cancer, etc., are not being affected by that reduction.
But there is a mismatch, where there are proven strategies
out there that are not being implemented because the resources
aren't available.
Mr. Hoyer. Thank you. Thank you, Mr. Chairman.
Mr. Regula. Thank you. Doctor Fleming, you've done a nice
job this morning. You've had a lot of very useful information.
I wish we had more time. I'm pleased we had a good turnout of
members, given the fact that this is the first day of our
recess. And you remember from your school days what recesses
do. [Laughter.]
PUBLIC HEALTH
Mr. Hoyer. Mr. Chairman, I think it's a reflection, as you
well know, and I think you articulated in the beginning, I
think we dwell perhaps too much on the fact that September 11th
changed the world. I think that is correct, I think it did. But
in fact what it did was it focused us as well on doing some
things that we knew were important.
You referred to public health. I've met, as you have, I'm
sure, with my public health officials in the five counties that
I represent. And all of them were very frustrated that prior to
September 11th, a very important facet of our public health was
not focused on. September 11th brought a focus to it.
As a result, CDC's importance, I think, has also been
emphasized. What we need to do is make sure that it is
emphasized not only from the fact of bioterrorism or the
threats that that causes us, but really the much broader
threats caused to us by non-terrorist activity, but naturally
occurring activity, which when you talk about the millions of
people that are dying daily in the world, in Africa from AIDS,
you know, are really a much greater threat to mankind in the
long term.
The environmental, you mentioned environmental, in the
Baltimore area, asthma is becoming a much more critical problem
and much more higher incidence of asthma in our urban areas,
obviously tied to environmental effects.
Thank you, Mr. Chairman.
Mr. Regula. Thank you.
Thank you, Dr. Fleming. And give our best to Dr. Koplan,
tell him we missed him this morning, and we appreciate all the
good work he's done. As Mr. Hoyer pointed out, you've got a
well kept secret, not so secret any more. But little by little,
the public is getting a growing awareness of the importance of
this agency to their well being.
Thank you for coming. The subcommittee is adjourned.
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SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
WITNESSES
CHARLES G. CURIE, M.A., A.C.S.W., ADMINISTRATOR
RICHARD KOPANDA, EXECUTIVE OFFICER
KERRY WEEMS, ACTING DEPUTY ASSISTANT SECRETARY FOR BUDGET, OFFICE OF
THE ASSISTANT SECRETARY FOR BUDGET, TECHNOLOGY AND FINANCE
Opening Statement
Mr. Regula. We will get started.
Carrie, I understand you are going to introduce one of your
constituents. We know you are a very busy and influential
person.
Mrs. Meek. Thank you, Chairman Regula and members of the
subcommittee. Every once in awhile as a Congressperson we get
the unique opportunity to introduce some very outstanding
people to the committee. This is one such day. I am very
honored and proud to introduce to you, for her first appearance
before this subcommittee, a dear friend, a wonderful human
being, and a true champion for the elderly, Ms. Josefina
Carbonell, the Assistant Secretary for Aging in the Department
of Health and Human Services.
Ms. Josefina Carbonell has extensive experience in dealing
with issues of importance to the elderly community. As the
Executive Director and Co-founder of the Little Havana
Activities and Nutrition Centers of Dade County, she is one of
the persons, Mr. Chairman, who has been I think a tireless
worker and a pioneer in providing nutrition and social services
to south Florida's seniors, so she knows about what she speaks.
She is not all theory. She can bridge the gap between theory
and practice in providing health, nutrition and social services
to south Florida seniors.
Her leadership and solid management still has made possible
the diversification, development and transformation of the
Little Havana Activities and Nutrition Centers from one small
site in Dade County to the largest aging, health and nutrition
project in Florida, and the largest Hispanic geriatric health
and human service organization in the Nation.
I can't think of any better suited to be our Assistant
Secretary for Aging than Josefina Carbonell. Her experience as
a care provider and an advocate for seniors make her a
wonderful choice to lead the Administration on Aging and help
us tackle issues facing America's seniors.
I am very privileged and pleased, Mr. Chairman, to
introduce to the committee Josefina Carbonell.
Mr. Regula. You could not have a better endorsement from a
better person. We know that you are good. She is also a member
of the powerful Appropriations Committee.
Mr. Curie, you are the Administrator of Substance Abuse and
Mental Health Services Administration. I assume that you have
support here with the two other panel members.
Mr. Curie. Yes, I do, Mr. Chairman.
Mr. Regula. We are pleased to welcome you. Your testimony
and anything else that you would like will be put in the
record.
Mr. Curie. Mr. Chairman, and Members of the subcommittee, I
would like to take this opportunity to introduce Mr. Richard
Kopanda, SAMHSA's Executive Officer, and Mr. Kerry Weems, the
Acting Deputy Assistant Secretary for Budget in the Office of
the Secretary, Department of Health and Human Services.
I am honored to present the President's 2003 budget request
for the Substance Abuse and Mental Health Services
Administration. Overall, the President has proposed slightly
more than $3.2 billion for 2003, an increase of $57 million
over last year's appropriation.
In the short time since November that I have spent as
Administrator, I have had a chance to begin to learn about what
is happening inside SAMHSA, and its relationship with State and
local governments, consumers, families, service providers,
professional organizations, our colleagues in HHS, Education,
Justice, the Office of National Drug Control Policy, and
Congress.
I would like to take a moment to recognize some of the
leaders in the substance abuse and mental health services
fields that are in attendance today. I am going to read their
name and then the organization with which they are affiliated:
Ellen Garrison from the American Psychological Association;
Julio Abreu from the National Mental Health Association; Jay
Cutler from the American Psychiatric Association; Donald
Whitehead from the National Coalition for the Homeless; General
Arthur Dean and Sue Thau from the Community Anti-Drug
Coalitions of America; Jennifer Collier, who is representing
both the Legal Action Center and the State Association of
Addiction Services; Andrew Sperling with the National Alliance
for the Mentally Ill; Tom Bryant, National Association of
County Behavioral Health Directors; Karen Freeman-Wilson, the
National Association of Drug Court Professionals; Kathleen
Sheehan, the National Association of Psychiatric Health
Systems; Rob Morrison, National Association of State Alcohol
and Drug Abuse Directors; Andy Hyman, the National Association
of State Mental Health Program Directors; Sis Wenger, National
Association for Children of Alcoholics; John Avery, National
Association for Alcoholism and Drug Abuse Counselors; and Dr.
Monica Gourovitch, Distilled Spirits Council of the U.S.
I thank them for being here, and appreciate both their
support and yours for our budget proposal.
As you may know, most recently I served as Commissioner of
Mental Health and Deputy Secretary for Mental Health and
Substance Abuse in Pennsylvania during Governor Ridge's
administration. With that background, I have known SAMHSA from
the outside and from the State perspective. I have also worked
at the community level as the CEO and Director of a Community
Mental Health Center in Carlisle, Pennsylvania and the Sandusky
Valley Center in Tiffin, Ohio. Over the years I have seen many
examples of true partnerships between SAMHSA and its
constituent groups. In the short time I have been atSAMHSA, I
have found a staff dedicated to achieving the vision of providing
people of all ages with or at risk for addictive disease and/or mental
disorders the opportunity for recovery and a fulfilling life that
includes a job, a decent place to live, family support and meaningful
relationships.
Ours is a shared vision of hope and recovery, focused on
providing individuals an opportunity for meaningful life in
their community.
To provide a focus for SAMHSA's activities, on page 5 of
our chart book we have identified a matrix of investment
priorities and cross-cutting principles. The matrix is included
in your handouts, and it helps guide where we want to put our
efforts and resources.
You will see among our investment priorities the
administration's New Freedom Initiative. Its focus is on
providing community-based alternatives for people with mental
illnesses. It is central to SAMHSA's overall vision.
Also within the context of the New Freedom Initiative is
the forthcoming President's Mental Health Commission. The
Commission will develop an action plan for investing and
coordinating Federal, State and local resources to serve people
with serious mental illnesses and children with serious
emotional disturbances.
Another priority for change is eliminating the abuse of
seclusion and restraints. The use of these practices represents
a failure of our treatment system. The President has also
expressed his commitment to reducing drug use, building
treatment capacity and increasing access to services that
promote recovery and help people rebuild their lives. He has
proposed an increase of $127 million in our budget to help
States and local communities to provide increased access to
treatment services.
SAMHSA's National Household Survey on Drug Abuse found in
2000 that approximately 381,000 individuals recognized their
need for drug treatment. About 129,000 of these people reported
that they made an effort, but were unable to get treatment. We
are working with the Office of National Drug Control Policy and
the States to implement a plan to reach out and bring these
people into quality addiction treatment services.
Mr. Regula. Are you saying that there are communities that
do not have facilities?
Mr. Curie. Most communities do have facilities; the issue
is capacity and access. Since the survey was conducted, we have
been honing in on those areas and having States identify areas
where they are seeing lack of access. That is where we want to
direct a major portion of the $127 million.
Another priority includes working within the criminal
justice system. Too often jails and prisons are substituting
for community-based care for far too many people with mental
illnesses and drug problems.
Reentry and diversion programs need to encompass not only
treatment, but also housing, vocational and employment services
and long-term support. Only when we address the issues of
mental illness and addiction will the revolving door between
prisons and life in the community stop spinning.
Some of these very same issues explain why reducing
homelessness is on our list of priorities. We know that many of
the people who are homeless have mental or addictive disorders,
with similar needs for treatment and long-term support.
SAMHSA also has a critical leadership role to play in
addressing the needs of people with co-occurring disorders. A
large number of people who are in our substance abuse or mental
health service systems have co-occurring disorders. Too often
they get care for one disorder but do not get care for both.
That is not just bad health policy, it is bad economic policy.
We could serve more people if we spent that money more wisely
in the first place.
People with HIV/AIDS who abuse substances or live with
mental illness have another kind of co-occurring illness that
remains high on our list of priorities. Our efforts will
continue to grow in the area of HIV/AIDS.
Finally, the terrorist attacks of September 11 put a new
public spotlight on mental health and substance abuse. Within
24 hours both SAMHSA staff and $1 million in immediate
resources were on the way to the State of New York. Within a
week, an additional complement of personnel and an additional
$6.8 million was made available not just to New York but to the
other eight affected jurisdictions. Within a month, another
$21.2 million was awarded to these States.
At the direction of Secretary Thompson, within 2 months
SAMHSA convened a presummit meeting, enabling the nine most
directly affected jurisdictions to share and learn from their
experiences in terms of the mental health and substance abuse
consequences of the attacks. Within 8 weeks, SAMHSA convened a
national summit with representatives from 42 States, the
District of Columbia, five U.S. Territories, two Native
American tribes, and 100 national public service, faith and
community based organizations.
We convened this conference to examine and enhance the
local, State and Federal role in addressing the mental health
and substance abuse needs of individuals and communities
before, during and after acts and threats of terrorism. As a
result, State teams appointed by their respective governors are
refining their current disaster plans to ensure the readiness
of mental health and substance abuse services in their
communities for the ongoing war on terrorism and in the event
of future attacks on the homeland.
An additional $20 million was appropriated in 2002 to
address post-traumatic stress disorders in children. The
President's 2003 request continues SAMHSA's involvement by
proposing an additional $10 million for efforts that focus on
the mental health consequences of bioterrorism activities.
Other activities supported in the budget proposal focus on
post-traumatic stress disorders, the mental health needs of
first responders, and preparation for potential future
bioterrorism emergencies.
To ensure that all of SAMHSA's programs are science based,
results oriented and aligned with the agency's mission, we have
initiated a strategic planning process that will guide our
decisionmaking in planning, policy, communications, budget, and
programs. The process is evolving around three core themes:
accountability, capacity and effectiveness. In short, we are
calling it by its acronym, ACE.
Even before that plan is set in place, we have already
taken steps to expand our partnership with the National
Institutes of Health to produce a comprehensive science-to-
services agenda that is responsive to the needs of the services
field. We have initiated a dialogue with the Institutes, and
have found a common commitment to this agenda. Over the next
year, we will be working together to define and develop a
science to services cycle that reduces the time between the
discovery of an effective treatment or intervention and its
adoption in community-based care. The Institute of Medicine
tells us that that translation can take up to 20 years. With
the near doubling of the NIH budget driving even more clinical
research and development, that gap may grow still greater
unless a fundamental change occurs in how scientific advances
are incorporated into community care.
Mr. Chairman and members of the Subcommittee, our matrix of
program priorities and cross-cutting principles, our strategic
planning process and our commitment to speeding research
findings to community-based care will allow us to see real
progress in the outcomes we seek.
The ultimate measure of our effectiveness will be gauged on
our ability to provide people of all ages with mental and
addictive disorders an opportunity to realize the dream of
equal access to full participation in American society.
Thank you for the opportunity to appear today. I look
forward to learning more about your ideas about how SAMHSA can
achieve its potential, and to working with you during my tenure
as SAMHSA Administrator. I am pleased to answer any questions
you may have regarding our budget.
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SUBSTANCE ABUSE PROGRAMS
Mr. Regula. We will have a number of questions for the
record, of course. Your agency has identified a number of needs
and economic costs; and yet, and I am talking about substance
abuse, your budget is down $25 million. That does not seem to
square.
Mr. Curie. $25 million [clerk's note: later corrected to
$45 million] in the substance abuse area.
Mr. Regula. You reduced your prevention program by $45
million.
Mr. Curie. There is a $45 million reduction in the budget.
As I mentioned in the testimony, one of the basic premises in
this budget is to establish a clear science-to-services cycle.
We are a services administration, and over time SAMHSA has been
involved in research-oriented activities. It is important for
us to be engaging the NIH Institutes on an ongoing basis with
respect to their research agenda.
That reduction in the CSAP budget is related to identifying
best practices through a research modality. What we are looking
to do now is partner with NIH to ensure that the activity
continues within the Federal Government, and that those dollars
are not lost in terms of the overall research agenda. That is
why it is going to be very critical for us as we take a look at
our budget to ascertain that the dollars that we do have in the
CSAP budget continue to support direct services programming,
ensuring that prevention is available in the communities, and
then partner with the Institutes in order to establish their
role. We must work with our constituency groups as well as the
Institutes to define a services research agenda for both
prevention and treatment, and then define our role in
continuing pilot programs based on those research findings with
strong program evaluation components. As we move ahead, we will
utilize the $600 [clerk's note: later corrected to $500
million] million we still have in prevention with the block
grants and capacity expansion programs.
We have had some difficult choices to make in this
particular budget process. Again, we took a hard look at the
appropriate role we should be playing, a hard look at the role
the Institutes should be playing, and really do believe those
reductions are going to be made up in partnership with the
Institutes and not have an adverse impact on the overall level
of services.
Mr. Regula. Walk me through. Substance abuser A in
community X, how does your program reach this individual? What
is the procedure?
Mr. Curie. There are a variety of ways. Our responsibility
for ensuring that both prevention and treatment activities are
supported in the community is accomplished by partnering at the
Federal level with other departments as well as with the
States.
Mr. Regula. Once you partner, then what happens?
Mr. Curie. Then the States, using both block grants as well
as targeted capacity expansion grants, contract with and grant
or allocate dollars to local communities and service providers
to ensure that services are rendered. Where the partnership is
important is in coordinating all the dollars that are going
from the Federal Government in the area of prevention, and
treatment and ensuring that they are working in concert as they
support activities at the local level.
We need to be providing prevention services in conjunction
with schools and other institutions that exist within
communities, including faith based organizations, working with
organizations such as the Community Anti-Drug Coalition of
America that General Dean and Sue Thau are here representing.
We need to ensure that those ongoing partnerships exist and,
through the grant process and State planning, that our
resources are effectively reaching the communities.
Mr. Regula. How do they reach the individual?
Mr. Curie. Through community-based providers.
Mr. Regula. Such as?
Mr. Curie. Such as the drug and alcohol providers which
currently operate in most communities.
Mr. Regula. Are these nonprofits?
Mr. Curie. Many are nonprofit, and many are for profit.
They get funding through block grants, indirectly through the
States, primarily. On the substance abuse side, SAMHSA is a
primary source of State funding. In other words, most of the
funding that goes from SAMHSA to the States through the State
drug and alcohol authorities are combined with State dollars.
Mr. Regula. Do the States pay their fair share?
Mr. Curie. Yes. They have to maintain effort to meet their
block grant maintenance of effort requirement. If one looks at
Pennsylvania, from whence I came, the dollars that we used
included the block grant dollars through the Drug and Alcohol
Authority, Medicaid or medical assistance dollars, and also
State dollars. These were combined at the State level to
contract with providers through county systems of care and
community systems of care. You may have a variety of providers
supporting inpatient services, detox services, outpatient
services, prevention services provided in schools, and services
in other institutions in the community.
Mr. Regula. I know you are new on the job, but do you look
at these programs and say is there a real cost-benefit here?
Are we changing behavior in the U.S.A. because of what we do?
Mr. Curie. Yes. In fact, we have been able, over a period
of years, to define most of those factors and principles which
do make a difference in terms of preventing substance abuse, as
well as assuring positive treatment outcomes.
Mr. Regula. How do you translate that into an individual
who has a problem?
Mr. Curie. Again, the treatment needs to be individualized.
We rely on the expertise of the providers who receive funding.
We have also been able to isolate factors which contribute
to ensuring that children do not begin to take drugs, or
diminish their drug abuse once they are in treatment programs.
We have identified model programs of prevention which have
decreased substance abuse by as much as 25 percent.
Mr. Regula. You are saying in the United States it is down
25 percent?
Mr. Curie. Not overall, but those are programs that we have
been able to identify as highly effective. What we need to do,
Mr. Chairman, is to make sure that as we identify such model
programs--and we have identified 39 in the prevention arena
that have demonstrated outcomes of reduced substance abuse with
young people not initiating drug use in the first place--our
goal now becomes ensuring that those factors are at play and in
place within programs throughout the country.
Mr. Regula. Do you pass this information on through some
sort of a Web site or bulletin to agencies across the country?
Mr. Curie. Absolutely. We have a Web site that receives
thousands of hits on a daily basis. Also, we have an ongoing
dialogue with State drug and alcohol authorities, and State
mental health authorities to communicate to them the latest
findings.
Mr. Regula. Overall do you think we are making progress?
Mr. Curie. I think we are making progress in understanding
what works. Where we need to make continued progress is
applying what we know and realizing the restructuring benefits
in the service delivery system. Our biggest challenge at this
point is moving systems in the direction of implementing known
best practices.
Mr. Regula. Do you think you are going to meet that
challenge?
Mr. Curie. I think we are. We will be working in
partnership with ONDCP, and the only way we are going to meet
the challenge successfully is through that type of partnership.
I mentioned work with the Departments of Justice and Education,
our other Federal partners, whose cooperation is going to be
critical. They work with institutions which impact the lives of
virtually every American in some way. SAMHSA needs to be about
leveraging those relationships and partnerships.
Mr. Regula. Mr. Sherwood.
Mr. Sherwood. Thank you, Mr. Chairman.
It is good to see a fellow Pennsylvanian.
Mr. Curie. It is good to see you, Mr. Congressman.
DEMAND FOR SERVICES
Mr. Sherwood. As appropriators, we understand that
everybody who works in your field has superior expertise and
the best motives in the world, and we understand that there is
tremendous demand for your services, but I would like to follow
up on the chairman's question.
How do we measure that we are making progress? Other than
we are just trying to do good, how do you justify to us that we
are going in the right direction and we are making progress? In
other words, what figures do we use or what information do we
have to tell us that we are reducing demand and we are helping
the overall problem, because as we look at it from a
layperson's point of view, that does not seem evident.
Mr. Curie. Understood. I believe that is a responsibility
of SAMHSA to disseminate information about effective services
and quantify service improvement as best we can. It is very
important to assess outcomes. Again, that is part of our
strategic planning process. SAMHSA must focus not just on
ensuring that treatment is available, but ensuring that
treatment works and that it translates into the people in the
community breaking the cycle of addiction, and being able to
manage their mental illness.
As I mentioned earlier, we know more about what is working
now through a variety of programs we have had in place with
strong evaluative components. Within the last two weeks we
released a study of the high risk youth program conducted by
our Center for Substance Abuse Prevention. We found that there
were interventions which brought down drug use substantially.
If one compares the control group that was not involved in the
program with the group that was, after an 18-month period the
people who went through the program abused drugs 28 percent
less than the control group. We were able to isolate factors
regarding how to tie programs into families and strengthen
families, how to work with children and adolescents, how to be
involved with schools and institutions.
That is an example of a program that works, consistent with
the model programs that I mentioned earlier. SAMHSA's
responsibility is to examine what is working in particular
situations and begin to focus on those services as part of the
overall system of care.
We can assess overall progress through the National
Household Survey. We also have an early warning network through
emergency rooms, and we use these systems to assess overall
ongoing usage. On page 21 of the chart book is an example of an
impact that we have seen on marijuana use. We noted that the
mid to late 1990s, marijuana use among those in the 12 to 17
age group increased. We are beginning to see that come down
now, achieving specific goals that we have set in partnership
with ONDCP. It will be very important for us to ensure that we
are implementing effective programs and documenting what works.
The bottom line is that we know much more about what works
today. It is a matter of seeing that knowledge applied.
Expecting results from the delivery system is going to be a
major focus in the future. We owe it to you to be able to not
only demonstrate and implement programs which work, but also to
work with you to determine how SAMHSA can invest our existing
resources in those programs that are showing positive outcomes.
That is going to be a major planning priority for SAMHSA in the
coming year.
Another CSAP example, is in the workplace. We are seeing
appropriate drug and alcohol treatment interventions that, for
every dollar invested in treatment, prevention and Employee
Assistance Programs, have resulted in a $1.40 to $13 return on
investment. They result in lower medical bills and improved
productivity for the employers that we have studied over a
period of time.
That type of effectiveness will be important to document on
an ongoing basis as we work in partnership with the States and
providers to implement effective models and interventions.
HOMELESS PROGRAMS
Mr. Sherwood. Judge Barrasse from Lackawanna County has
just reiterated to me his serious concern with the lack of
available treatment programs for drug and alcohol. I think
probably the blight on the U.S. that it is so hard to
understand or explain is that we have probably the best economy
in the world, and yet so many homeless. I think there is a
great tie-in. How do you think we are doing there?
Mr. Curie. I think that is an excellent example. If we look
at a variety of programs that SAMHSA has implemented over the
years, we have been able to determine which programs are
effective in addressing homelessness, especially those
individuals with mental illness as well as addictive disease.
In the Center for Mental Health Services budget we have
requested over a 17 percent increase in PATH funding. This
program funds States to ensure that there are supports in place
to address the needs of homeless people. It not only provides
them a place to live, it helps them gain the skills that they
need to be part of the community.
The reason that funding for homeless programs is increasing
is because SAMHSA is achieving results from that funding, and
we want to continue to foster them. We are concerned about
homelessness in light of the fact that the economic times are
harder now. The Department has made homelessness a priority.
The Deputy Secretary, Claude Allen, is chairing a work group of
which SAMHSA is a very active participant. We are looking to
partner with the Centers for Disease Control and HRSA in this
regard. In fact, we just supported a summit in San Antonio a
month ago where SAMHSA brought those agencies together,
including their directors for HIV, to address the HIV problem.
We look to establish the same type of partnership in addressing
the homeless issue.
We are adding $22 million in 2003 for homelessness
programs. The same principles apply whether you are bringing
people out of institutions into the community, or bringing them
out of homelessness into participating in the community. We
need to not only focus on treatment and access to care, but
also examine the skills they need in terms of a job and the
skills they need to navigate in the community. Those supports
are very important.
Mr. Sherwood. Mr. Chairman, thank you.
POST-TRAUMATIC DISORDERS PROGRAM
Mr. Regula. Mr. Hoyer.
Mr. Hoyer. Mr. Curie, I serve on the Treasury-Postal
Subcommittee, which oversees ONDCP; and obviously for a decade
now, and General McCaffrey does not like to call it a war, so
whatever it is, an effort to prevent and cure is probably not
the proper word, but at least to wean off substances.
I have got some questions about traumatic abuse that I am
going to ask, but if I have time left, I want to get back to
that because it seems to me that your Department, working very
closely with ONDCP, is critical, both in your prevention and
education efforts.
Let me ask you about the National Child Traumatic Stress
Initiative, which you are familiar with.
Mr. Curie. Yes.
Mr. Hoyer. It is good Ms. DeLauro is here because we have
been working very hard on that. In the Children's Health Act in
2000 we authorized $50 million. We put $20 million in the bill
last year, and then we added $10 million to it in conference.
The chairman was very helpful.
First of all, you probably do not have it now, and it would
take longer than the 5 minutes I have, but Congresswoman
DeLauro and I would like a progress report as to where we are
in the expenditure of that money.
Mr. Curie. We can give you more specific information, but
we have made progress. The good news with these particular
dollars is that the Center for Mental Health Services has begun
setting up an actual networks around the country to make
resources available to States and localities to address trauma
in children. Obviously there are mental health consequences,
and that effort was underway even before September 11. That
puts us in a good position to address the new trauma associated
with the ongoing war on terrorism and the aftermath of the
attacks.
We are establishing that network and working with
universities across the country. We have received many
responses to our grant announcement, and are adding 25 projects
this year. So things are well underway. I can give you a more
in-depth progress report at a later time regarding where in the
country and how we see those post-traumatic stress projects
linking with State mental health authorities and local provider
networks.
POST TRAUMATIC STRESS DISORDERS FUNDING
Mr. Hoyer. I am pleased to hear that.
I was not pleased, however, that the $10 million that we
added in conference was not added to the base. So as I
understand it, we are back at the lower base. With respect to
the $10 million extra, will that be incorporated in these 25
projects? Or is that part of the $20 million?
Mr. Curie. We are looking at utilizing those dollars to
build further capacity through those networks. There is an
additional $10 million requested for bioterrorism, around which
we are building an agenda to address needs in our public mental
health and substance abuse system, but that is separate. In
fact, 5 of the 25 projects are proposed as 3-year awards. We
are going to be using that mechanism.
Mr. Hoyer. I am concerned about the 3-year awards because
it looks to me like we are stretching out the dollars because
we have frozen at the $20 million. In other words, the $10
million in the supplemental was not added to the base.
Now, it appears that you are stretching out the $10 million
to cover 3 years of grants, as opposed to $10 million per year
with the expectation that we put 10-10-10. Am I correct? Is
that what we have done?
Mr. Curie. Yes, that is correct.
Mr. Hoyer. I would presume that Congresswoman DeLauro and I
are going to try to work on that. I don't know whether you will
be allowed to answer this question. Was that what you requested
to the Department or OMB?
Mr. Curie. The budget process is a process that we all must
work through.
Mr. Hoyer. I know the process well.
Mr. Curie. We had some tough decisions to make in terms of
the budget priorities.
Mr. Hoyer. I understand that. My question is: Is what you
got what you requested either from the Secretary or from OMB?
Mr. Curie. Yes.
Mr. Hoyer. In other words, you did not in making your
request to the Secretary, and that which was relayed to OMB,
did not include the $10 million in the base?
Mr. Curie. Right. This was consistent with our request.
Mr. Hoyer. There seems to be some consternation on your
right. I speak not politically but geographically. You may not
be able to answer the question, but the answer ought to be
accurate. Let me tell you why. It is a difficult question for
people to answer working within the administration. I
understand OMB may have said we only have X dollars available.
As a program administrator, your shop may have concluded we
cannot spend the $10 million. There is a difference. One is
that the $10 million, if appropriated, could not be effectively
spent. The other is, we do not have the money so we cannot give
you the money.
That is why I asked that question, which I think is a fair
question for Members of Congress who have a responsibility for
appropriating the money to ask, so we have an understanding
what those who are on the front line and responsible for this
objective feel.
Mr. Curie. I understand, Mr. Congressman, and I definitely
appreciate your support and leadership in this area because it
is very important to the mental health of children. Trauma is a
very important issue that we are committed to addressing.
To answer your question, we did have some tough decisions
to make in terms of a tight budget year. We attempted to
stretch resources where we could yet still move ahead.
Obviously, in many situations if there were additional dollars,
we would be in a position to use them wisely and move ahead
with this type of agenda.
Mr. Hoyer. There is no doubt you would spend them wisely.
If the committee gave you $10 million for this program, and in
effect gave you the same level or higher, you have $30 million,
we are authorized at $50 million, you got $20 million from the
committee, $10 million in thesupplemental. The question is if
you got an additional $10 million, would that money be used effectively
in this program?
Mr. Curie. Yes, it would be used effectively.
Mr. Hoyer. I think that is the best I am going to get, and
I will take it.
Let me go back then to my last question, Mr. Chairman.
As you may know, the ONDCP has a number of HIDTA centers
around the country. We have spent over $200 million on these
centers. They serve a law enforcement coordination aspect.
There were five initial, and then the Baltimore-Washington was
added on as the sixth essentially at the beginning. There was a
unique status in the Baltimore-Washington HIDTA in that there
is a prevention component. The University of Maryland is tied
in with that prevention component. You have prevention as a
very important part of your aspects.
In your work with ONDCP, I would hope that you would stress
the importance of prevention. I do not want to say what the
Director believes or does not believe, but in the past the
prevention component was not a priority for him. My point being
every law enforcement official I have talked to, every medical
professional says if you do not invest significantly in
prevention, you will never have enough money on the law
enforcement or jail space, and you will never stop the demand
side. Therefore, the farmers of the world who are poor will
produce a product that they can sell high. That is just a fact
of life. Do you agree with that?
Mr. Curie. I think it is well stated, Congressman. I agree
that it is critical for SAMHSA, in partnership with ONDCP, to
ensure that prevention is a very important priority of the
demand reduction program of ONDCP. I have had some productive
meetings with Director Walters as well as with Dr. Barthwell,
who is Deputy Director for Demand Reduction, and I am confident
that we will be able to craft a strong prevention agenda
together.
Mr. Hoyer. Thank you.
POST-TRAUMATIC STRESS PROGRAM
Mr. Regula. Ms. DeLauro.
Ms. DeLauro. Thank you, Mr. Chairman.
I am sorry I missed the opening testimony.
If I might, let me just follow up on some of the questions
that my colleague from Maryland has posed. It is true that we
are very much interested in this area. We spent a lot of time
last year discussing the issue of post-traumatic stress in
children, and the incidence prior to September 11, and the
greater incidence after September 11. There are some pieces
here. Let me put this in a context, and maybe I am misreading
numbers.
I just find overall that the administration's mental health
budget as it relates to children, I find it troubling and let
me just tick off why. Take a look at children's mental health
program, no change. There is a $63,000 addition. For all
intents and purposes, it is level funded.
Child and adolescents PTSD, it is $20 million, although
basic understanding, the chairman, ranking member, Mr. Hoyer,
myself, I don't believe there was a committee member who was
not aware that we were talking about $30 million to be expended
this year. That was clear. I don't believe there was any
fudging, any confusion at all in that number. Now we are
looking at $20 million plus 10 over 3 years.
Youth violence prevention, no change.
Mental health block grant, no change. Again, that in and of
itself is very, very troubling to me about what direction we
are going in looking at one of the most serious problems that
this country faces. That is complicated as well by what is
happening in States. I will give you Connecticut, which has
cutback substantially on mental health programs, and
particularly as they relate to children, at a time when we are
seeing the need for increased assistance and treatment.
So we at the Federal level are compounding what is going on
in our States and leaving at the mercy of these illnesses
thousands and thousands and perhaps millions of children. In
terms of where our overall priorities lie, I think we are
failing with what we ought to be trying to do.
Now I want to go back to the post-traumatic stress program.
Your understanding as well as our understanding was that we
have a program that is authorized up to $50 million. We were
able to get $20 million. We got an additional $10 million from
the supplemental, but we were all on the same page, including
you at SAMHSA, that we were talking about $30 million to be
expended this year?
Mr. Curie. Speaking as the new Administrator, that was not
necessarily my understanding of the situation.
Mr. Kopanda. The emergency appropriation actually came to
SAMHSA and we became aware of it after we had submitted our
budget request to the Department and OBM. So in terms of the
answer to the former question, no, we did not request
continuation funds, but that was because that was not part of
our base at the time.
Ms. DeLauro. I would be happy to go back to all of my
colleagues, and the chairman and I spoke many times about this,
and the ranking member spoke many times about this, so there
shouldn't be any confusion about what the legislative intent
was in terms of the use of this funding.
What we ought to do is address that issue and make sure
that in fact we are spending those dollars this year so that in
fact we can build on a program that is authorized at up to $50
million for a very critical program.
Let me ask you a bunch of questions. $30 million, as a
result of that an increase if you had the $30 million, how many
more centers? You talked about the network that has been set up
around the country. That is about 18 centers, as I understand
it, at the moment. What can you do with the additional money?
How many more centers?
Mr. Curie. The average cost per center is between $300,000
and $400,000. With that average cost, you can get an idea what
the additional dollars would produce in additional centers.
Ms. DeLauro. Can you get back to us as to what the $30
million gets you in terms of additional centers?
Mr. Curie. We can do that.
[The information follows:]
Question. If you had the $30 million how many more centers?
You talked about the network that has been set up around the
country. That is about 18 centers, as I understand it, at the
moment. What can you do with the additional money? How many
centers? Can you get back to us as to what the $30 million gets
you in terms of the additional centers?
Answer. In FY 2001, SAMHSA established a network of 17
National Child Traumatic Stress Initiative (NCTSI) centers with
a primary responsibility for providing effective treatment and
service delivery approaches for child trauma in community and
speciality services settings and one National Center for Child
Traumatic Stress to provide national leadership and focus. With
$30 million, SAMHSA would be able to award approximately 18
additional NCTSI centers plus supplement 4-6 existing centers.
These funds would also support the continuation of 17 NCTSI
centers and the National Center for Child Traumatic Stress.
Ms. DeLauro. I want to know where they are now, where they
are located, what we can do, what your intent is, and where to
locate them.
I yield to the Chairman.
Mr. Regula. Is there any evidence as to what the success
rate is at the centers? Are they making a difference?
Ms. DeLauro. They are working, Mr. Chairman.
Mr. Curie. We do not yet have outcome data as we are now
establishing the centers. We just started awarding them in
September.
Ms. DeLauro. When will the new programs be notified of
their selection?
Mr. Curie. This month.
Ms. DeLauro. You know what those centers are?
Mr. Curie. Yes.
Ms. DeLauro. With your potentially doubling the number of
centers receiving the grants, what are the internal mechanisms
that you have to deal with in terms of your own resources and
personnel to administer these programs? Do you have adequate
personnel and resources to be able to administer?
Mr. Curie. We utilize both staff and contractual services
to ensure that these centers are set up and monitored on an
ongoing basis. That will be structured into the process.
Ms. DeLauro. And there is also a proposal that exists to
extend the authorization of the program for 2 additional years
to 2005. Do you support that effort?
Mr. Curie. Absolutely, in light of the current landscape.
From my perspective, seeing this was a program already under
development, we felt like we had a running start on addressing
the new type of trauma we must deal with. Obviously, there is a
lot of bad news in terms of trauma and the environment that
kids must cope with today.
The good news is that the vast majority of children in this
country are resilient and have good families that will help
them through this crisis. But we need to make sure that these
centers are established and the resources are available because
there are clearly vulnerable children who became more
vulnerable because of the events of September 11, and because
they must cope with ongoing trauma already in their lives.
Ms. DeLauro. The fact of the matter is that oftentimes with
this level of trauma, the symptoms of the trauma can show up
soon after the event, but the trauma may not show up until
months later, or maybe years.
With all due respect in terms of resilient families,
resilient families need access to resources to be able to help
youngsters who find themselves in real difficulty. We saw
tremendously outrageous numbers of children whose lives are
filled with violence, either experiencing violence themselves
or witnesses to violence, and this was long before September
10. That is why it was a good judgment in terms of people
trying to put this program together. They saw a need and
responded to it; and everybody responded after September 11 to
say we now have a much more serious problem here.
Let us appropriate 20 plus 10 so that we can really truly
make a difference in this effort by setting up more of these
centers around the country. I beg of you, please do not
shortchange these youngsters. I see a budget about mental
health that is so troubling with the scale of the problem that
we have today, that I don't believe as a Nation that we--we are
irresponsible if we do not do something about this issue. We
will fight for this $30 million this year.
Mr. Regula. Mr. Kennedy.
CHILDREN'S MENTAL HEALTH
Mr. Kennedy. Thank you, Mr. Chairman.
I think Congresswoman DeLauro hit many points that I also
want to make. I concur with her opinion, and with the ranking
member, Mr. Obey, who has made children's mental health a real
priority, and has worked diligently to ensure that it is
reflected in the budgets.
In that regard, we obviously need to do so much more than
we are doing. I had a meeting with the Business Education Round
Table, of RI, all senior executives of every major corporation
the other day, and to a person, all of them understood that our
special ed population is exploding in our schools because we
have not done enough to intervene early in children's lives to
ensure that we shape and mold them in a way that gives them a
positive trajectory.
I am working on this through the Department of Education
and Department of Justice with the title V funds and I like
programs like Safe Schools, Healthy Students which combine
funding from all of the various agencies. Unfortunately that is
being underfunded with certain agencies.
I want to emphasize what Ms. DeLauro is talking about and
the need to intervene early. Otherwise we pay for it through
the rest of our lives. To this point, we have a budget where
the administration has correctly requested almost $100 million
for children's mental health services because an estimated 21
percent of children in the U.S. have a diagnosable addictive
disorder, yet 66 percent of those with a diagnosable disorder
do not expect to receive mental health services. In short, the
government has made children's mental health a priority because
we recognize this as a vulnerable population in need of health.
The irony is that while children's mental health is
relatively underfunded our seniors are far worse off. And we
always talk about how kids are underrepresented in all of our
budgets because they do not have a voice, and seniors have more
of a voice, but it is not reflected in thesenior mental health
budget. Statistically 21 percent of children have diagnosable disorder,
and we have $100 billion for them, but we have over 26.4 percent of
seniors with mental health disorders, and only 3 percent get treatment,
leaving 97 percent untreated.
So 21 percent of children get $100 million and yet there is
26 percent of seniors, and they get $5 million. And the only $5
million they get is the $5 million that we worked in this
committee to put in last year.
I would just say, and I spoke to the Secretary about this,
we are going to have a baby boom generation that is going to
retire. We are going to bust the Medicare budget. We better be
smart about the way that we treat diseases, otherwise we are
going to pay for it through the back door.
SERVICES FOR THE ELDERLY
Over 70 percent of the Medicare admittances in emergency
rooms are drug and alcohol related for senior citizens, 70
percent because of the abuse of prescription drugs, we have a
big problem and we do not have any money for it. I think this
budget certainly does not reflect that we have got a growing
baby boom generation that is going to demand a lot of services.
I have spoken to you about this in my office and I know
that you appreciate this issue. I just want to say on the
record this is something that definitely needs more attention
and I hope you can comment about your feelings about the need
for more senior mental health treatment.
Mr. Curie. Mr. Kennedy, I appreciate your remarks and
observations. You have just described what I would consider an
historic issue regarding the public mental health system in the
country.
In my experience as Commissioner of Pennsylvania, if you
look at the priorities that State mental health authorities
have placed on core populations through the years, not
necessarily senior adults, or children with serious emotional
disturbances, I think what you are identifying is an existing
need which is only going to become greater. Clearly it is an
area that must be addressed as a major first step by not only
SAMHSA, but also by State mental health and local authorities.
We do have an aging workforce in the population. State
mental health authorities and local authorities must consider
how to work with the administration to not only address the
fact that people with serious mental illness are living longer,
but as people live longer more mental diseases evidence
themselves.
So we are now developing a plan with the Administration on
Aging to address this issue long term. We must engage the
public mental health system at the State and local level, where
the seniors are located. We have identified prevention efforts
and we are dedicating resources in prevention, not only in the
area of children but also in the area of seniors because of the
growing problem with abuse of prescription drugs and alcohol.
And as we know, our physical chemistry of us changes as we get
older.
In fact, we have examined recent reports from our Household
Survey identifying the substance abuse disorders in older
adults and treatment needs. This is another example where we
are more clearly identifying what the problem is. For years the
seniors' problems were not even recognized. Now we are
identifying what works. We need now to go about the process
that you are talking about, how do we integrate services as
part of a real system of accessible care. It is a clear
priority.
I appreciate the $5 million that this committee
appropriated for services for the elderly in the 2002 budget.
SAMHSA needs to partner with AOA, CMS, and all of the entities
that take care of our seniors. We need to leverage our
resources because we are actually a small player in terms of
funding, but we still can provide leadership and leveraging in
that area.
MENTAL HEALTH PARITY
Mr. Kennedy. I look forward to working with you in that
area. One way to pay attention to that area is to provide
parity in insurance coverage under Medicare. It is
discrimination. It is flat out discrimination. It is a
violation of people's civil rights, as I see it, because if you
have a mental disability you are discriminated against. If you
have cancer, you are not discriminated against, and God bless
it, I want to support funding for cancer. But we get nothing in
mental health. 50 percent co-pay for mental health, but that
does not hold true for all of the other physical ailments.
We have the World Health Organization, the Surgeon General,
everybody saying it is physiological. All of these smart people
coming up here know better, but yet our country's policy is
still in the dark ages. Can you comment on that?
Mr. Curie. I think you are reflecting what we are so far
learning from the data. We need to study the impact where
parity is in place. This has been a long standing debate,
whether to achieve parity for mental health coverage for
Medicare and in the private sector.
Mr. Kennedy. Secretary Thompson supported parity when he
was Governor of Wisconsin. How do you feel about it?
Mr. Curie. I think that the data are indicating to us, as
we look at preliminary findings and States that have passed
parity laws, that with a managed care overlay, you can actually
control the costs. We need to examine the outcomes in
situations where we have parity. Are people really gaining
access to care, and are people really being treated in ways
that we anticipated under the parity laws? We are in a
situation right now where we are able to get more data to
inform us of the decision. Federal employees are now under the
second year of their mental health parity plan. We should
examine the track record of Federal health care benefits, and
determine what are the real costs. We also need to look beyond
the cost, at whether people are really receiving quality
treatment. Are the earlier interventions with treatment and
diagnosis because people have access to care; are they helping
lighten the burden on the public system of care?
We have not had very complete information. Part of what we
need to do at SAMHSA is help complete that information and
continue to paint that picture.
Mr. Kennedy. I respect your answer. I think the
administration is very lucky to have you as Director of SAMHSA.
I think your hands are tied because the administration has not
chosen to step up to the plate yet. I hope that they do. They
have said enough about the NewFreedom Initiative, and the
President's father doing the Americans with Disabilities Act, and he
wants to be the one that follows through on that implementation.
If he wants to be the President that follows through on his
father's legacy, this is going to be the barrier he needs to
break. I know he has a commission that is studying mental
health. I hope that they come up with a recommendation that we
do go to parity.
The question should not be the cost. If the question is
cost, we should not have coverage for cancer, heart ailments.
We should not have insurance at all. Insurance costs money. So
let us block it out. If that is the reason we do not have it,
let's not have insurance. We should look at it on a basic
fundamental scientific level. Is it physical? Yes. Then it
deserves coverage.
If your company does not want to pay for it, then we have
the problem with insurance for all Americans. That is another
issue, but the premise is that we should not mix the two. We
should say we know it is physical. It needs to be covered. If
it costs money, let us go to the health insurance side and
worry about it on that side, end of story.
I appreciate your input, and I would certainly like to get
some more feedback from you as we move forward in this
Congress, and hopefully pass parity.
MENTAL HEALTH SERVICES
Mrs. Northup. Thank you, Mr. Chairman.
I think this is a good example of people who can look at
exactly the same facts, have the same wish for the same
outcomes, and come to different conclusions about how we best
get there. I, too, am very concerned about the issue of
treating mental illness. I would disagree that the place to
start fixing the problem is in the private insurance market,
but in the public insurance market, which is what you are
responsible for.
I think our public community mental health centers are a
failure. I can see the results of it in my district, and I see
the signs of it all across this country. When we decided to
deinstitutionalize people with mental illnesses, I think we
assumed that the community mental health centers would pick up
and provide for people the necessary opportunities for
interventions that would allow them to live more fully in their
communities.
What has happened is that as we increase the dollars, and
it is certainly not in your budget, but it is all of the
Medicaid billing that they are in charge of doing. I am sure
the committee knows that mental health centers are given the
responsibility and opportunity to draw down almost unlimited
Medicaid dollars for mental health benefits for people in this
community. They can contract out with different providers,
whether it is homeless centers or veterans organizations that
provide mental health services. And increasingly what I think
we see is that the community mental health services are
skimming off the top by servicing the easy-to-treat clients and
failing to address in a comprehensive way those that most need
the services.
So what we have are those that are more deeply affected,
those that are often pointed to in the course of this debate,
and I would like to work with my colleague because I think we
can profoundly change the opportunities that are available for
people that have the need for services both in the public and
the private sector.
But the people, especially in the public sector that are
the most profoundly afflicted, are the least likely to have
insurance. They are dependent on the public system. The problem
is if you have a stress class or a weight control class--which
our mental health centers are now conducting--those people tend
to show up at 1 p.m. every Wednesday. They are functional. They
may have some mental challenges. The homeless do not show up at
1 p.m. on Wednesday. The services that are delivered to them
need a profound level of care. You have to meet them where they
are. You have to provide the food and the shelter.
What we find is more and more of the homeless services that
really fall in the category of mental health are being asked to
be provided through HUD because Health and Human Services has
done just a disastrous job in providing services for these
people.
Primarily we see these centers contract with the homeless
centers for small amounts of billing opportunities to provide
for mental health services, and then they walk away from those
hard-to-treat services. We hardly have any outcry from the
homeless groups and the other groups that provide the best
services because they are afraid that the community mental
health service will cut them off entirely if they raise their
voice against the local community health services.
Do you have any comment or can you give me any reassurance
that things are going to get better?
Mr. Curie. You have described a scenario with which all of
us in the field are familiar. We have seen situations where
people who have been a core responsibility of the public mental
health system, with serious mental illness, would have lived
most of their life in an institution. You are right, many
lessons have been learned through the process of
deinstitutionalization. We have found that when people have
been outplaced into the community with only minimal treatment
support, they have inevitably failed, especially if the
responsibility was placed on that individual to keep seeking
care.
We now know that there are interventions and model programs
which actively reach out to such individuals and engage them in
treatment.
In Pennsylvania, my most recent experience, we had the
CHIPS program, Community Hospital Integration Projects Program.
I think Mr. Sherwood is familiar with that up in Lackawanna
County. It is very active; we created a video depicting the
successes out at Clark Summit State Hospital.
What we found was as we downsized State institutions,
public mental health systems needed to keep the money in the
system and transfer that money into community-based models. It
cannot be just given to an outpatient clinic, as you described,
but must provide those supports and services in the community
which bring people a life. This is consistent with the
President's New Freedom Initiative and will be an area of focus
for the President's Mental Health Commission.
The President's Mental Health Commission is going to
examine those interventions which have worked, rehabilitation
interventions, and interventions involving case management.
Community treatment models will be examined which have kept
people successfully living in the community.
Mrs. Northup. First of all, I don't think what works for
one person necessarily works for another. We need different
models.
Mental health centers are both the planning agency and the
delivery agency. And so what they tend to do is givethe harder
to deliver services to a nonprofit or under contract, and I might say
at minimal dollars. They give away minimal dollars and then they cherry
pick. They keep internally the services that are the easiest to
deliver. I think we know in many of our communities where the best
providers are. I think you have to hit the community health centers
over the head with a bat to free up the dollars so they go to the most
effective organizations, albeit they may look different and have
different models--just as we raise our children differently. Every one
of us are motivated by different things. They do not all have to look
alike, but we have to get the dollars away from the organizations that
are cherry picking and paying exorbitant salaries to the people that
work for them, while they are giving pennies to the organizations that
are having the biggest benefit.
Mr. Curie. I would agree that we need diverse providers,
that we need to work toward not just relying on one kind of
provider because many types of needs exist. We are working with
the State mental health authorities to develop performance
partnerships which will define improvement outcomes for
people's lives, not only to keep individuals out of the
hospital, but to provide them a healthy life in the community.
We have found if people get a job and a decent place to
live, have meaningful daily activity and maintain strong social
relationships, they do succeed in the community. That is what
our array of services needs to be doing.
Mrs. Northup. And the organizations that provide those are
getting pennies from our community mental health block grants.
Mr. Curie. The President's Mental Health Commission will be
looking at offset analysis. In other words, they will consider
what we know works, what are we now spending our money on now,
and how we can put our available resources into what works.
That offset analysis is going to be critical, I think, to
arrive at the very improvements that you are describing.
Mrs. Northup. If I can just follow up with one more
question.
Whether we are looking at the big system or whether we are
talking about family members of someone that is suffering,
generally that child of theirs or that family member does not
have coverage. We should talk about the sort of comprehensive
intervention that ought to be available. In my district, my
friends here might be shocked to know, our community mental
health services drew down $60 million last year. And the
homeless are not being served. None of that is equal to the
kind of services that HUD provides through their homeless
grants.
If this is not a waste of money and cannot be better spent,
to me, the whole system is broken. We ought to start there.
Quite honestly, you could probably give us better information
of how to get dollars, mental health dollars, to the harder-to-
treat community than any other group of people. It may not
always be as rewarding to service the hard-to-treat because it
can be two steps forward and a step back. Ask any of their
families, they will tell you.
Mr. Curie. What you just described is definitely a core
mission of SAMHSA in terms of address the hard-to-treat
population. In Pennsylvania I remember sitting down at what is
called a drop-in center, which is a consumer run service that
seems to work well for consumers and their families.
I asked the question around the table as I was sitting
there, they fixed breakfast for me that morning, I asked them
how many of them had been in a partial hospital or day
treatment program which for years had been funded in
Pennsylvania as really the only day treatment option.
One gentleman spoke up and said he was in a partial
hospital program for 16 years, and I looked at him. I asked him
how long he had been coming to the drop-in center, and he said
for 2 years, and it is the best 2 years he had ever had. He
does volunteer work, he has some part-time jobs, he is involved
in church. He is working with Goodwill. He has made friends. He
seemed genuinely content and proud. He said for the 16 years he
was in the partial hospital program, I asked him what did he
think of that experience. He said there are only so many ways
you can learn to brush your teeth over 16 years.
Mrs. Northup. I am not advocating going back to a hospital
model. I am just talking about shaking the dollars.
Mr. Curie. I think some of the resource investments give
people activity, but they are not bringing real improvements in
people's lives. I appreciate your support.
Mr. Regula. Was the $60 million you mentioned Federal
money?
Mrs. Northup. The majority of it is Medicaid dollars that
they bill for mental health. In every one of our areas is a
community mental health organization that has the billing
rights for all mental health services in Medicaid. They
basically allocate a particular nonprofit so many dollars but
they will be the only billing agent for mental health services.
Mr. Regula. Who delivers this service?
Mrs. Northup. In my district they keep internally the easy-
to-deliver services.
Mr. Regula. Your agency does not deliver these services?
Mr. Curie. The agencies you are describing may get some
funding through the State. You are correct in your assumption,
ours would be a very small amount because the mental health
block grants are small, as are the block grants to the homeless
groups and others. State and local organizations must
prioritize the most serious needs in the community.
Homelessness is always at the top, and they provide a few
dollars to the homeless organization to cover that
responsibility. Then they hire counselors on staff and bill
Medicaid for the easier to treat afflictions, where the people
are able to show up every Wednesday.
MENTAL HEALTH COMMISSION
Mr. Regula. Will the President's Commission address the
issues that have been raised by my colleagues?
Mr. Curie. The President and the Commission need to set
that full agenda; and I would anticipate so. My understanding
is that CMS will be engaged in the President's Commission, and
I think the types of issues that Mrs. Northup described clearly
are ones that will need to be addressed in the action plan that
the President is expecting. The Commission will identify what
is needed to make the public mental health system work,
especially for people with serious mental health illness.
Mr. Regula. This provoked a lot of discussion. But,
unfortunately, we have another panel and we have to move on.
PARITY IN BLOCK GRANT FUNDING
Ms. DeLauro. Mr. Chairman, one piece of this you can get
information to us on, my question is parity between the
substance abuse block grant and the mental health block grant.
The substance abuse block grant got a $60 million increase, a
request from the administration, and the mental health block
grant was flat funded. Quite honestly if you do that in terms
of the block grant program, you are going to see the States
that will lose funds under the administration's proposed freeze
are: Ohio, Pennsylvania, Kentucky, California, Wisconsin, and
Mississippi. It is a serious issue here. I don't know what your
view is on that.
And can you supply the subcommittee with the amount of
additional funding needed for the mental health block grant to
hold all States harmless?
Mr. Regula. Let us put all of these questions in the
record.
Ms. DeLauro. I want to know why we do not have parity
within the effort in terms of substance abuse and mental
health.
Mr. Curie. I will follow up.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Hoyer. Mr. Chairman, may I make an observation? This
document, page 13, I found to be interesting. It is the
projection of SAMHSA as to the cost of mental health substance
abuse, crime, criminal justice and premature death. The
interesting thing is that they project about a $310 billion
cost of all of these. We invest in SAMHSA to overcome this loss
of 1 percent.
Ted Agnew was elected governor the same year I was elected
to the State Senate in Maryland, 1966. I think it is
appropriate of that chart and our discussions. Ted Agnew said
in an excellent inaugural address, he said that ``The cost of
failure far exceeds the price of progress.'' That is what this
chart shows, and that is what this discussion is all about, and
I think it is what Mrs. Northup's discussion is all about. If
we effectively use dollars, we are going to save a lot of money
by investing in prevention as opposed to paying the price of
failure to prevent, failure to cure, failure to intervene.
Mr. Curie. Well stated.
Mr. Regula. Thank you for coming.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Wednesday, May 1, 2002.
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
WITNESSES
CAROLYN CLANCY, ACTING DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND
QUALITY
LISA SIMPSON, DEPUTY DIRECTOR, AHRQ
RITA KOCH, DIRECTOR, DIVISION OF FINANCIAL MANAGEMENT, OFFICE OF
MANAGEMENT, AHRQ
KERRY WEEMS, ACTING DEPUTY ASSISTANT SECRETARY, OFFICE OF BUDGET,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Regula. We'll get our second panel, Agency for
Healthcare Research and Quality. We're sorry we're holding you
up as much as we are, but this is important stuff.
Well, we'll get started here. Thank you for coming. I do
want to express the Committee's condolences on the passing of
Dr. Eisenberg, who was obviously a leader of great insight.
It's been a bit of a challenge for your agency to lose a leader
like that. Leaders make such a difference. But I'm sure that
you're all carrying on very effectively.
You have an important role to play, and so Dr. Clancy,
you're going to speak and then the others will add to it. Thank
you.
Opening Statement
Dr. Clancy. Thank you, Mr. Chairman.
I know I speak for all of my colleagues in saying that we
feel very fortunate to have worked with Dr. Eisenberg for the
past five years.
Mr. Chairman and members of the Committee, I'm pleased to
be able to be here today to present the President's fiscal year
2003 budget request for the Agency for Healthcare Research and
Quality, or AHRQ. With me today are Dr. Lisa Simpson, the
Deputy Director for the Agency, Rita Koch, who directs our
Division of Financial Management, and Kerry Weems, who's the
Acting Deputy Assistant Secretary of the Office of Budget, from
the Department of Health and Human Services.
AHRQ'S MISSION
AHRQ's mission is to conduct, support and disseminate
research to improve the quality of health care, reduce its
costs, improve patient safety, address medical errors, and
broaden access to essential medical services. A primary focus
of this mission is to ensure that the research we support is
translated into research that can improve people's lives.
This mission, to which the Committee has provided guidance,
is driven by the needs of the users of our research, patients,
doctors, nurses, health system leaders and policy makers.
IMPROVING HEALTH CARE
Let me be concrete and describe just some of the ways that
AHRQ is already improving health care. I see examples of this
in my own practice as a clinician and supervising medical
residents. When a patient with pneumonia is seen in our
practice, the resident goes immediately to their hand-held
computer and checks a tool from an AHRQ funded study that helps
them know which patients should be hospitalized.
But the impact of AHRQ's research goes beyond improving
care in our clinic to improving the Nation's health care. As
was just mentioned in the previous hearing, an AHRQ supported
study that was published today in the Journal of the American
Medical Association demonstrated that one can actually improve
the delivery of a drug called beta blockers to improve outcomes
for patients who are having coronary bypass surgery, a very
common procedure in this country.
Another example, AHRQ provides the Center for Medicare and
Medicaid Services with evidence-based information to inform
technical assessments for their coverage decision. Based on a
recent assessment that we supported, Medicare now covers the
treatment of actinic keratoses, a important precursor to skin
cancer.
In another study, an AHRQ-funded study found that many
breast fed non-white infants developed nutritional rickets, a
very rare bone disease that most doctors have never seen. The
results prompted the State of North Carolina to provide vitamin
D supplementation to all breast fed infants in the State
through WIC.
In yet another example, AHRQ's research has led to the
development of patient information materials on prostate cancer
screening that help men make informed decisions about
treatment. This information has been used widely to help
improve patients' understanding of the prostate specific
antigen test, or PSA.
Finally, another trial that was funded by AHRQ and HRSA
found that bag valve mask ventilation used by EMTs works as
well for young children who stop breathing as does putting a
tube down their throat, without the risk of subsequent injury.
As a result of this study, the L.A. County and Orange County
California medical systems have ordered all their paramedics to
begin using the less invasive technique, because it is just as
effective. In addition, the American Academy of Pediatrics has
modified its educational programs to encourage the use of the
bag valve masks.
AHRQ'S FY 2003 BUDGET REQUEST
I'd now like to present AHRQ's 2003 budget request. For
2003, we are requesting $252 million, which is a decrease of
$49 million, or a 16 percent decrease from fiscal year 2002.
The request will enable us to focus on four areas: patient
safety, development of ground breaking reports on quality and
disparities in health care, translating research into practice
and helping Americans make more informed decisions when
choosing a health plan.
INFORMED DECISIONMAKING
Mr. Regula. How do you help Americans to make more informed
decisions?
Dr. Clancy. We do that through research that actually
identifies their concerns, that also identifies the most
effective strategies for presenting the information in ways
that's comprehensible and relevant to them, and then by
evaluating whether or not in fact they're using that
information effectively.
Mr. Regula. How do you communicate that to them?
Dr. Clancy. A variety of tools. Most Americans are just as
diverse as the members of this body,members of any large
organization. Some patients want to get this information from the web
and they want graphs and charts and lots of details. Some patients want
a much more simplified paper version.
Mr. Regula. The web is a very important tool to you, I
would assume.
Dr. Clancy. Absolutely.
Mr. Regula. Both from the standpoint of the medical
profession as well as the public.
Dr. Clancy. Without question.
Mr. Regula. In fact, it is your tool.
Dr. Clancy. It is a very important part of what we do. But
we also need to recognize that some patients don't have access
or aren't yet computer literate. So we make sure that we
provide information for them that they can get as well. But
we'd be happy any time to show you some of these tools.
To focus on the four areas I just mentioned, we're going to
need to cut some of our existing programs. We estimate that
we're going to need to cut non-patient safety grants by 46
percent, and non-patient safety contracts by 31 percent. In
addition, we're not going to be able to fund any new grants not
in patient safety in 2003.
Our request also includes $10 million to cover the
continuing annual costs of the sample expansion of the
Department of Commerce's current population survey.
PATIENT SAFETY
The first area for AHRQ is patient safety. In 2003, AHRQ
will be able to contribute its ground breaking work on
improving patient safety and reducing medical errors. Very
early, AHRQ-sponsored research on medical errors and patient
safety laid the groundwork for current efforts to address this
critical health care problem. According to 1999 estimates from
the Institute of Medicine, medical errors in hospitals alone
claim between 44,000 and 98,000 lives every year.
In fiscal year 2001, for example, AHRQ funded research at
the University of California, San Francisco and Stanford which
outlined evidence for 79 patient safety practices. A number of
these are already being adopted by purchasers. In 2001, the
agency also funded $50 million worth of research in patient
safety that will yield evidence based practical tools and
strategies for settings as diverse as intensive care units,
community health centers, nursing homes and patients' homes.
The fiscal year 2003 budget request includes an increase of
$5 million, for a total of $60 million, for improving patient
safety. Our additional investment in 2003 will have two parts.
First, we'll implement local safety improvement priorities
through grants that will provide incentives to put systems
based interventions in place in health care organizations. As
you just acknowledged, Mr. Chairman, these grants will include
an emphasis on the use of technology and informatics.
As a physician, I trained in the era of index cards and
clipboards. The residents I train, as I mentioned a moment ago,
all use personal digital assistants.
Second, we will develop a program to train patient safety
experts who will enhance patient safety efforts in local
communities and organizations by providing technical
assistants. These experts would be something like the
Congressional fellows and scholars that your offices often
host. You benefit from their expertise during the time they
spend with you and your staff, and they leave behind knowledge
that you and your staff can use as needed. This program was
developed in specific response to the express needs of States.
NATIONAL REPORTS ON QUALITY AND DISPARITIES
The second area of our request will support the development
of two unprecedented reports on quality and disparities in
health care in the country that have been mandated by the
Congress. First, we will spend $53.3 million to support the
medical expenditure panel survey, or MEPS. This $4.8 million
increase from 2002 will allow us to survey more people and to
ask more in-depth questions about such issues as racial
disparities, chronic illness and quality of health care. One
million dollars of this increase will improve the information
available in insurance offering by employers and the cost to
them and their employees.
HEALTH CARE COST AND UTILIZATION PROJECT
Second, the 2003 request provides continuing support for
the health care cost and utilization project, or HCUP. This is
Federal-State-industry partnership to develop information used
by hospitals in States to compare quality of care in hospitals
and emergency rooms. HCUP will be funded at $4.1 million in
2003.
TRANSLATING RESEARCH INTO PRACTICE
The third area is translating research into practice. TRIP,
as we call it, is a very important step of AHRQ's research
focusing----
Mr. Regula. Research into all areas?
Dr. Clancy. We focus on translating evidence that we have
developed as well as developed by NIH and other agencies as
well. And it's focused on closing the gap between what's known
and what we actually do.
We know that all too often, patients receive care that is
not based on the latest scientific evidence. And we take the
challenge of promoting evidence-based practice very seriously
and believe that our work is not complete until the research we
sponsor is translated into improved health care. However, since
we don't regulate provider purchased health care, we don't have
these levers available to improve health care quality. So we
rely very critically on partnerships to achieve our goals.
For example, the article I mentioned a few minutes agothat
was published today was achieved because of a very important
partnership with the Society of Thoracic Surgeons. They collect data on
over half of the coronary artery bypass surgeries done in this country,
and they use that data to feed back information to their physicians, so
that they can improve the quality of care.
In 2003, we will fund translating research into practice at
$7 million.
CONSUMER ASSESSMENT OF HEALTH PLANS
The fourth area is to ensure that Americans have evidenced
based information to make health care decisions. In 2003, we
will continue to fully support the consumer assessment of
health plans, or CAHPs, as it's called. You or your staff may
have used CAHPs, a section of the Federal Employee Health
Benefits Program book to make choices about health plans.
In this year, we're going to move beyond simply reporting
differences in plans or giving patients report cards about that
to using that information to improve the quality of care that's
provided.
Mr. Chairman, I'd like to thank you and the Committee for
giving me the opportunity to present the President's budget
request of $252 million for AHRQ in 2003.
[The justification follows:]
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INFORMATICS
Mr. Regula. Dr. Simpson, did you want to make any comments?
Dr. Simpson. Thank you, Mr. Chairman.
I would just add that your question about informatics and
the web is really an exciting opportunity for the kind of work
that we sponsor. One of the programs, for example, is the
National Guideline Clearinghouse, which is a web-based tool
that provides information about clinical practice guidelines
for doctors, health plans. It's on the web so you can actually
look at it yourself, and is used very widely in this country,
over 94 million accesses.
It's a partnership, again, as Dr. Clancy said, with the
American Medical Association and the American Association of
Health Plans. That's a critical example, as well as the
consumer types of tools that we sponsor.
Mr. Regula. I am concerned about the half of the American
public that does not use the web. How do we get to them with
all these useful tools?
Dr. Clancy. It seems to me that there's two strategies that
we pursue. One is having paper based and other sorts of tools,
at least for people who can read. An area that we are growing
increasingly aware of is the problem with literacy in this
population, and one that is of deep concern to us.
A second strategy that has been used in some of our
projects has been to develop programs to make computers
available for populations that don't have them at home, for
example, through libraries or other community organizations.
That has been remarkably successful.
Mr. Regula. So you distribute to the public libraries, for
example?
Dr. Clancy. In some cases, investigators have been able to
get computer companies to donate them.
Mr. Regula. Mr. Istook.
HEALTH CARE COST
Mr. Istook. Thank you, Mr. Chairman.
Dr. Clancy, I appreciate your being here. Mr. Chairman,
this is one of the greatest areas that I have with the proposed
Administration budget. Dr. Clancy, I know, did not stress it,
but we have a major problem, because I believe the most
important work that this agency does is exactly the work that
OMB decided should be deleted from their budget. And that's the
research to help find more affordable ways for medicine to be
practiced, and to translate medical research developments into
action.
Their budget includes something like $83 million of cuts to
wipe out this entire effort. You may recall, Mr. Chairman, that
last year, I posed this question to Acting Director Kirschstein
of NIH and to HHS Secretary Tommy Thompson, about the need to
be having greater research into making health care affordable.
And they both said that was a very important initiative that we
should have underway.
We have double digit inflation in health care costs and
health care insurance, rising prescription drug costs, billions
of dollars going into research, to find more ways to provide
treatment. But it doesn't make it affordable. In fact, we had
the survey that was presented by Blue Cross last year that
showed, of the health care costs escalation, about a third of
it is attributable to being driven by new research that showed
new ways to do things and therefore, people wanted it to be
done, but it wasn't affordable.
I don't believe that they've sought to make it up any place
else in the budget, the effort to put significant resources
into making medicine that's practiced affordable. Not just
telling people, we're going to reduce your reimbursement rates,
not telling people we're just going to try to control
administrative overhead, but actually helping them find more
cost effective ways to treat people. Because it does no good to
have marvelous new research procedures of treating people if
those are not affordable, if you cannot translate it into
action.
And the Administration proposal, and I have some insight
into perhaps why it came about, but it's one of the most wrong
headed things I've seen. If anybody is here from OMB that is
the individual at OMB that was responsible for that, shame on
you. When health care costs are getting out of sight and we say
that the only agency, which is under-funded to begin with, that
is charged with trying to make health care affordable and
helping the health care community do it, and that's what we
wipe out of the budget, it's a pretty sad chapter.
Dr. Clancy, I won't ask you if you necessarily endorse
everything that I've said, that way I won't put you on the
spot. But my question, simply put, is where in the budget, if
it's not in your agency's budget, where in the budget are we
pursuing ways to make health care affordable, as Dr.
Kirschstein has said we need to be doing, and as Secretary
Thompson has said we need to be doing? Who's doing that?
Dr. Clancy. Let me just say, Mr. Istook, that a very
important part of our research portfolio in the past, and we
think a unique contribution that the agency can make, is in
complementing the work done by NIH and others in trying to make
sure that the return on investment for developing new treatment
or diagnostic interventions is achieved, by making sure that
those most likely to benefit receive the intervention, and
those who will not benefit or may even be harmed do not.
COST EFFECTIVENESS RESEARCH
Mr. Istook. That's the TRIP, the translating research
into----
Dr. Clancy. That's part of it. We also have a very specific
initiative focused on research on cost effectiveness. One area
where we've been able to make someinroads in there is looking
at the use of pharmaceuticals.
Mr. Istook. But Dr. Clancy, my question is, and I
understand you're Acting Director, and you're presenting the
budget that's been provided for you. My question is, if you are
not providing, if AHRQ is not providing the resources to
translate research into affordable patient care, is there any
place else in the Administration budget that we have resources
allocated for that mission?
Mr. Weems. Mr. Istook, AHRQ would be the main place where
that would occur.
Mr. Istook. So in other words, if we take it out of AHRQ,
it ain't going to happen, despite the need expressed by the
Director of NIH and by Secretary Thompson, certainly with which
I agree?
Mr. Weems. AHRQ is the place where that mission directly
happens. There are other places in HHS where one might see work
on that occurring. But AHRQ is the main place where that
happens, sir.
Mr. Istook. And that is what is de-funded under the
Administration's proposed budget, that particular portion, the
major portion of AHRQ's mission, that's what's being de-funded?
Dr. Clancy. Yes.
Mr. Istook. Okay. I appreciate that. I think the point is
made. Thank you, and I'll work to see that doesn't happen.
Thank you, Mr. Chairman.
FY 2003 REDUCTIONS TO EXISTING PROGRAMS
Mr. Regula. A couple of questions. You're going to have to
manage these severe cuts. Are you going to do it across the
board with your grants, or are you going to selectively look at
grants that have a higher or lower priority?
Dr. Clancy. That's a really good question, Mr. Regula, and
one that we're struggling with. We have not come up with a
final decision yet in terms of how we'll do it if this proposed
budget is enacted. We will be doing it based on broad
consultation with our advisory council, with our stakeholders
and the users of our research, and also following the principal
of maximizing return on Federal investment in the research
that's already been supported.
A little over half the grants that would need to be cut
under this budget have already been up and running for a couple
of years, and others are newer. So that's going to be the sense
of tradeoffs that we need to make.
Mr. Regula. So you'll have potential loss, because of lack
of continuity in your grants you will to some extent lose what
you've already invested?
Dr. Clancy. Yes.
RESEARCH RELATED TO NURSES
Mr. Regula. Well, if Mr. Istook prevails, it may not
happen.
But we are concerned, because it's an important function.
We've heard in our public witness testimony from nurses who
have stressed the importance of nurse working conditions on
patient safety. Have you done any studies and if so, what's the
result?
Dr. Clancy. Last year, we were given an very important
opportunity to invest in research related to working
conditions, much of which was focused around nursing issues.
There's a number of laws that you've heard about at State
levels, for example, that are looking at ratios of staffing,
how many nurses to patients and so forth.
These grants actually are a very important complement to
that approach by looking at how nurses are organized. For
example, does it make sense if you are taking care of patients
who are HIV positive to have them in a dedicated unit where the
nurses have a lot of expertise, or does it make more sense to
have them spread across different floors in a hospital? In the
case of that particular study, it turns out that the dedicated
AIDS units actually do make a lot of sense in terms of the cost
of care and patient outcomes.
So we've funded that kind of work. We've also conducted
some internal studies to show that staffing ratios are indeed
associated with avoidable errors, so the fewer nurses that are
available per patient, the more avoidable errors you see.
Mr. Regula. Last week we had a witness testify who works
with nurses who is a sociologist, and said that stress is a
factor in nurses leaving the profession, that the workload, the
stress of being put into very responsible decision making
processes, would that be your experience in the research you've
done, that stress is a significant factor? Because we are
losing a lot of individuals from the profession, and there's a
looming shortage.
Dr. Clancy. It's certainly been my personal experience as a
clinician, and it is something that we are also focusing on in
some of the studies in this program, as well as trying to
identify strategies to help people deal with that stress. If
you're stressed, for example, because you're worried about the
potential for errors, evidence-based information technology can
help reduce that chance of errors, and that's going to reduce
stress. But those are precisely the types of issues that we're
examining.
MALPRACTICE
Mr. Regula. You deal with what I guess would be malpractice
issues. How do you get those brought to your attention, that
there is a problem of faulty diagnosis or faulty practices? How
does that actually come to your attention?
Dr. Clancy. We don't deal directly with malpractice. We do
study factors that are associated with increased liability and
so forth. Interestingly, there's some overlap, but not as large
as you might think, between actually providing negligent care
and having a lawsuit. You would think that they would be one
and they same, they're not. Not all patients who receive poor
care sue.
Mr. Regula. But how do you learn about the negligent care
is really what I'm asking. Forgetting about malpractice.
Dr. Clancy. In one instance, we actually sponsored a study
where we looked at the relationship between physician-patient
communication patterns and malpractice. How we did that was to
work with a physician's malpractice insurer to identify
physicians who had two or more claims against them as opposed
to those who had had none. Then the investigator, with in the
physician and patient permission recorded the encounters in the
offices, and found that there were significant differences in
how physicians communicated with patients between physicians
who had been sued and those who had not.
Mr. Regula. And you share that information with the medical
community and hope that better communication will result in
better services?
Dr. Clancy. Yes. In fact, some health care systems have
made this a big priority. They've used the findings from this
study to develop their own programs and follow how their
clinicians do over time.
DEPARTMENT OF COMMERCE'S CURRENT POPULATION SURVEY
Mr. Regula. With your tight budget, why are you being asked
to contribute to the Department of Commerce's current
population survey, I think $10 million? It seems to me that
only exacerbates the problem you have on the shortfall.
Dr. Clancy. It makes $10 million less available for the
other research that we support, yes.
Mr. Regula. Why would your agency be even considered to be
involved?
Mr. Weems. Mr. Chairman, AHRQ participated in a couple of
the large surveys which have been mentioned before. They can
best help us frame the questions and analyze the information
that comes back as we work with the Department of Commerce and
the Census, too.
Mr. Regula. Commerce gets information flow that would be
useful in their studies?
Mr. Weems. Yes, and we're also going to ask them to augment
the questions that they ask to be able to provide the State
level data that we need.
Mr. Regula. Mr. Istook, do you have anything?
Mr. Istook. No further questions, thank you.
Mr. Regula. Well, thank you very much. We'll have questions
for the record to be submitted, and we'll certainly take a good
look at your budget and the importance that it has to the
delivery of medical services. And most importantly, to the
delivery of high quality services to the patients. I guess your
real mission is to ensure that the patient gets the best
possible care. Is that a fair statement?
Dr. Clancy. That's exactly right. And our mission is to
make sure that what works is what happens in health care.
Mr. Regula. That's a pretty big order.
Dr. Clancy. It is.
BIOTERRORISM
Mr. Regula. Okay, well, thank you for coming. We're sorry
we're short of time, but as you can understand from the
previous panel, bioterrorism is a high priority. I assume you
have some impact on our response to terrorism in your agency.
Dr. Clancy. Yes, actually in 2000 the Congress gave us $5
million to support research that would look at how the health
care system can be critically linked to the public health
infrastructure. For example, very recently, we now support a
web site where doctors and nurses can get continuing medical
education credits in return for learning about anthrax,
smallpox and other potential bioterrorist agents. That was just
expanded to expand the number of clinicians who can get that
kind of credit there.
We're also looking at strategies for trying to use, again,
information technology to identify outbreaks earlier and so
forth, and to enhance hospital preparedness, and are working
closely with our Department colleagues on a number of these
issues.
Mr. Regula. So you have a lot of cross-currents of
communications, NIH, CDC?
Dr. Clancy. Absolutely.
Mr. Regula. The military, all the players in the health
care delivery system.
Dr. Clancy. Yes. And as Mr. Allen mentioned in the prior
hearing, we also have the lead for the Department on something
called the Council on Private Sector Initiatives, where there
are representatives across the Department of Health and Human
Services from the Department of Defense, from the FBI, the
Office of Homeland Security, and the Office of Emergency
Preparedness, FEMA, excuse me, is what I meant to say, trying
to make sure that when private sector entrepreneurs or
companies have a good idea that they think might be helpful in
the fight against bioterrorism, that they are routed to the
right agency, so that we're aware of everything that's going on
in the private sector as we begin to get our arms around this
problem.
Mr. Regula. Well, thank you very much for coming.
Dr. Clancy. Thank you
Mr. Regula. The Committee is adjourned.
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Thursday, March 7, 2002.
HEALTH RESOURCES AND SERVICES ADMINISTRATION
WITNESSES
ELIZABETH JAMES DUKE, ADMINISTRATOR, HEALTH RESOURCES AND SERVICES
ADMINISTRATION, WILLIAM HOBSON, ACTING ASSOCIATE ADMINISTRATOR,
BUREAU OF PRIMARY HEALTH CARE
DR. PETER VAN DYCK, ASSOCIATE ADMINISTRATOR, MATERNAL AND CHILD HEALTH
BUREAU
DEBORAH M. PARHAM, ACTING ASSOCIATE ADMINISTRATOR, HIV/AIDS BUREAU
DR. SAM SHEKAR, ASSOCIATE ADMINISTRATOR, BUREAU OF HEALTH PROFESSIONS
JON NELSON, DIRECTOR, OFFICE OF SPECIAL PROGRAMS
WILLIAM R. BELDON, DIRECTOR, DIVISION OF DISCRETIONARY PROGRAMS, OFFICE
OF THE ASSISTANT SECRETARY, BUDGET, TECHNOLOGY AND FINANCE,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Regula. Well, I think we will get started. We are
scheduled at 9:45. We have a lot of material to cover today,
and we look forward to your testimony. Ms. Duke, I guess you
are going to lead off on behalf of your agency, and then I see
you are accompanied by a number of people. So if you would like
to summarize your testimony, it is an important agency, because
it really reaches out to the public and it impacts on them more
than some others. So we would be interested in what you have to
tell us. So welcome, and your full statement will be made part
of the record.
Ms. Duke. Thank you very much. We will submit that for the
record. The staff who accompany me this morning are actually in
the middle of the George Washington Parkway, and so two of them
are with me, Dr. Peter van Dyck on my right and Mr. Bill Beldon
from the department's budget office.
Mr. Regula. Well, we will give them a chance when they get
here. At least it is pleasant surrounds if they have to park
out there.
Ms. Duke. I am delighted to be here today to talk about the
HRSA 2003 budget. As you know, HRSA's programs reach into every
corner of America, providing foundation for the safety net of
health care services relied on by millions of our fellow
citizens. We deliver preventive and primary health care to the
needy, unemployed and underserved individuals and families. We
administer the Ryan White Care Act that gives low-income people
living with HIV/AIDS the care and medication they need to get
better and to stay well. We work with the States to ensure that
babies are born healthy and that pregnant women and their
children have access to health care. We help train physicians
and nurses to provide health care in our services that are
needed by everyone. We oversee the Nation's organ
transplantation and bone marrow systems.
Our telehealth program is a vital and growing part of
HRSA's approach to expanding access to health care. Secretary
Thompson and I have vowed to ensure that health--telehealth
consultation and distance learning are not just innovative
grant programs in their own right.
[The statement of Dr. Duke follows:]
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PUBLIC COMMUNICATION
Mr. Regula. I would like to ask you at this point, do you
get a lot of hits, as they say, in the parlance of the Web
sites? Are people using it?
Ms. Duke. People use our Web sites, and we do get--thank
you so much. It helps to turn on the mike. Yes, we do get a lot
of hits on our Web site, and we are in the process of
modernizing our Web site right now. And we are working on a
low-income portal to allow people not only to get to our Web
site, but to get to all services that are provided across
government. So we are doing a lot with our Web site.
Mr. Regula. What kind of information? I wake up in the
morning with an ache and a pain. Can I call them and say, this
is what is bothering me? What would you recommend?
Ms. Duke. You are not going to get medical care in the
direct sense, but you are going to get sites. For example, you
might get the numbers of people to call. For example, through
our Maternal and Child Health Bureau, we have worked with
Hispanic organizations to set up an 800 number that people can
call to get services provided by native speakers. So, for
example, you would be able to get to a doctor who would provide
certain kinds of services or could find those services in a
culturally competent way. So there is a lot on our Web site.
Our rules are on our Web site, and I could ask each of my
colleagues if you would like to sort of summarize some of the
things they have put on their Web sites, if you would like.
They have just emerged from the George Washington Parkway.
Mr. Regula. They look reasonably relaxed.
Ms. Duke. They do. They look pretty good.
Mr. Regula. Well, it seems to me--what was the name of the
group in Ohio that we gave? Net Wellness is an Ohio group that
you can call, and they have doctors who are on call that will
respond to questions.
Ms. Duke. That is right, or various ways to correspond with
them. I don't know if you are aware of this program, but it is
an innovative program started by the State, and we put some
funding in last year.
Right.
Mr. Regula. And I wondered if it was a parallel to what you
are doing.
Ms. Duke. With the program I have just referred to, the 800
number for Hispanic-speaking clients, if they call that 1-800
number, they will get to a central service that will provide
them a Spanish-speaking person who can direct them to the kind
of service they need. They can make the direct connect for
them. So that if a pregnant woman calls and wants services in
her own language, they can connect her with one of over 3,000
providers on that database--and we can get you where you need
to go.
Mr. Regula. How does the public become aware of this? It
seems to me it is a great service, but I dare say that----
Ms. Duke. That is one of the things----
Mr. Regula. A small percent of the public knows about.
Ms. Duke. We are working on that right now. Secretary
Thompson has a great concern to make sure that the public can
know how to get to us, and so what we are building is an HHS
portal that is an entry way to every service that HHS provides
in an integrated way.
Mr. Regula. So it would be one-stop shopping?
Ms. Duke. Yes. That is what is involved and actually HRSA's
IT shop has the lead for the development of that portal.
Mr. Regula. How soon will that be online?
Ms. Duke. Well, I think with Secretary Thompson, it
probably will be online very rapidly. Our aim is to have it up
this year, so they are starting that project right now.
Mr. Regula. Members ought to be made aware of this, because
you could stick a little squib in your newsletter saying, did
you know that you can get this service? And if they put that in
a newsletter, that eventually reaches pretty much the full
population, assuming a member puts it out. And that would be
one way to get it out, because there are so many resources in
this city that people just don't know about.
Ms. Duke. Absolutely.
Mr. Regula. And this would be a vital one for them.
Ms. Duke. Absolutely. And that was one of the concerns,
that we have this wonderful new technology, and to make it
serve people rather than having people have to figure out--the
issue is how to present your services in a way that addresses
why people call you rather than presenting the services in a
way that you are organized to do the work, and that has been a
major change over the last years.
Originally, these services were sort of built in terms of
this is the way we are organized to provide the service, but
that isn't the way people ask for services. So that is what we
are in the process of redoing, is getting it to be a user-
friendly approach that people can come in and simply link
through to the service they need.
Mr. Regula. Let us know when you have got that up and
running.
Ms. Duke. We will do.
Mr. Regula. Maybe I will send a dear colleague to my
colleagues advising them of this, and then they would have the
option of putting something in on a newsletter that could be
very useful to the public.
Ms. Duke. Great. We have a portal now, but it is simply not
what we want it to be. So I will let you know what our
timetable is and also let you know when we are ready to go.
Mr. Regula. Thank you. Sorry for interrupting.
TELEHEALTH
Ms. Duke. Oh, no. Not at all. I was telling you about our
telehealth program, that also does distance learning and
provides medical consultations for people in distant places,
and that is one of the services that now has a grant program,
which we will continue, to provide innovative services, but our
goal this year is to push telehealth availability into every
HRSA program so that we will use this technology to make our
services more accessible and to drive down costs.
HEALTH CENTERS
Mr. Regula. Well, now, you fund the community health
centers; correct?
Ms. Duke. Yes, we do.
Mr. Regula. Wouldn't it be very useful to them to have
this----
Ms. Duke. Absolutely.
Mr. Regula [continuing]. Access contact? How many of them
know about or use it?
LONG DISTANCE LEARNING
Ms. Duke. Some of them do. Actually this is one of those
things where we don't know all the answers, and lots of people
are ahead of us, in the sense that many of them have already
put together distance learning capacities.
Through the innovative program that the Congress has funded
for some years, we have put systems out there. And so States
have been using telehealth already. We have been using some
telehealth, but our goal is to put it in over program because
you are absolutely right. If a health center has access to a
telehealth consultation, when a case presents that is beyond
the immediate--of the folks involved, they could ask the best
specialists in the country to help.
SCHOOL PROGRAMS
Mr. Regula. Switching gears a little bit, many of the
schools are getting wired for this type of thing, long distance
learning. Would it be conceivable that you could offer a course
on good health practices and then a school could plug in, or in
Ohio, we have a central point where these programs come in, and
then schools can pull off of that net.
Ms. Duke. Yes.
Mr. Regula. I mean, it seems to me it would be an
enormously valuable education tool.
Ms. Duke. I think it is. Actually, last week I was meeting
with a group of State maternal and child health directors. One
of them was telling me about a situation where the school had
the equipment, but the school nurse saw a need and got the
maternal and child health director for the State to pull
together a group to use the school's equipment under the
leadership of the school nurse to provide services and
education on oral health. This is really an educational issue.
Teaching about oral health right there was just part of their
ordinary use of the school equipment.
But in addition, they were able then to take the same
equipment they were offering the educational program on, and
were able to set up consults with specialists who are miles and
miles away to save them the distance--you know, their travel
would have been 500 miles to get to the next closest
specialist. These consults were using the camera equipment that
was bought for the school system and were able to provide these
services. They have now set that up as a regular program. She
then was telling this to the other Directors as a way of
enhancing their capacity. So we try to take these good
practices and get them shared with other States.
Mr. Regula. It seems to me it would have a terrific
potential. You have CDC that is trying to teach young people
the dangers in smoking, and this would be a perfect tool,
better, I think, than a billboard.
Ms. Duke. Oh, absolutely.
Mr. Regula. Because you have got a captive audience in a
classroom situation.
Ms. Duke. Right. So we will try to work with more--and in
fact, as we are putting out our grant announcements for next
year, we use a one-time announcement, and it comes out in the
summer that announces all of the grant programs we are planning
for next year.
As we are putting that out, we are going to be telling our
grantees this year that we want them to tell us how telehealth
could increase access to education and to health care, as well
as how it could reduce costs in their grant proposals.
So we are really trying to mainstream this whole use of new
technology.
Mr. Regula. Well, I think it is a great idea and I think if
we can be helpful in any way, because the opportunity is in the
classroom.
Ms. Duke. It really is. It is there.
Mr. Regula. Well, thank you. Go ahead. I am sorry. I keep
interrupting you.
Ms. Duke. Oh, that is okay. This is a wonderful program,
and I am thrilled to have the opportunity to talk about it. I
really am.
HEALTH CENTERS
Some of the things that we know--that we do, you already
know about, but I think to summarize a few of them and to tell
you about what we think we would like to have for a funding for
them, we are asking for 6.1 billion for our programs for this
year. They will help to support the programs in our Bureau of
Primary Health Care, there are sort of the rock of the safety
net program that we had. We will be looking at the second year
of the President's initiative to expand the health center
network to 34--4,400 accesspoints over 5 years. We will move to
3,400 this year.
Many health centers are doing some very innovative things.
We are doing things like trying to control blood pressure by
working with population groups, by working with diabetes, by
working with community groups to try to manage the issue
around----
COLLABORATIVE PROGRAM
Mr. Regula. Okay. Now, if a community health center has an
innovative program that is working well for their clientele, do
they tell you about it?
Ms. Duke. Yes, sir.
Mr. Regula. And do you tell the rest of them about it?
Ms. Duke. That is one of the things we are trying to do. We
are trying to get more health centers to participate in--we
have a program called the Collaborative Program that works
with--well, and actually, we have a new one coming up on cancer
this year, so we actually do try to get that message out. We
have a diabetes collaborative that has been out for a while.
Mr. Regula. Through all the health centers?
Ms. Duke. We have over 300 involved, and we are trying to
get more involved.
Mr. Regula. Do you have a newsletter you send to them?
Ms. Duke. Let me ask Bill Hobson, who is sitting all the
way to my left. Do we have a newsletter that we send that tells
them of these good things we are doing in the collaboratives?
Mr. Hobson. Mr. Chairman, we don't have a newsletter per
se, but we have State associations of Health Centers in all 50
States that profile and promote best practices in their
newsletters. In addition we have training programs and guidance
documents that inform Health Centers on ways to improve. We
make sure that in all Health Center meetings, that we do
profiles of our collaborative program, and some of the benefits
that accrue, both to the health providers in terms of increased
efficiency in providing care, as well as improved outcomes to
the patient.
Mr. Regula. So you really share this good information?
Mr. Hobson. Absolutely, at every opportunity we do. We
consider it to be one of our more effective programs. We
consider it to be groundbreaking. Community health centers have
been noted to be national leaders in this area of improving the
way in which clinical services are provided.
Mr. Regula. Well, so much good gets done that doesn't get
disseminated.
Ms. Duke. That is one of the challenges that I think we
face is getting the good news out about what we can do, and a
lot of the good things that we can do we accomplish because we
are working with other people who share the goals but are
coming at those goals from different point of views and
different places in this very complex government, State
government, local government, faith-based groups.
We are trying to bring them all together to accomplish the
goals, not just talk about accomplishing them.
Mr. Regula. Right.
Ms. Duke. That is where we are.
You know about our health centers, and I can tell you share
the view that--about the good works they do. We are asking for
$114,400,000 additional dollars this year.
Mr. Regula. Saves the emergency rooms.
Ms. Duke. It does.
Mr. Regula. No question.
Ms. Duke. It drives down the cost of emergency rooms, and
it prevents chronic illnesses, and so we do a lot of work that
needs to be done there, and the thing is we need to reach out
and get more folks involved in that work.
Mr. Regula. I agree.
NATIONAL HEALTH SERVICE CORPS
Ms. Duke. We use--in the health centers, we use a lot of
our National Health Service Corps, which is part of the safety
net that has been around for over a quarter of a century, and
this year we are asking for an expansion of the National Health
Service Corps. We have asked for a $44 million increase in
order to allow the National Health Service Corps to grow as we
are growing the health centers so we will need more providers.
Mr. Regula. Are they volunteers?
Ms. Duke. No, they are not. What they are, they come in
sort of two parts. They are scholars for whom we provide
scholarships and loan repayors, until the sense that they are
folks who have completed their training and we engage them for
periods of either 2 or 3 years to work in high-need areas. And
that program produces 2,300 people in the field right now.
Mr. Regula. So they move on from this assignment to----
Ms. Duke. They could move on. I think the nicest part of
that is research we have done shows that we actually have a
retention rate that at the end of the 2 or 3-year assignments,
we have about 68 percent of them, at the end of 5 years, are
still serving in the needed areas, and even after 15 years we
have 52 percent of them still serving low-income populations.
Mr. Regula. That is remarkable.
Ms. Duke. So it is a wonderful story. So this is a very
important program, and it is one that we rely on for direct
health care services.
HEALTHY COMMUNITIES INNOVATION INITIATIVE
We have a very innovative program in our budget this year,
and that is the healthy communities innovation initiative and
this is a new interdisciplinary program--it is a demo program--
that is designed to address three of the most rapidly growing
diseases in the United States, and they are diabetes, asthma
and obesity. And the Secretary feels very passionately about
the need to engage in preventive health care here, because
these are very expensive killers, and weare determined to try
to do something about that.
Mr. Regula. This is where you can use your long distance
learning and your Web site.
Ms. Duke. You bet, absolutely. Because a lot of this is
education, it really boils down to what people can do for
themselves, how can they change their lifestyles, and if they
know the risks, then they have some incentive to make those
extra changes. We are going to try to learn a lot through these
demonstrations, learn what works and see if we can make a
difference. So that is a big program, with a request for $20
million.
SECURITY AND PREPAREDNESS
We are very much involved, as you know, in the security and
preparedness of our public health infrastructure as a result of
September 11th, and HRSA will be directing five programs in
that area. And the request is for $618 million.
Mr. Regula. Well, the Secretary yesterday talked about
making the public health system seamless.
Ms. Duke. Yes, he did.
Mr. Regula. For lack of a better term, where the State and
the locals are coordinated. We had a scare of meningitis up in
my area, maybe a year or so ago, and, you know, they weren't
sure who was in charge, the mayor, the township trustees or the
public health department, the city or the county, and everybody
got in the act and finally CDC came, and that kind of put a
relief valve out there.
But if I understood the Secretary correctly, you are trying
to get these seamless so that they are all working together. Is
that basically----
ONE DEPARTMENT
Ms. Duke. That is basically the idea. The idea is to have
them working seamlessly together and seamlessly we will work
with them, and so this is part of the Secretary's goal of
having one Department of Health and Human Services that works
seamlessly within and facilitates seamless services throughout
the system. And that is what we are trying to do in this
coordinated approach.
And, you know, this is a big project, and it is on a very
fast track, and so this is going to be a management challenge,
and I think we are up to it. But it is going to be a big
challenge.
EMERGENCY/HOSPITAL PREPAREDNESS
Mr. Regula. Do you get the hospitals involved?
Ms. Duke. Yes.
Mr. Regula. Because they tend to each go their own
direction.
Ms. Duke. Yes, we do. In fact, one of our programs is the
hospital preparedness program, and we will be working with CDC
and Office of Emergency Preparedness and HRSA to get the
hospitals involved to work through the State health
departments, the States are involved, and then we have steering
committees that are made up of all of the relevant stakeholders
so that everybody gets in on the takeoff and so that we are
pulling them together.
So, for example, the State Offices of Rural Health,
Emergency Preparedness, will all be sitting at the table as
this money is coming together and helping to develop the plan
that will become a State plan. And that committee structure
will continue and it won't just apply to HRSA's grants, but
rather to HRSA's grants and CDC's grants, so we are trying to
bring it together here and trying to bring it together in
States as well.
HOMELAND SECURITY
Mr. Regula. I assume that Governor Ridge's operation, if
they get it defined clearly, would be in part of this, homeland
security.
Ms. Duke. The Department works closely with homeland
security on this as well.
Mr. Regula. Well, I am going to be in a meeting with him
later on today. I will--anything I should be telling him?
Ms. Duke. Well, I think you can tell him that we are part
of his team.
Mr. Regula. I will.
Ms. Duke. Thanks.
ORGAN DONATION/TRANSPLANTATION
Another part of our program--and HRSA has a very diverse
mission and a very challenging mission, but we are also--we
also are involved in the organ transplant--donation and
transplant program, and this is something, as you know, the
Secretary feels passionately about, because every day there are
60 transplants, but every day, 10 to 15 people die because
there are not enough organs, and the Secretary very much wants
to increase donation in this country. And so we have a major
initiative to increase donation. He announced it last April
17th, and that program we have asked for a $5,000,000 increase.
Mr. Regula. I thought he made a great comment yesterday.
Your heart and your lungs don't need to go to heaven with you.
Ms. Duke. I think that he is absolutely right. You know,
you can do good even after.
NURSING SHORTAGE
Another part of our work has to do with providing health
care providers, and this is an area that we are particularly
concentrating on this year, is the nursing shortage. The
nursing shortage is real. We are all getting older, and nurses
are getting older, too, and retiring. And the pipeline bringing
folks in is not keeping pace.
Mr. Regula. I hate to keep interrupting you, but you keep
bringing up ideas here.
Ms. Duke. It is great.
Mr. Regula. The nursing shortage, I have a friend who is
head of the sociology department, and said that in her
particular school they work with the nurses because one of
theproblems is burnout, stress that is causing people to leave the
profession, because I guess they become the recipients of everybody's
burden. Is that a fair observation?
Ms. Duke. It is a very fair observation. It is a very
stressful work. I think the thing about it is that people go
into it because they love it, and they stay in it because they
love it. But at some point it becomes a threat to your health.
The hours are long. The working conditions are tough. The pay
is low. It is a very, very stressful career, but at the same
time people love it. And I think the thing that many of the
nursing groups are doing is trying to address the issue of
burnout, especially in those fields where you are dealing with
very tough situations day in and day out.
And so the professions have offered seminars on taking care
of yourself as a professional in order to allow people to
survive the stresses and to live full lives that allow them to
contribute still the next day.
Mr. Regula. Do the curricular offerings in the nursing
education field anticipate this? Do they prepare these
candidates up front for this kind of a challenge?
Ms. Duke. I don't know the answer to that, but perhaps Dr.
Shekar might know that. Does the curriculum provide that?
Mr. Shekar. Thank you, Dr. Duke. We have a number of
programs that look at issues to increase the value that nurses
feel being in the profession, such as career ladder programs.
In fact, we have somewhere in the range--the low 50 types of
programs that are scattered through our basic nurse education
program and our advanced nurse education program that allow
nurses to move up the ladder and have greater value and greater
training so they can do more with their nursing degree and
background.
Mr. Regula. So you warn them up front that this is not
going to be a day at the beach, being in the nursing
profession. They are going to be faced with stresses and here
is how you cope?
NURSE TRAINING PROGRAM
Mr. Shekar. It is really multidimensional, and also at
various stages of the training process, as Dr. Duke probably
expanded on, we have a program that we are even looking at,
students in junior high and high school, called kids in health
careers, and we are trying to get folks to think about nursing
and be prepared for what is involved with the nursing
profession, from junior high on.
Ms. Duke. And I know when my own daughter was in high
school and college, she did a lot of internships, so that she
actually was experiencing nursing from the point of view of the
professional nurse an had a mentor, and now as a nurse
practitioner, she now has nurses in training who come and work
with her and she provides mentoring for them.
I also know that in developing her own vision of a career,
she said to me early in her career, I am going to plan to do 3
to 4 years on the floor which is very intensive and I will be
very up to date on what is happening, and then I plan to do
some work in an outpatient clinic, and I will meet patients at
a different stage in the illness, and I think I need to pace
myself through a career.
So she got that from somebody and I am afraid she doesn't
get that from me because I am not a nurse and I don't know how
to counsel. But somebody helped her think through a strategy of
how she should train, but also a strategy for how she should
manage her career so that she could remain at optimum use to
the profession and to her patients.
Mr. Regula. Very interesting. Somebody gave her good
advice.
Ms. Duke. Sounds that way to me, yeah, or else she has good
common sense.
Mr. Regula. Well, they say the apple doesn't fall far from
the tree.
Ms. Duke. Thank you very much.
NURSING PROGRAM/NURSING EDUCATION LOAN REPAYMENT
We have in this budget increases for our nursing program.
We are asking for $99 million for our nursing program this
year, and the distribution will go $1 million toward advanced
nursing, and almost $5 million toward our Nurse Education Loan
Repayment Program, which is a marvelous program that we could
talk about at a later point if you wish.
ABSTINENCE EDUCATION
Another piece of our program has to do with dealing with
the issues of teen pregnancy and out-of-wedlock sexual
activity, and in our budget for the whole department, we have
$135,000,000 for abstinence only education activities.
$123,000,000 of that program is in the HRSA budget, which is an
increase of $33 million. And that will provide for community-
based and State-based programs.
Administratively, we have tried to tighten up our ship and
get as much productivity as we can, and we are supporting the
Secretary's goal of increasing the IT efficiency at the
Department. That is in our administrative budget.
BUDGET DECREASES
We have some major decreases in our budget in health
professions, education, in the Community Access Program, in the
State Planning Grant Program and Children's Hospital Graduate
Medical Education Program have the largest reductions. But
basically, our view of this budget is that it will allow us to
remain the anchor of the health care safety net. We have a lot
to do, and we think we are up to the challenge. And I am
available for questions, and my colleagues have arrived from
the Parkway.
Mr. Regula. Well, would they each like to comment, or would
you like to----
Ms. Duke. I would like to introduce them if I might.
Mr. Regula. Absolutely.
INTRODUCTION OF WITNESSES
Ms. Duke. On my right is Dr. Sam Shekar. He heads the
Health Professions Bureau. On his right is Dr. Peter van Dyck,
and he heads the Maternal and Child Health Bureau, and on his
right is Bill Beldon from the budget office of the Department.
On my left is Deborah Parham, and she is the acting head of our
HIV/AIDS Bureau; and on her left is Jon Nelson, and he heads
our Office of Special Programs that has the organ
transplantation and donation program in it. And on his left is
Bill Hobson, who is acting head of our Bureau of Primary Health
Care.
Mr. Regula. Well, maybe you can respond to questions as
they might involve your particular----
Ms. Duke. I will. I will refer them to them as well.
Mr. Regula. Sir, are you ready to go?
Mr. Miller. Thank you, Mr. Chairman. I am glad to see all
of you here today, and there are so many different programs you
cover, and it is exciting the stuff that we get involved in.
ORGAN DONATION/TRANSPLANTATION
Let me start off--when I first walked in--I am sorry I was
a few minutes late there, but you are talking organ donation,
and I mentioned yesterday that I personally experienced that
last October. Our daughter donated her liver to her son at
Mount Sinai, New York. So I spent a lot of time in the hospital
in New York City, too, during that period of time. And it was
very successful, and they are both doing well, but we are
fortunate for our son's sake that our daughter was able to step
forward. She is the mother of our only grandchild. So it was a
tough time.
So I obviously have a great deal of interest. There is a
Member of Congress who is a living donor--donated his liver in
Massachusetts just over a year ago that, you know, as Tommy
Thompson--they are heroes. So I want to help that area. I mean,
we never talked about it publicly much before the event,
because it was a very personal and private thing to us, but the
Sarasota paper wrote an article on Thanksgiving Day.
We agreed to tell people. Understand that you can make
donations, and it means the difference of a life. And so
whether you are a living donor--a liver transplant, you know,
is still a fairly rare thing, and there has been some problems
with it. You know, it is not like it is a common-type surgery,
like some others, kidneys and such.
So tell me more what you are doing and what can be done to
help make people aware of it, not just the one that you can't
take to heaven with you, but the living donor ones, too. But as
has been reported about some of the problems of living donors,
you know, do no harm, and if a living donor goes out and
doesn't survive, you have taken a healthy person's life away
from them. And so you have got to be cautious as you approach
this. I know the medical profession obviously is very concerned
about it.
So let me hear you talk a little bit about organ donations,
please.
LIVING DONOR
Ms. Duke. I will kick it off a little bit, and then I will
ask Jon Nelson to join in that discussion. Living donation is
actually the fastest growing area, and one which we expect to
continue to grow. We had about 5,000 living donors for kidneys
last year, and about 300 for liver donations. This is an area
of tremendous hope and potential. At the same time, it is one
that is not entered into lightly. We had a recent case in New
York where we lost the living donor, and that is a risk. And so
we are very concerned about informing the public about the
potential about the risks and ensuring that people to make
informed decisions. It is an area I think that we will see more
of, and I think over the next years, we will be seeing more in
donation cadaveric, as well as living donation. The paper this
morning has a story from Saudi Arabia on a uterus donation,
which was a first. So that was an amazing piece of surgery.
So it is an area of tremendous potential. In living donors
there is real risk, but there is real life-saving here, and so
I am going to ask Jon to talk a little bit more about the
living donor program, and then we can talk more about what we
are doing to try to get people to think about not going to
heaven with their organs.
Jon.
Mr. Nelson. Thank you, Dr. Duke. Obviously, the Secretary
is encouraged with your enthusiasm, and he shares that and has
since he was confirmed a year ago. Living donation, as Dr. Duke
said, is not a procedure without some risk. For that reason,
the Department has been cautious in its promotion and support
of living donation. In 2001, just last year, the number of
living donors probably exceeded the number of cadaveric donors.
So as Dr. Duke said, it is the area of most growth.
Notwithstanding that, the number of organs that you recover
from a living donor is limited to one. Whereas the number of
organs you recover from a cadaveric source are about 3.2
organs.
TRANSPLANTATION
So most of the transplants for some time will be from
cadaveric sources, and the Department's efforts and its
promotional activities to encourage donation to get those
people, the 50 percent of the people who when offered it, had
opportunity to donate, who choose to say no, to encourage them
that this is something that out of this extraordinarily
difficult time in their life that something good can come from
it, to encourage them to say yes.
That is the focus of our efforts. At the same time, on the
living donation side, we are working with the clinical
communities, the surgeons and the physicians who are intimately
involved with donation from people who are typically related to
the person who is on the waiting list to receive a transplant.
So that the people who are going to make the decision to donate
to a loved one do so in the most informed way as possible. It
is clearly a procedure that is not without some risk. To ensure
that the donors know what those risks are, are willing to take
it because they think that a greater good can derive from it.
Mr. Miller. Is it regulated at the Federal level?
Mr. Nelson. Transplantation as a medical procedure is
regulated locally through State--within the hospitals--within
the State Health Departments, and regulated also through
medical associates. Our involvement is mostly for operating the
transplant system, the organ procurement and transplantation
system, which is the real-time matching system between donors
and recipients so that when someone dies in Florida, the most
suitable recipients are quickly identified, and that process
occurs as quickly as possible so that those organs are shipped
and transplanted and the people can survive.
Mr. Miller. There is an article--I studied this last year,
obviously, and there is an article about--I think it was a New
England Journal article, I am guessing in May,about the growth
and the number of institutions offering liver transplants growing
faster than the standards, because there hasn't been that much done,
maybe 2,000 of them.
So it is not like it is a very common surgery, and all of a
sudden, dozens and dozens of liver transplant programs were
popping up all over the United States, and there is a growing
demand, and it is going to be growing, especially with the hep
C concern in this country and the number of people, the demand
is going to be far greater than the supply, and so that is the
reason--but you are saying that, for example, if--as these
hospitals keep popping up, even though there is no--I guess
generally--what is it, the medical term, standards of--yeah,
how you do that. There was a concern about that. I don't know
where that stands.
Mr. Nelson. Well, there are over 700 transplant programs in
the United States. Many of those transplant programs will occur
within the same transplant hospital in a transplant center so
that a particular hospital could have a kidney program, a
kidney pancreas program, a liver program, as well as heart and
lung programs. There are real advantages to that, as well as
some disadvantages, as you are clearly aware. The advantages
are that people don't have to travel far from their families
and support systems, who are so important in this process for
receiving a transplant. These are very, very difficult
procedures regardless. They are not--never really entirely
routine.
We encourage in a variety of ways, and I mentioned working
with the clinical societies for establishing standards and also
our contractor, UNOS, and the OPTN, to have the standards,
protocols for transplant as well, and to ensure that there are
standards of practice and training requirements for all
transplant professionals, as well as the hospitals which
provide really the infrastructure for those procedures.
Mr. Miller. What is the most common? Is that kidney?
Mr. Nelson. Yes.
Mr. Miller. And what is next?
Mr. Nelson. Probably liver would be soon after that, and
livers actually travel better than--almost as good as kidneys.
So livers can--it is called ischemic time, from the time it is
clamped and no longer has a blood supply, to the time it is
unclamped and in its new person, can be 12, 14 hours. Kidneys
can survive 24 hours, so they really are much more mobile.
Mr. Miller. What is the ratio of cadaveric versus living
donors?
Equal numbers?
Mr. Nelson. In 2001, there were about 6,000 living donors
and also the same number of cadaveric donors. In 2002, if you
look at the trends, it will be substantially more living
donors.
Ms. Duke. But the issue is that with the cadaveric, you
have the possibility of about three times as many transplants,
because there are more organs.
Mr. Miller. How many organs--you know, how many different
transplants are possible from one cadaver?
Mr. Nelson. Of solid organs, about 3 to 3.2, but typically
there are many other life-saving procedures that derive, their
tissues, their eyes. There are a lot of others with the consent
of the family that can with be life-saving, as much as the
solid organ transplants.
Mr. Miller. Well, we felt very good about the experience,
and thank God it is behind us. I tried to donate and I went
through the testing. And in the very end, I did not. But they
sure did not want a 59-year-old applying. They sure told me up
front. They said you would be the oldest. But I did learn some
more about hospitals because we were in the hospital for a
while there, and I was very pleased with everything.
So at any rate, it was interesting being around nurses for
2 weeks. I think our son was in for 2\1/2\ weeks. You found
some outstanding ones, and you really admire them working on a
Saturday night, a Friday night and the shift changes. I am just
amazed how many have been there 25 years. They are fortunate at
this particular location--I think they are geographically
located convenient to the housing, a lot of the people, too. I
think they could get there easily. That was important. But I
have been concerned--in my area of Sarasota, Florida--am I
taking up too much time?
Mr. Regula. All you want.
Mr. Miller. Lots of senior citizens. Health care is
probably my biggest industry because of all my seniors. I have
got as many seniors as anybody in the Nation, as far as
Congressional district, and so there is a real challenge of
staffing, and it is not just the nurse practitioners which are
there, but it is the nursing assistants. How do we generate the
numbers with all the nursing homes? And nursing homes are 365
days a year, 24 hours a day, and I know the legislature
recently passed, well, we are going to toughen up the standards
and raise the standards.
Well, that is great, but you better find people to work.
Whereas some industries have been able to utilize more of the
immigrant population, when health care you have got to be able
to communicate, and that is a challenge.
So I think we did put language in the bill last year to try
to encourage that. I know we helped States to try to come up.
Talk a little bit more about what can we do--I mean, not just
the anesthesiology nurse, but the one that is working on the--
--
BASIC NURSING
Ms. Duke. Basic nursing?
Mr. Miller. Right.
Ms. Duke. One of the things we are trying to do is to get
more folks into the pipeline into health professions in
general, but into nursing in particular. Just last week, the
Secretary launched a program called Kids Into Health Careers,
and we launched it at a local junior high school, and one of
our messages here is that there are 270 health professions.
Nursing has within it so many subspecialties and so many
opportunities to serve, that we really want to get kids
interested earlier so we can begin to build that pipeline.
Some other things that we have done is we have provided
programs, working with universities, medical schools, area--
health education centers, to help prepare students for the
curriculum that they are going to need to have in order to
train for those professions. So we do some programs, summer
camps, for example, to help kids get more proficient in
science, to help kids master the necessary math skills so that
we are reaching out to try to do two things, to get them
interested and then get them to the basic prerequisites to be
able to participate in the training for the program.
The other thing we are trying to do is to reach into the
support areas of nurse's aides and so forth to try to offer
them the opportunity to have formal training to move into
nursing as a profession, and so we actually have a full step-
by-step bringing people in at the associate level, bringing
them in at the bachelors level, and then the possibility of--
the possibility of going on from there.
NURSING EDUCATION LOAN REPAYMENT PROGRAM
Mr. Miller. Scholarship money fairly, rarely available? I
sense it is. So if somebody wants to become a nurse, they can
find some scholarship, whether--in my case, at a community
college or something, to be able to work--get--I mean, whether
it is the Federal level--I am not just talking about the Pell
grants or the other, but is it----
Ms. Duke. There are a variety of opportunities in nursing.
One of the programs that we have that I am just tickled with
and we have expanded it over the last year, is the National
Nurse Education Loan Repayment Program, which is a program that
allows us--for agreement for the nurse to serve in an
underserved area, we will pay back part of her education loan
for 2 years, and then if the nurse is willing, we will extend
it for a third year.
Last year we had a basic appropriation of about $2 million,
and the Secretary in looking at this same problem said to me,
if I gave you $5 million, could you do something? And you know
the Secretary. You say, yes, sir. And I said, yes, sir, we
could. And we--what we did with that money is for our money
last year, we were able to provide 1,032 nursing years of
service by reaching out to nurses and getting them into the
field.
You know, we have about 500,000 nurses who are trained as
nurses but aren't working as nurses, so we are trying to reach
out and use these as incentives to get people to be involved in
nursing, to go where we need them to be in nursing homes, into
rural areas where we need health care providers.
So using this Nurse Education Loan Repayment Program has
helped people look at the possibility that they are not going
to be in debt for the rest of their lives, and that they can be
in areas to really provide service.
NATIONAL HEALTH SERVICE CORPS
In addition, we have opportunities for advanced nurses in
our National Health Service Corps. We have scholarships there.
The Education Department has nursing scholarships, and some of
the States have scholarships as well. So, I think the main
thing is getting across to the perspective student that--and
this is what I said to the junior high folks last week, is that
we can help you. We can help you find the support you need to
get the prerequisites educationally, and we can help you find
the money. So you are not out there alone. There is a big
infrastructure of people who want to help.
Mr. Miller. And the pay scale is getting up now that it
is--you know, it is like pharmacists are making--coming out of
school, you make a pretty good salary as a pharmacist, and I
think nursing is getting up there.
Ms. Duke. Nursing salaries have improved. It is still one
of the areas that nurses cite when they cite for reasons why
they left the profession, and we have tried to study that
500,000, to understand what they are doing. Many of them have
left because there are greater opportunities for nurses--women
today, and some of--and the profession is still largely women
have simply taken higher paying jobs, but the salaries have
improved. So the loan repayment possibility is an attractive
feature.
Mr. Miller. Well, then, I have another line of questioning
here, unless you want to go and we alternate?
Mr. Peterson. Go ahead.
Mr. Miller. This is another issue about the HIV issue, and
you all do have Ryan White. You don't do the housing here? You
don't have the housing monies. How much is Ryan White, and how
much is----
Ms. Duke. Ryan White is a billion nine, and Deborah Parham,
who heads our HIV/AIDS Bureau, could talk a little bit about
the housing program.
Mr. Miller. How much is housing, do you know? That is in
HUD, I--yeah----
Ms. Duke. It is a HUD issue, and Deborah says that this is
not one we feel qualified to talk about.
RYAN WHITE
Mr. Miller. One of the things when you have large Federal
programs--and I am supportive of Ryan White and the concerns.
We saw this in the National Endowment for Arts, all of a sudden
you get some scandal that is blown out of proportion. I have
seen it in agency after agency, and I don't know--I did see
something about, you know, some problems with Ryan White, how
some monies are being used. And the last thing we want to do is
undermine a program over some, you know, thousand dollar or
$10,000 money. You know, it has happened to agency after
agency. Talk about the controls and how you can--and some of
this--and it may not be all factual, but I am just--you may be
aware of more of them than myself. How do we control or keep
that from happening? I think you may need a microphone for this
lady here.
Ms. Duke. I will hand it to Deborah in a moment. The HIV/
AIDS program has been reviewed by the Inspector General and by
the GAO on several--I think 16 different occasions, and
basically we are doing a pretty good job of policing that
program overall, and it is a large program at a billion nine.
But there are situations that happen, and that is part of our
stewardship responsibility. And we have several programs that
we are working on to try to ensure accountability for the funds
we hand out. I am in the process now of establishing an
integrity unit within my office to ensure that we have a
regular review of our grantees around the quality of their
clinical services but also the quality of their stewardship of
the public's money, and we have otherrequirements, regular
reporting and relationships. We have biweekly phone calls with our
grantees. So we have a relationship with our grantees, but then our
grantees have subgrantees, and that is when it gets more difficult. But
I will ask Deborah to comment further on those works. Deborah.
Ms. Parham. Thank you. Like you, we are very concerned when
we hear that there is money that is being spent not as it was
intended, and like Dr. Duke said, we do have some controls in
place. One thing about the Ryan White Care Act is that a lot of
the money goes to the cities and to the States, and then they
are responsible for monitoring the subgrantees. So what we do
at the Federal level is give them technical assistance on how
they can do that, and how they can improve their monitoring
systems.
For those programs that we directly fund, it is much easier
for us. We can go out and provide on-site technical assistance
to them in the clinical, administrative, fiscal and MIS areas
and we do that. So, yes, there are programs that you hear about
in the news. The one thing that I think that is not said in the
news as much is that where we do find that there is fraud and
abuse, those people are tried, and there are sanctions. Some of
them are in jail now. So the system is working in terms of
finding where those places--where the money has been spent
inappropriately we are able to address those issues.
Mr. Miller. Well, the $1.9 billion program is a lot of
money, and I understand now, you know, a lot of it is, in
effect, block granted to the communities, and then it goes to
the next level, and all of a sudden you have got some dumb use
of the money that embarrasses the whole program, and that is
how programs I have seen get weakened up here is when some
subcontractor--you know, I will use the National Endowment for
the Arts as another illustration. It goes to the museum and
then a museum grants it to the artist, and before you know it,
you have got something that is really dumb, and why are we
doing that, and everybody agrees that it shouldn't have
happened.
So the controls need to be as tight as they can, because
otherwise it has the potential of undermining the program, and
I am supportive of the program, so I wish you well on that.
Ms. Parham. One other thing that I just want to add is
that, as Dr. Duke said, we do have the Inspector General who is
looking at programs right now, and one of the things that they
are going to do is to look and see what we are doing at the
Federal level, as well as what the grantees are doing to
monitor their subgrantees and give us feedback in terms of ways
that they think we can improve the monitoring.
Mr. Miller. Citizens Against Government Waste Organization,
which is a fiscally conservative group, and it lists all these
illustrations of how money is not well spent. So you need to
watch that. So thank you very much. And Peterson, we need to
figure out the vote situation.
RURAL HEALTH
Mr. Peterson. Well, you can come back for another round,
too. Just to follow up on the educational issue, my health care
provider--I serve a very large rural district in northern
Pennsylvania. Providers there are as concerned about employee
availability as they are reimbursements, and that is a big
concern is reimbursements have always been a problem in rural
areas. Has there been any thought of combining with the health
care professions collectively? I scold them all the time that
they don't sell well.
In years gone by, going to health care was where you
could--if you had good health care skills, you could get a job
anywhere in America, no matter where you or your mate went,
there were usually jobs available, and that is still true
today. And the need of health care is going to grow a lot
because of our aging population, especially in rural areas that
I serve. So has there been any thought of having that kind of a
promotion to young people and to maybe people who are going to
be retrained? Health care is a field where, you know, you can
go anywhere in America and get a job. I mean, this is job
security. If there is one field that has job security, I would
say it is health care, but yet I don't see that message out
there.
Ms. Duke. That was one of the messages. The Secretary
talked to the young people about when we launched kids into
health careers last week. He said to them, if you are looking
at having the possibility for mobility, this is a career choice
that offers you that option. So it is one of the themes that we
do strike in our messages out from the Department. I am not
sure that the individual professional groups make that a part
of their campaigns, but I meet with them regularly, and I will
raise that with them at the next meeting.
Mr. Peterson. It would seem like a few Federal dollars
combined with industry dollars could really get the message out
there. We could be sort of the glue that ties them all
together.
In rural areas the technicians are a huge problem,
recruiting docks is always a problem and adequate nurses is
always a problem, but now it is the technicians and the problem
is in a lot of areas within 100 miles--or 200 miles, we don't
have anybody teaching technicians. Do you deal with that issue
at all, trying to get institutions and hospitals to join
together and offer the programs that are necessary in the
hospital setting?
Ms. Duke. We are aware that the--that in the 270 health
professions that make up health care for this Nation, that we
have sub fields that are not plentifully filled, and
technicians are definitely one of the areas. That is one of the
things we have--in the package for kids into health
professions, we actually have a section on lab techs, so that
we are trying to teach young people that health professions are
more than doctors and nurses.
We have documented the shortage of pharmacists, for
example, and making students aware that they too could be a
pharmacist, and that doesn't mean that you necessarily would
practice in the local drugstore. You might be practicing in a
major medical center, or you might be practicing in a rural
health clinic. But that pharmacy is another profession. So we
are trying to get people to look at more than just entry into
the doctor and nurse corps, but rather into the broader
profession.
And we do meet with the associations regularly about how we
can do more linking together to make more out of what we have,
and that is where, again, telehealth is anotherpossibility
where tests can be done in one site, processed in another and results
sent back, so that it is another opportunity for us to help in areas
where having a full cadre of appropriate health professions isn't
there. So this is one of those things where I think telehealth that we
talked about a little earlier this morning is going to make some real
improvements for folks.
NURSING WORKFORCE
Mr. Peterson. Back to the nursing issue, I have seen
where--you know, I think the move towards predominantly
bachelor degree nurses is part of our nursing problem, because
they have a lot of other options. I am not against the
bachelors degree, but they have a lot of other options, and ask
the nurses who can get an 8-to-5 job, doing quality assurance
and all kinds of jobs, and they are not going to nurse on the
schedules that nurses work if they can get an 8-to-5 job and
make as much or more money.
So I don't think you are going to recruit them back, in my
view. But I have seen people enter the field as a nurse
assistant and they were good, and then they go and they become
an LVN, and they were good, appeared then as they get their
children raised and they go and become a nurse.
Ms. Duke. Absolutely.
Mr. Peterson. Not a bachelor degree nurse but an----
Ms. Duke. An associate. Yeah.
Mr. Peterson. And I think that is the track, and I don't
think those are very likely to leave nursing. They are not
going to have the job opportunities doing things that bachelor
degree nurses do. I think that is the problem--that is part of
the problem I think. Bachelor degree nurses, I have two young
ladies who came out of their--their families were in
accounting. Well, they have realized now one more year of
schooling, they can be a CPA, and they said if we are just
going to do paperwork as a floor nurse, we are going to be
CPAs. And they are both going to night school, and are going to
leave nursing, and that is a tragedy to the health care field.
Ms. Duke. This is one of the problems I cited a little
earlier is that there are more career opportunities. Nursing is
still largely a woman's profession. And as more professions
have become available for women, particularly higher paying and
one of the pieces of the working conditions that you have
pointed to is hours, that people have moved out of health
professions in general and in nursing in particular. But I
think that the--there is a continuum of services in nursing,
and that is one of the attractions I think of the field. There
is a continuum. That we need people in all of those levels, and
one of the reasons we do need bachelor nurses is that at the
bachelor's level, they are able to deal with the complexity of
this modern medical system, where a shot isn't a shot and a
test isn't a test. There is a very complex set of tests and a
very complex set of options. So we need associate nurses, and
that is the fastest growing section of our nursing population.
Mr. Peterson. I am going to have to ask you to sit tight
for a few minutes. I have got to run and vote. I am down to the
end, and as soon as somebody runs, we will resume the hearing.
So this hearing is in recess till we get back.
[Recess.]
Mr. Miller. If we could have everyone take their chairs, we
will begin.
As you know, there was a vote that took place, and that is
one reason I got up and left early. A lot of times one will
leave early, cast their vote. We don't expect a second vote,
and then come right back and continue the hearing, because it
happens--you know, yesterday was--Mr. Thompson was here, and
yesterday at the same time Mr. Powell was here. You just have
to interrupt the--the director of the FBI was delayed. So
unfortunately you don't control that.
COMMUNITY HEALTH CENTERS
But I have a couple more questions. The community health
centers, rural health, is that under your----
Ms. Duke. Yes, community health centers.
Mr. Miller. We have an outstanding one in my area, and
there has been a really outstanding director that runs the--I
just use the material rural health. But they have expanded it
in a lot of different areas, and it has been a great asset to
my community. Describe that for me for a minute. Who would--how
is that----
Ms. Duke. That Community Health Center Program?
Mr. Miller. Uh-huh.
Ms. Duke. I will kick that off, and then I will turn to
Bill Hobson, who is the acting bureau head for that program.
The community health center program is sort of the bedrock
of our safety net program. There are about 730 grantees in this
program. They are community-led health care providers. They are
all across the country. About 47 percent of them are rural.
They provide a variety of services, and they have been the
linchpin for health care in the area, often serving as the base
for a network of integrating services within the community
working with hospitals and other providers to make sure that we
have networks of services. And that is one of the things that
we have tried to foster through our work is networking of our
services.
I will turn to Bill Hobson to talk a little bit more about
that health center program.
Mr. Miller. I have two major communities in my area, and
one has an outstanding one with a diverse group of programs and
really nice facilities, as nice as you want, high quality
doctors, and the other one doesn't do that much, and I am not
exactly sure. Is it--I don't want to criticize them toomuch,
but there is quite a contrast. But go ahead.
Mr. Hobson. Sure. We have a wide variety of programs within
the community and migrant health centers and the other-
consolidated health centers that we fund under this national
initiative. We have some programs that have been in operation
for a longer period of time, have a more secure funding base,
have more well-developed service systems and possibly have a
better facility. Other programs, because of some of the
particulars of the neighborhoods that they serve, don't have as
many other resources beyond the Federal grants to take
advantage of or because they haven't benefitted from some of
the very best leadership, aren't as developed. We have a wide
range of programs, given those factors.
However, we insist that all these programs really meet
minimum standards with respect to the quality of care that they
deliver. We do on-site reviews averaging every 3 years
including reviews that focus on clinical services, financial
management, administration and governance, and we leave each
one of those programs that we do a site visit on with a list of
things that they need to improve.
So we feel pretty comfortable that most of the centers
clinical care programs, are very strong. That is not to say
that we don't have a lot to do in terms of bringing all of our
facilities up to speed and fully developing all of our programs
around the country. Approximately 51 percent of the grants that
we have right now are in rural communities. In other words, the
service areas that they have self described to us are for rural
communities. Approximately 47 percent of the users that we see,
and that is of the 9,600,000 users in the program, are seen in
our rural programs as well.
Mr. Miller. Is that funded separately from urban or inner
city type health programs?
Mr. Hobson. No. Basically they are funded under the same
authority. If you look at the consolidated health centers,
there are several components. We have a community health center
program, and under the community health center program, the
sites can be both in urban and rural areas. We have a migrant
health center program, where all of the sites are almost
exclusively in rural areas. We also have a primary care public
housing program that focuses on direct service delivery in
public housing units. We have a very small school health
services program, and we have additional services that are
available to the homeless population, our health care for the
homeless program that was started originally under the McKinney
Act.
Mr. Miller. Well, the one that we have in Manatee County I
have just been impressed with. I spoke at it when they
dedicated the new physician practice area, and it is as nice as
you would want anywhere. Then I went and visited a year or so
ago their facility for family health, and just the--I mean, I
would be very comfortable for my family or me to go to those
facilities, as far as seeing the facilities and the quality of
the people there and the attention and care. And they are
large, not small operations.
So I guess--and part of it I think is local leadership has
taken that effort. That just varies sometimes. I guess that is
true of all kinds of social services a lot of times, if it is
at the local level. If you get a highly motivated, dedicated
leader--I know our head--I mean, our Meals on Wheels program in
one community is really strong, because for many years we had
a--and we still do. But she started it and got it going.
So I think it is--do you see that, too? I mean, how good
that local executive director is or that local board?
Mr. Hobson. That sometimes tends to show up quite a bit as
you look at the facilities and the way the program appears. But
one of the things that we really don't have, is, a lot of
resources that we make available from the Federal program to
focus on developing facilities. A lot of the programs raise
funds in their individual communities to develop their
facilities. What we tend to focus on and we tend to judge the
program by is the quality of the providers that they have, and
by and large the 4,400 physicians that we have in the program
nationally are board certified physicians who have finished an
approved residency program. We feel that the bedrock or the
core of the program is our highly trained, highly motivated and
very committed clinicians that we have been able to employ.
Mr. Miller. Having nice facilities makes it easy to attract
the people, too. So I guess we were very fortunate in Manatee
County.
ABSTINENCE EDUCATION
Let me switch to another subject, and that is abstinence
and education you brought up. That is a politically charged
issue, and I think everybody would agree that is great. So the
goal, I don't think--how does it work at the Federal level as a
Federal responsibility? Is it a Federal responsibility? Does it
really--you know, has it--what studies show from a--that it
really does--is a good use of dollars?
Ms. Duke. One of things that this program has in it is a
3.5 percent funding for an evaluation of the program, including
a longitudinal study. So we are going to know a lot more about
its effectiveness as a result of what we aredoing this year.
The Assistant Secretary for Planning and Evaluation is going to lead
that evaluation effort for us. We are in our second year of that grant
program, and we are seeking funding for a third year of it. As part of
that, we are going to launch a really intensive evaluation that I think
can answer those questions more authoritatively.
Mr. Miller. I am sure it is difficult to measure that
single variable. That is true in any--I guess all--especially
longitudinal studies. How do you----
Ms. Duke. It is sort of like many of the things that we do,
and it is really one of the frustrations, which of many things
contribute to an outcome and sorting out our role is the dicey
methodological chore. But there are specialists who deal with
the subject of social program evaluation who are putting all
their mighty muscles to developing this, including the
longitudinal study; and I think that that is a very important
piece.
Mr. Miller. How much money are we talking about in this
year's appropriation?
Ms. Duke. For FY2003 we are asking for $73 million, and
this year we had $40 million.
Mr. Miller. How does that work? Is it a grant?
Ms. Duke. Well, actually, there are two programs. There is
a community-based program, which is the one I was just talking
about. The community-based program is a discretionary grant
program, and that means that we put out an announcement telling
the world that we want to fund some programs to achieve these
specific goals, and the legislation has within it the specific
eight criteria that these programs must adhere to. Then
applicants send in their applications.
Last year, in the first year of the program, we had 377
applications. We had funding for 20 planning grants and 33
implementation grants. Those funds are now in use in the first
full year of that cycle.
In 2002, we will run another cycle, and we will have
sufficient funding for about a hundred grantees.
COMMUNITY HEALTH CENTERS
Mr. Miller. Does the health--community health centers get
involved in family planning issues?
Ms. Duke. I will hand that to Bill.
Mr. Hobson. Family planning services are considered to be
part of the comprehensive scope of services that community
health centers should provide. They don't tend to focus on
family planning services, per se, but almost all community
health centers would provide those family planning services as
a part of their routine service program.
Mr. Miller. If they offer obstetrical services?
Mr. Hobson. Yes, and that really depends on whether they
have been able to establish an obstetrical care program. You
generally need several physicians capable of doing deliveries
that are part of the nighttime call and the weekend call
systems. Sometimes in order to offer obstetrical care services
that is done in partnership with local hospitals.
Other health centers that have enough of a critical mass of
physicians who are delivery trained will provide that service
themselves. More than 75 percent of health centers provide
[perinatal] care services.
Mr. Miller. Do y'all handle family planning monies?
Ms. Duke. No. The family planning money is handled by the
Office of Population Affairs in the Department.
Mr. Miller. Ours is called rural health, and I don't know
why--maybe that is just a historical name, and maybe it has
changed, and I might be embarrassed by saying it is still rural
health because I have been around for too many years. But--why
is it rural health? Is that how it originally started?
Now, they also have been able to get physicians who
received money for their medical education to come serve a 2-
year period or something to work there, and then they stay. I
mean, ours--it happens to be a nice coastal community that
doesn't seem that rural, but it is.
NATIONAL HEALTH SERVICE CORPS
Ms. Duke. We have sort of two programs that are related
here. One is the National Health Service Corps where we provide
the physician or clinician to come and serve for a period of 2
years or perhaps even with an extension to 3 years, and many of
those providers actually do become residents and remain in
those communities. The retention rate, 15 years after they have
finished their obligation is still over half of them remain
where--serving underserved populations.
COMMUNITY HEALTH CENTERS
We do have community health centers. About half of them are
in rural areas, but we also have a rural health--an Office of
Rural Health that has rural hospitals and rural health clinics
as well. So we may be funding them through different streams,
but they are all within HRSA.
Mr. Miller. I know people go to this facility--I mean, it
is a sliding scale, and so you could--I mean, it is amazing
that, because it is nice facilities and quality care, that they
do have their share of--people pay the full, you know, amount,
because it is so nice.
So there is a lot of programs in the government we should
be pleased and proud about and excited about, and that is the
one I happen to be familiar with.
I will now let Mr. Peterson take back over, and I thank you
very much for the job you are doing.
ORGAN DONATION AND TRANSPLANTATION
If there is anything on organ transplant, obviously, I have
a very personal involvement, and we think we have a liver
caucus in Congress because this other Congressman is a member
of the other party because the two of us are sointimately
involved with this issue.
Ms. Duke. Thank you very much.
PEDIATRIC GRADUATE MEDICAL EDUCATION
Mr. Peterson. I want to shift gears with you here.
Pediatric education money, I guess I was interested in
the--I was surprised at the cut. I toured Pennsylvania's
children hospitals--I chaired Health at the State for 10 years,
so I toured them then, and I have toured two in the last 3
months, and that is one of the most specialized businesses
there is. I mean, they are working on babies about that size
with surgeries in their beds. I mean, it is one of the most
dynamic--and I guess to not treat them equal to other teaching
institutions or other teaching disciplines, I just don't
understand, because it is at the beginning of life. It is where
we really should, you know, have our expertise and train our
pediatricians and our specialists for children. Any thoughts on
that item?
Ms. Duke. This budget reflects the very tough choices that
had to be made as the Department has tried to focus on a series
of priorities. We clearly have a priority in the use of funding
this year for dealing with repairs to the public health system,
to deal with the preparedness issues associated with the
realities of the world after September 11th, and that has been
an absolute priority.
In the Health and Human Services budget, we also have a
priority for funding the National Institutes of Health, which
is a world-class institution that does such important work, a
benefit to everyone. In our budget, we have an absolute
priority on the direct delivery of care to the population; and,
based on those priorities, a lot of tough decisions had to be
made. Among them was the cut in the pediatric GME. That program
has grown sevenfold over a very brief period of time, and the
whole issue of how we deal with residency education in the
United States is one that the Secretary feels needs attention.
But in the variety of unpleasant choices that had to be made,
this is one where the cut was felt to be prudent.
Mr. Peterson. Well, I appreciate your reluctance that it
was a cut. I mean, I can sense your--I have one more question,
and then I will----
Mr. Regula. Take all the time you want.
COMMUNITY HEALTH CENTERS
Mr. Peterson. Community health centers, do you have maps
of, like, where they are at in Pennsylvania?
Ms. Duke. Yes.
Mr. Peterson. Can that information be made available to me?
Ms. Duke. Yes.
[Maps follow:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Peterson. How do you choose a community?
Ms. Duke. Let me answer that in two--let me answer your
question in two parts.
Yes, we do have maps of where our community health centers
are, and we will make sure you have one.
The second thing is one of the things that I am working
very hard on this year is actually, again using the technology
that we talked about a little earlier this morning, is we are
trying to do some geomapping of where all of the HRSA health
care services are. Because one of the things that we want to be
able to see is where we have the opportunities to assist with
the integration of those services at the local level. So my IT
shop is working very hard to pull that data together and use
the new geomapping technology to be able to bring all of that
together, and we are going to use that for the basis of
monitoring our programs to ensure not just integrity but also
the opportunity for pieces of the health care system to work
more intimately together and to stretch those dollars better
because we are not duplicating.
So the answer to your question is, yes, we have some maps
on hard pieces of paper, but what I am hoping to get is the
mapping that will show us those linkings on an Internet site
ultimately.
So I will let Bill Hobson talk a little bit about the
selection process, which is a competitive process. And Bill.
Mr. Hobson. Thank you, Dr. Duke.
Yes, we solicit applications----
Mr. Peterson. A little bit closer to the mike.
PRIMARY HEALTH CARE
Mr. Hobson. Yes. We solicit applications on a competitive
basis, as Dr. Duke outlined. However, we tend to identify areas
of need where there are access problems for primary health care
services in each State, working with our State offices of
primary care as well as the associations of health centers that
we have in each State. We have a process that is ongoing right
now that we term our State strategic planning process that
attempts to identify those areas that would be appropriate for
a new health center site.
Once those areas are identified, we try to assist local
community organizations in developing a good application and a
good service delivery plan for those communities. Or in some
cases we try to interest another community health center in
putting a satellite health center in those areas of need. So
although it is an open competitive process, we try to work to
target the highest areas of need and develop infrastructure so
we can serve those underserved populations.
Mr. Peterson. Having come from State government, would you
say that the effectiveness of the State health department in
that role depends on whether their communities are successful
or not and how much they help them and guide them?
Mr. Hobson. State health departments have been extremely
helpful in a number of States. Quite often the State offices of
primary care are most often located within the State health
department. They provide assistance in attempting to get the
designations that are required for the placement of a health
center. Health centers are located in a geographic area that
has a designation as a medically underserved area or serving a
population that has a medically underserved population
designation.
Those designations have to be applied for, and the State
offices have been particularly helpful to local communities in
preparing the applications that they need and reviewing those
applications and also in identifying areas of high need within
the State.
Mr. Peterson. Okay. Well, thank you. I reluctantly give the
gavel back to the chairman. I was just being funny.
Mr. Regula. Okay. Mr. Sherwood.
Mr. Sherwood. Thank you, and I am sorry that I haven't been
here earlier, but I had other things going on this morning.
NURSING SHORTAGE
What I would like to ask you about, my area in northeastern
Pennsylvania is extremely short of nurses, and everyone tells
me that as the current crop sort of retires and goes--as they
get older, go to working part time, that this situation is
going to get worse, and it is exacerbated by--even though we
are worrying about the economy right now, it has generally been
pretty good and that profession is not as well paid in
relationship to other opportunities as it used to be.
So in line with this and what I am told by all my hospitals
is a great shortage and what they think will be a continuing
shortage, I am very concerned that we have some cuts in the
program for nursing education. In the past, some of the nurses
training universities in my district have got some help out of
that.
I am not just one to ask for more money, but I want your
thinking on how we are going to get around this and how we are
going to have enough nurses to do what we have to do.
Ms. Duke. The reality is that we are facing a nursing
shortage. We have just released our nursing survey, which tells
us that the pipeline of people coming into the profession is
not keeping up with the people leaving the profession. We have
also been looking at the relationship between the supply of
nurses and the growing demand for services within the
population. The bottom line of all of that is that we are in a
nursing shortage.
We have specific studies of specific States. Some States
have been in nursing shortages for quite some time, but we now
have documented a nationwide nursing shortage, and we know that
is very real.
The budget that we presented for this year offers an
increase for nursing education. We have asked for $99 million,
and it is a $6 million increase--is a $1 million request for
increase at the advanced level and a $5 million increase for
the Nursing Education Loan Repayment Program, which is a
program that has grown very rapidly over the last year. It is a
program that really gets nurses on the floor now, because we
can help them pay for their education, but they are fully
educated and ready to be on the floor.
With the increase we had last year, we had a $2,000,000
program. The Secretary directed $5,000,000 for us to expand
that program. We were able to produce 1,032 years of nursing
service with our money from last year by commitments from
nurses who are fully trained for 2 or 3 years of service in
underserved areas. So this is a program into which we plan to
put more attention next year with the probability that the
funding we are asking for would allow us to add 700 nurses in
underserved areas.
So we recognize that we need to go directly into nursing
education, and thus we have the programs I have described.
KIDS INTO HEALTH CAREERS
I also talked a little earlier about a program that I
really feel sort of passionately about, which is our Kids Into
Health Careers Program, which is a program where we are working
with the education world to open up the possibilities to young
people about career opportunities in nursing but also in other
health professions. In that program we put together materials
for children from kindergarten through 12th grade, talking
about what those professions are and theexcitement within them,
and specifically in nursing the multitude of activities that constitute
nursing as a profession.
That is the future, is to attract young people to do two
things, one, be interested in the profession, but, two, to
prepare themselves to have the prerequisites to do the training
necessary to enter the profession.
NURSING AWARENESS
Mr. Sherwood. I think nursing, like being a fireman or a
policeman or an NCO in our military services, has been a great
way up for a great many people, and so I think we have to make
sure that we are putting the good information out about what a
rewarding career it is in the correct communities.
KIDS INTO HEALTH CAREERS
Ms. Duke. That is an important part of what we were talking
about in this Kids Into Health Careers, is getting the idea out
that this is--it is a wonderful set of professions. There is an
opportunity to be of service, to have a life with meaning as
well as to have a career that has great flexibility and
intellectual challenge. So our challenge is to get the word out
that this is an area for intense preparation and a good life.
Mr. Sherwood. I think we need to make sure that a new
generation of kids understand that this is a way to be a
respected member of society.
Ms. Duke. Yeah.
COMMUNITY HEALTH CENTERS
Mr. Sherwood. On another note, I would like to commend you
and the President for the Community Health Center funding
increase.
Ms. Duke. Thank you.
Mr. Sherwood. I have two centers in my district that just
do a great job for the uninsured. They do a great job for
people who really without them would be on the short end on
health care. So I think it is a good program, and I am glad to
see your funding increase.
Ms. Duke. Thank you very much.
Mr. Sherwood. You bet.
Mr. Regula. Okay?
Mr. Sherwood. Good shape. Thank you.
Mr. Regula. You are right on the Community Health Centers.
Are yours both Federal? It is a great way to relieve the
emergency rooms and provide health care for a certain segment
of a population. I like those.
Mr. Jackson.
Mr. Jackson. Thank you, Mr. Chairman.
Mr. Chairman, I have about five questions, and I can ask
them in the first round or try and get them in in the second
round.
Mr. Regula. Your first and second round will be the same
one.
Mr. Jackson. I think you are probably right, Mr. Chairman.
Welcome, Administrator Duke, and thank you for your
testimony. Let me apologize for being tardy this morning.
TITLE VII
Yesterday, Secretary Thompson indicated that the President
chose to eliminate virtually all funding for title VII
programs, in part because the data indicating that only 33
percent of individuals who participate in these programs go on
to practice in medically underserved areas. As I mentioned to
the secretary in the hearing, the subcommittee has received
testimony from a number of witnesses in recent years who place
that number at a much higher figure. I am hoping that you can
provide the source data that supports this 33 percent figure.
Can you?
Ms. Duke. We will provide that for the record for you.
[The information follows:]
The data that support the findings that 30 percent of
individuals participate in our programs practice in underserved
areas come from the Bureau of Health Profession's (BHPr's)
Comprehensive Performance Management System (CPMS). These data
are collected from approximately 1,500 grantees and reported on
an annual basis to our Agency.
Ms. Duke. The question is a relative question. The question
is--I think the Secretary's response was in relation to where
to put money, to put it into direct services where we could
ensure that providers went to areas where they were most
needed. In the National Health Service Corps about which he was
speaking, we can assure that the members of the National Health
Service Corps are serving in underserved areas, and that has
been an area of his particular concern.
Mr. Jackson. I am very interested in seeing the data,
because, for obvious reasons, it has raised great concern
amongst our constituents.
NEWBORN HEARING SCREENING
My second question is about the universal newborn hearing
screening. Your budget proposes to eliminate the dedicated
funding source for universal newborn hearing screening. However
while your budget assumes that these activities will be covered
under the maternal and child care block grant, there is no
increase proposed for the block grant program. Data from the
National Center for Hearing Assessment and Management shows
that only 67 percent of babies are now screened for hearing
loss before one month of age. Of those screened, only 56
percent who need further diagnostic evaluations actually
received them by 3 months of age, and only 53 percent of those
diagnosed with hearing loss are enrolled in early intervention
programs by 6 months of age.
My question to you is, does this data suggest to you that
muchmore work needs to be done by State and local health
officials and providers? Also, do you anticipate that your proposal to
eliminate this funding may have some adverse impacts on the State's
ability to reach the goal of universal screening and intervention, and
might even be a setback in some areas if States have to eliminate the
health personnel work in this critical area?
Ms. Duke. We also believe that the hearing screening is a
very important service for babies who are about to leave the
hospital. Literally today I will become a grandmother for the
fourth time.
Mr. Regula. Congratulations.
Ms. Duke. Thank you. I will leave this hearing and go
directly to assist with that birth, which is a pretty exciting
thing, and----
Mr. Jackson. Maybe I should submit the rest of my questions
for the record.
Mr. Regula. I might add that I just became a grandfather,
well, the third time, but a newborn about 4 weeks ago. But I
didn't assist.
Ms. Duke. I have had the pleasure of helping deliver the
first three. So this is a marvelous thing, and I value that
hearing screening program very much.
We believe that hearing screening program is well
established and that State and local organizations are
committed to that program and that it is growing well. We
believe that the availability of the maternal and child block
grant will continue to assist that.
I met with five directors of the maternal and child health
program last week who are absolutely dedicated to the program.
Clearly, they recognize that they might wish it to be
otherwise, but they are committed to fostering that program and
carrying it forward.
So I do think the second part of your question suggests
that we do have a dialogue with our partners in the States and
the communities, and I do think that program will continue. But
I could ask Dr. Peter van Dyck, who heads our Maternal and
Child Health Bureau, to comment further on it if you would
like.
Mr. Jackson. Thank you, ma'am.
Ms. Duke. Peter.
Mr. van Dyck. We have a set of 18 national performance
measures that all States must meet. One of those performance
measures is the percent of newborns screened for hearing before
they leave the hospital. So State MCH programs are committed to
newborn hearing screening. We have made good progress.
There is some way to go, as you have suggested. I think the
Maternal and Child Health directors are dedicated to doing
that. I think they will continue to advance the programs, even
though there may not be specific funding.
Mr. Jackson. Well, my question hasn't been about their
dedication. It was about whether or not there was sufficient
funding in lieu of the budget request to cut funding for the
program and whether or not their dedication could be
supplemented with additional resources to help them accomplish
their goal. My question was referring to those issues.
Dr. van Dyck. I think the State directors will try to--
because they have this performance measure to meet, will try to
reset priorities in the State if necessary to help them meet
that performance measure and to continue this program which has
had such a nice start over the last 3 years or so.
Mr. Jackson. Thank you, sir.
Mr. Chairman, I have one last question so that the
Administrator can get to a great moment in her life. It is
regarding HIV and AIDS----
Ms. Duke. It is all right.
RYAN WHITE CARE ACT
Mr. Jackson. Similar to many States around the country,
Illinois is facing severe shortages in Medicaid budget cuts
that could affect the reimbursement and/or access to
medications for people living with HIV and AIDS. Cuts in State
low-income programs mean that more people will seek life-saving
treatment for HIV/AIDS through Care Act programs. If Ryan White
Care Act programs are continuously flat-funded, states may be
put in the difficult position of choosing between funding HIV/
AIDS treatment programs and being prepared for other public
health needs. Given no increase in the Ryan White Care Act
fund, how can Illinois and other States be expected to address
the growing HIV/AIDS epidemic while also maintaining a solid
public health infrastructure?
And that is my final question. Thank you, Mr. Chairman; and
thank you, Administrator Duke.
Ms. Duke. The program is level-funded at $1.9 billion. It
is a large program. The program respects the reality that this
is an epidemic that is very difficult to work with, to conquer,
but one that we are committed to conquering. The Department as
a whole has a very large commitment to the AIDS epidemic. We
have a commitment in the Department of almost $13 billion. We
have a funding through Medicare and Medicaid, about half of
that, and then we have discretionary funding at NIH of almost
$3 billion. We have our program at almost at $1.9 billion, and
we have funding with CDC and surveillance and prevention. So,
as a department, we are working very hard on the HIV/AIDS
effort.
The funding for the drug programs, we recognize that the
drug programs for folks on a full regimen of drugs could be as
expensive as $10,000 to $15,000 a person. We recognize that
those expenses exist.
We also have some changes in the medical world about when
people go on those services. They go onto these services later,
which has made some change in the--loosening up some
availability of funds. So we recognize the dilemmas, but,
again, there were some tough choices in this budget with the
priority around the broad requirements to build our public
health infrastructure to deal with the issues after the 11th.
So the level funding has some issues involved, but we believe
that some compensation can be made by this broader association
of $13 billion coming from the whole Department.
I might ask my colleague, Deborah Parham, who heads our
HIV/AIDS Bureau, to talk a little bit more about that, if I
may.
Ms. Parham. Thank you.
The only thing that I would add to Dr. Duke's comments is
that there was a $100 million increase in the Ryan White Care
Act programs between 2001 and 2002, and we are just getting
those dollars out now into the communities. We believe that in
2003--of those new folks that we are getting into care now, we
will be able to maintain them in care.
The other thing I would say is, not only--Dr. Duke did
mention the $13 billion in AIDS and HIV money in the
Department, but when you look across the Department at other
programs, for example, the Community Health Center programs,
there are a lot of people with HIV and AIDS who access care
there. These SAMHSA programs as well, people can get care
there. So the Ryan White Care Act program is the payer of last
resort by legislation. So there are other programs where people
can get services as well.
Mr. Jackson. Thank you, Mr. Chairman.
Mr. Regula. You got everything you need?
Mr. Jackson. I do not want Administrator Duke to be late
for her next event.
Ms. Duke. I will get there in time. They tell me, I will be
fine. Thank you very much.
UNIVERSAL HEARING SCREENING
Mr. Regula. Well, I just wanted to follow up on Mr.
Jackson's comment on this universal hearing thing. It seems to
me that you can't rely on the block grant people to do that. I
would rather take something out of the block grant and earmark
it here so we get a hundred percent of screening.
Ms. Duke. Well, one of the things that we have done in
recent years in this program is--and I think this is really a
model program for the government--is the creation of the
performance standards--these aren't Federally imposed standards
on the States, but rather these standards have been worked out
in partnership with the States and the Federal Government. Each
State has had the opportunity to choose----
Mr. Regula. They could add money to it, I guess.
Ms. Duke. That is right. There is a deep level of
commitment to this program, and the performance standard for
hearing is one that they have chosen to be part of, in the
sense that they participated in putting this together. We
believe there is a high level of commitment here to carrying
that forward.
I did not sense in the--I met with five State Directors in
a small session for about 2 hours last week, and then I met
with a large group earlier this week, and I did not get a sense
of a flagging commitment to this program.
Mr. Regula. But given that only--there is one-third that
are not receiving it, as I understand it, one-third of the
babies do not get screened.
Ms. Duke. That we are making progress, yes, that is
correct. We have about 65 percent who are screened now.
Mr. Regula. It doesn't seem to reflect a high level of
commitment on the part of the States if that many are being
omitted.
Ms. Duke. Well, when we started, it was only 34 percent. So
in the short history of the program, we have doubled it.
Mr. Regula. What do you think it costs per child to do
this? How do they do them? Do they have a machine, or what is
the process?
Ms. Duke. I am going to ask Peter to talk about the actual
specifics of it, if I may. But this is one of these marvels of
modern technology, because the equipment that exists to do this
is in hospitals. It is not in private physicians' offices, and
that is why we want to get the screening done before the baby
leaves the hospital.
Let me turn to Peter.
Dr. van Dyck. Well, we probably all remember, some of us
who are a little older, perhaps seeing the nurse or the
physician clap their hands to see if the baby might startle.
That was newborn hearing screening for a number of years, and
that wasn't very successful, unfortunately.
Now, we do have new technology that is not expensive, can
be done by nonmedical personnel, at least as a screening. The
babies that test positive in the screening in the hospital then
require a more specific otologic test with specific people
trained to do it to make sure that the screening test was
accurately positive.
It is important to get these children, then, into service
by 3 months of age or at least get the second test and get the
service provision started, and we would like to get them into
early intervention and speech training and all the other things
that go with it by 6 months of age.
Mr. Regula. Do we--is the money used to buy equipment for
the hospitals?
Dr. van Dyck. Money is generally not used to buy equipment.
The money is used generally for staff, organizing the program,
facilitating and organizing the follow-up and tracking of
people, training of the appropriate personnel who would do the
screening in the hospital or do the follow-up and then public
awareness materials so parents know that they should be asking
for a screen and know what to do if the screen is positive.
Mr. Regula. It seems to me like we ought to be getting
close to a hundred percent. This is not a terribly expensive
procedure. It is vitally important to that child.
Dr. van Dyck. The program--this is its third year, and when
we began, we were at 34 percent, as Dr. Duke said. So within
two to two and a half years we have made remarkable progress.
Forty-seven States now have grants, and we hope that most of
the remaining States will get a grant this year, 2002.
Mr. Regula. They have to apply for those?
Dr. van Dyck. They have to apply, yes, sir.
Mr. Regula. Well, Congressman Walsh sponsored the
legislation, and he has a deep interest in this. He has a
number of questions I am going to submit for the record on his
behalf concerning this program.
CHILDREN'S GRADUATE MEDICAL EDUCATION
Children's Graduate Medical Education, I see you cut out
the $85,000,000 that we put in last year to get them up to a
hundred percent of the authorization. It seems to me that this
is just as important as graduate medical education for the
other physicians. So why do we want to treat these people
differently? They start at the earliest point in an
individual's life, is the pediatrician and those that deal with
the young children, and on a scale of one to 10 it seems to me
they are more important than the ones over here.
Ms. Duke. The training for pediatricians in the country,
this is an important source for training, and we recognize
that. I think that has been recognized in the sevenfold growth
of this program over the last few years.
As I have said earlier in the day, the budget reflects a
lot of choices around priorities, and in the reasoning here we
recognize that the whole issue of how we fund graduate medical
education is one the Secretary feels we need to take a good
look at. On this one, when they looked at it, the reasoning
basically boils down to this is still a very generous package.
It does provide about $58,000 per resident, and the decision
was that that would probably in the course of things be----
Mr. Regula. Excuse me. Staff tells me that $51,000 is the
number that we got from your budget justification.
Ms. Duke. I think that is actually accurate, and I have
misstated. It is slightly under $20,000 direct and slightly
over $30,000 indirect, and that totals to $50,000. I apologize
for the error.
MEDICARE/MEDICAID
Mr. Regula. What do you suppose we spend under the
Medicare/Medicaid program that funds the conventional----
Ms. Duke. I don't know that answer, but Bill Beldon may
know.
Mr. Beldon. The estimate for 2003 is approximately
$8,000,000,000.
Mr. Regula. That is total.
Mr. Beldon. That is the total for graduate medical
education out of Medicare.
Mr. Regula. How much do you think that--using the $51,000
figure, how does that compare per patient or per----
Mr. Beldon. I think the estimate is about $65,000 to
$68,000.
Mr. Regula. Frankly, I don't think there should be an
administration, because it is just as important to an
individual to have good pediatric care, perhaps more important
than the conventional. Of course, the argument is, well, that
child isn't on Medicare and, therefore, that should not be a
responsibility of Medicare. But that child is going to be on
Medicare some day.
Mr. Beldon. I think the distinction is that the
$8,000,000,000 is on the mandatory side of the budget. This is
in the discretionary side of the budget. The choices she was
talking about were the choices that the Secretary was faced
with, and he didn't have a choice on the $8,000,000,000.
GERIATRICS TRAINING
Mr. Regula. I suggested to Ways and Means that they amend
that, but it should cover across the board, because I think how
well you are at 75 is affected by how you are treated at 12
months, and you are talking about a total well-being of an
individual, which leads me to another question. That is, you
took out the money for geriatric training, and that is--again,
we have an aging population. Demographically, they are going to
be a larger percentage. Doesn't it seem that we should be
making a little more emphasis on giving the physician
population experience in dealing with geriatric procedures and
medicine?
Ms. Duke. While we have not continued the funding, the
generous funding for geriatric this year, we have made a
commitment that in our entire program we will put an emphasis
on geriatric services and the use of the geriatric specialists
that we have been able to provide in order to make that more
widely available. Because we are an aging population, and we
believe that making that commitment throughout our program can
deliver those services.
Mr. Regula. I would just be interested in yourprofessional
opinion. I have suggested that at least there ought to be some course
requirement, maybe just a couple of hours, for every physician on
geriatric medicine. Because if they treat a patient at 45, it may very
well affect that patient's health at 75. It would seem that every
physician should have some understanding of the special problems that
result from geriatric medicine. What do you think?
Ms. Duke. As someone who spends some time in hospitals with
aging parents, you certainly long to make sure that each person
that he or she meets along the way understands the difference
between a 95-year-old and a 30-year-old. And my colleague, Dr.
Shekar, whispered immediately in my ear, we agree. So I
appreciate that we agree.
Mr. Regula. So do I. Well, I think--I am just a layman, but
it would seem to me in medicine you should always be thinking
about the total person. Life is made up of a whole series of
impacts or steps, but perhaps that is one of the things that
concern me is the fewer and fewer what I call general
practitioners, family medicine. I know in our case all three of
our children were brought into this world by the local
physician who did the cuts and the scratches and the whole 9
yards. He was in a small town, and we lived out in a farm, and
he was our family physician, did the whole 9 yards. That is
sort of a passing phenomena, isn't it?
MEDICAL HOME
Ms. Duke. Well, one of the things that we try to do through
our health centers and through a lot of our programs is to
arrive at the concept of a medical home, which is a little more
bureaucratic way of saying we would like people to have an
association to a health-care-providing entity and even a
person, with the idea that there is more likelihood that things
will get treated earlier. Because when we were growing up and
we had that access, things got taken care of in a timely way
and we didn't end up at the emergency room with an expensive
critical illness when it could have been handled a lot earlier
and a lot cheaper along the way.
So one of the things that the Maternal and Child Health
program talks about in its program, in Healthy Start and in the
broader program, is getting across the concept of a medical
home for children.
If you would like, Peter could tell you a little bit about
some of the efforts we are making to try to make that happen.
We can't always change the world of providers, even though we
are trying to do that as well.
Mr. Regula. Well, I think economics and liability, medical
liability, have driven the general practitioner in a way out of
the scene, because--well, enough said about the liability
problem, but if you want to comment.
Dr. van Dyck. There is legislation that talks about medical
home for children in the children's health insurance program,
and for children with special health care needs. We feel it is
a very important concept; and it is not necessarily just a
physician but a clinic, nurse or physician assistant who can
provide ongoing regular care for that particular child and
family.
There are now a number of studies which suggest that these
children are more often insured. They make more appropriate
visits. They get referred to specialists more appropriately.
They have less hospitalization, and they have less emergency
room use. And it is all because they feel comfortable in having
a place to always call, whether they are referred on from that
place is fine, but at least they have a home.
So it is a very important concept, I think. If we can build
it among children, infants and children, and get the family
comfortable with that concept and actually encourage that
concept with them, then it will follow to the next generation.
We have put quite a bit of effort into this.
Mr. Regula. Well, I think that you make a good point there
that--in terms of the well-being of that individual there is
some real value to having one physician who is your hometown
doctor, if you will. But I notice the difference in our own
children which had that and my grandchildren, which seems like,
when they take them, it is a different kind of a specialist
every time they go to the doctor. And I don't know. Maybe that
is a better way. I am not sure. But it has certainly changed.
Ms. Duke. It is a changed world.
Mr. Regula. The medical environment, if you will.
You have all been very helpful. Excellent testimony. I
think your agency has a wonderful opportunity to leave a great
legacy for people in so many different ways, and I am sure you
all respect that opportunity that is yours, and we are going to
do the best we can in funding it and helping you.
Off the record.
[Off-the-record discussion held.]
Mr. Regula. Well, good luck.
Ms. Duke. Thank you very much.
[The following questions were submitted to be answered for
the record:]
Mr. Regula. Do you know if it is going to be a
granddaughter or grandson?
Ms. Duke. It is going to be a granddaughter, and her name
will be Allison Christine, and we hope she will be healthy.
Mr. Regula. That is right. Well, I have got an Olivia
Ireland about 4 weeks ago.
Ms. Duke. That is great. Thank you very much.
Mr. Regula. And this wonderful staff bought me two books
called Olivia. I didn't even know they had a book called
Olivia.
Ms. Duke. That is the fun part of being a grandparent. They
keep forcing you to learn stuff that you didn't think you would
have to learn.
Mr. Regula. How many do you have?
Ms. Duke. Personally, this is my fourth granddaughter. My
nurse daughter has a 3-year-old and a 1-year-old, and my second
daughter has a 2-year-old--little over 2--and the new one who
is to be born today.
Mr. Regula. Someone said if I knew grandchildren are so
much fun, I would have started with them.
Well, thank you. You have all been great.
With that, we will adjourn the hearing and let you be on
your way.
Ms. Duke. Thank you very much.
[The following questions were submitted to be answered for
the record:]
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DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED
AGENCIES APPROPRIATIONS FOR 2003
----------
Thursday, March 21, 2002.
CENTERS FOR DISEASE CONTROL AND PREVENTION
WITNESSES
DAVID W. FLEMING, M.D., DEPUTY DIRECTOR FOR SCIENCE AND PUBLIC HEALTH,
CENTERS FOR DISEASE CONTROL AND PREVENTION
WILLIAM GIMSON, ASSOCIATE DIRECTOR FOR BUDGET AND FINANCE
KERRY WEEMS, ACTING DEPUTY ASSISTANT SECRETARY, BUDGET, DHHS
Mr. Regula. Okay, we will get started. I appreciate Mr.
Obey and Mr. Wicker being here, in view of the fact that we are
recessed for a couple of weeks. So the fact that they're here
shows their dedication and interest in something that is a very
important topic.
I just thought coming down the hall, if we had a hearing on
Enron, there would be a line a mile long out there. [Laughter.]
And there was no line. Yet what you do is more important to
the people of this Nation than Enron, by a long shot.
CDC is somewhat of a well kept secret. We to some degree
discovered it as a result of September 11. We discovered it in
my district when we had a meningitis scare and everybody was
kind of panicking until CDC got on the scene and then
everything just calmed down. Likewise at the Ford plant in
Cleveland when they had a scare from Legionnaire's disease. You
are the 911, using that another way, for America in a lot of
ways. We're happy you're here, Dr. Fleming, to represent the
agency and tell us about the things that are important to the
people of this Nation.
Mr. Obey, would you like to make any comments?
Mr. Obey. No, Mr. Chairman.
Mr. Regula. Okay. Dr. Fleming, your full statement will be
made a part of the record. We'd like to have you summarize it
for us.
Introduction
Dr. Fleming. Thank you, and good morning, Mr. Chairman. I'm
David Fleming, Deputy Director for Science and Public Health
and the Centers for Disease Control and Prevention. This is my
first appropriations hearing.
Despite that fact, I am nevertheless delighted and honored
to be here today on behalf of CDC, our Nation's prevention
agency that protects the health of the American people. Mr.
Chairman, I would like to submit our written statement and I
would like to summarize that for you now.
Mr. Regula. Without objection, so ordered.
BIOTERRORISM ATTACKS
Dr. Fleming. Summarizing isn't easy, because as you may
have heard, we've had a busy year. On September 11th, life
changed for the Nation and for CDC. The horrible events of that
day and the anthrax attacks that followed brought into focus
the urgent public health challenges that we were facing like no
other event, and also the need for investing in our Nation's
public health infrastructure.
The events of September 11th precipitated the greatest
challenge in CDC's history, and resulted in an unprecedented
response. Ten minutes after that second plane crashed into the
World Trade Center, CDC's emergency operations center was up
and running.
Mr. Regula. Ten minutes?
Dr. Fleming. Ten minutes. And although we couldn't know it
at the time, Mr. Chairman, it would be running continuously, 24
hours a day, for the next 91 days. Within hours, even though
all airplanes were grounded, CDC emergency response personnel
were in the air with material from the national pharmaceutical
stockpile, on the way to Washington and New York City.
By early that afternoon, CDC's health alert network had
already started transmitting emergency messages to key public
health officials throughout the country. And that was only the
beginning. Over the next four months, CDC was a key part of the
Federal team that guided our Nation's response to the
bioterrorism events. We delivered almost 4 million doses of
antibiotics in 65 separate deployments to 10 different States
to prevent anthrax. The average time from us receiving those
requests until delivery in the field was five hours.
We coordinated laboratory testing of over 70,000 suspected
anthrax samples, from every State in the country, and tested at
CDC 6,000 of those samples, of the most critical samples using
state of the art methods. We provided through teleconferences
training to over a million and a half providers throughout this
country, and through our MMWR and health alert network,
provided key recommendations to millions of additional
providers. We provided public information every day to the
media. In October alone, CDC's web site was accessed 175
million times.
Most importantly, though, CDC deployed almost 600
professional staff into the field, and mobilized an additional
1,500 staff at our facilities throughout the country. These
individuals served by gathering critical public health
information, by investigating cases and suspect cases, by
developing new treatment and prevention guidelines, by
counseling those directly affected and providing technical
assistance to our State and local partners. They did this with
the utmost professionalism and confidence, often away from
their husbands or wives or children, and potentially at risk
themselves. We're very proud of them.
These actions by your country's public health system saved
many lives. The investment this Committee had the foresight to
make before September 11th paid off. We had made substantial
progress to developing the capacities of public health agencies
at all levels, Federal, State and local.
But the events of last fall also showed that we need to be
even better prepared. We need to correct the weaknesses that we
identified and build the capacities not yet developed.
Fortunately, though, our basic strategy is sound. The best
way to protect against any health threat is to develop and
enhance our already existing public health system andtools, not
only at the Federal level but at the State and local level as well.
Because while only a few States were involved with anthrax illness,
every State in this country was involved in this crisis. We saw so
dramatically how State and local health department partners are the
core of our public health system and how they must be ready to
responding to all public health threats.
Thanks again to your support, we have just awarded over
$900 million in funding to strengthen State and local health
departments. These resources are going to be used to plan for
this new generation of public health threats and to assure that
our responses are supported by a fully staffed, fully trained
work force, strengthened public health laboratory facilities,
enhanced surveillance and epidemiologic response capacities,
secure, up to date information systems, and an improved health
communication capability.
We are trying as hard as we can to be smart with these
investments. We are working closely with all parts of the
Department. We are building in measures of accountability. We
are preparing for those unknown threats by enhancing those
proven systems that deal with our natural, day to day threats,
like the meningitis outbreak in Ohio. And we are bolstering
State and local health department infrastructure, because it is
that infrastructure that supports every public health action.
There is one more task that is facing us. This fall, public
health was strained to the breaking point, dealing with the
challenges that were brought on by the terrorist attacks. CDC
and other public health agencies were also working around the
clock to attend to the other public health challenges that are
facing this Nation today. We must continue to attend to them in
the future.
So as we prepare for treating injuries from a terrorist
attack, we must also work to push every day injury and violence
from its rank as the leading cause of premature death in this
country. As we plan how best to respond to botulism or plague
or tularemia attack, we must also work to prevent the everyday
infections of HIV and tuberculosis and hepatitis C and e-coli,
and to assure the safety of postal workers, and we enhance our
ability to respond to a chemical terrorist attack. We must also
work to reduce the burden of existing occupational illness and
to better understand the relation between chemicals already in
our environment and illness already in our people.
As we develop adequate supplies of smallpox vaccine, we
must also assure the adequacy of our supply of standard
childhood vaccines, and work to increase the lifesaving
vaccines in adults, like pneumococcal vaccine and influenza.
And as we work to prevent anthrax hospitalizations, we must
also work to prevent hospitalizations from chronic diseases,
which are the leading cause of death and disability in this
country.
These problems are urgent. They are fixable, as fixable as
bioterrorist preparedness, by applying knowledge already gained
through research, putting it into practice on the front lines,
proven strategies, strategies that can prevent diabetes and
fire deaths, that can prevent heart disease and birth defects
as surely as antibiotics prevent anthrax.
To meet those needs, Mr. Chairman, today I am asking for a
total request for CDC of $6.6 billion. This request represents
our President's and this Administration's commitment to CDC and
our Nation's capabilities by preparing for, and responding to,
acts of bioterrorism, other terrorist attacks and public health
emergencies. Our request includes resources to continue to
improve preparedness of State and local health departments, as
well as CDC. It also supports our Nation's ongoing battles and
other health threats, the preventable causes of illness that we
deal with every day. It includes increases in breast cancer
prevention and our Secretary's initiative to healthy
communities.
In conclusion, this has been a busy year for CDC. But there
has never been a more exciting time to work in public health.
And I am doubly fortunate to be able to work during this time,
at the best public health agency in the world. Make no mistake,
this is also a tremendously challenging time to be in public
health. But as I have traveled around the country during this
crisis, I have heard a consistent message, not only CDC, but
all of this country's public health front lines are ready to do
what needs to be done. We are up to this challenge.
So in closing, I'd like to thank this Subcommittee for your
continued support in protecting and improving our country's
public health system. Rest assured, you are making a wise
investment.
Thank you very much. I would be happy to answer any
questions you may have.
Mr. Regula. Thank you.
In the interest of time, I'll defer my questions. Mr. Obey.
Mr. Obey. Thank you, Mr. Chairman.
PUBLIC HEALTH INFRASTRUCTURE
Dr. Fleming, you're in the process of distributing the $920
million that Congress gave you last year to strengthen State
and local public health departments. As many in this room may
recall, and as I certainly well recall, the Administration had
to be dragged, kicking and screaming, into accepting that
money. The President at one point told me personally that if
the Congress appropriated one additional dime above his budget
request he'd veto the bill that contained the increase.
Congress increased the President's proposal more than ten-
fold, and guess what, he didn't veto it. Thank God for small
favors. Can you tell us how that money is going to be used?
Dr. Fleming. Yes, thank you, Representative. First off, I
am delighted to report that the request for that money is
continuing in the 2003 budget that we are here to talk with you
about today. These dollars are critical to improve our Nation's
public health infrastructure. So we, with the Department, have
been working very hard to plan how best to allocate them, both
quickly but in a manner that assures accountability and in a
manner that makes us as well preparedas possible.
Working with our State and local partners, I think we've
come up with an absolutely wonderful way to do this. These
dollars have already been awarded to States. States right now
have been able to use the first 20 percent of the emergency
funding and are right now preparing their applications for that
remaining 80 percent.
What we've done here is really a new way of doing business.
These dollars are designed to fill in the holes, fill in the
gaps that people found, as a result of September 11th and the
anthrax attacks. As a result, we, the Federal Government, don't
want to be, nor should we be, absolutely prescriptive in
saying, here's exactly how these dollars need to be spent.
Rather, what we've done is, working with our State and local
partners, defined the outcomes that we want to achieve, what
are the capacities that it is we're trying to develop.
We have identified about 20 of those capacities. Health
departments are now looking at those capacities and they are
looking at how well prepared they are to attain those
capacities. They are then coming back, with the deadline being
April 15th for their grant application, to say, given their
unique circumstances at the State and local level, what the
most important piece is that they need to invest in to achieve
those capacities, we've designed it and we're hoping that as a
result, the applications that come back from States will be
different from one another. Because States have chosen to make
different investments already. There is different funding that
is available to different States.
But the bottom line is, at the end of the day, using these
dollars, we will have a public health system that is far better
prepared to deal with bioterrorism, but as importantly, far
better prepared to deal with other infectious threats that this
country faces. We are building that capacity on the underlying
or fundamental capacities that make our public health system
sound. So we will have a sound, better public health system in
this country as a result.
IN-HOUSE CAPACITY
Mr. Obey. Thank you. As you know, the supplemental
appropriation bill last year also gave you $100 million for the
agency to use to improve your in-house capacity, to deal with
bioterrorist threats and public health emergencies. Again, the
White House and OMB had to be dragged into accepting it. They
proposed an appropriation half that amount and then threatened
veto of anything over it.
How are you making use of that in-house capacity that we
provided?
Dr. Fleming. And thanks to the Committee once again for
that appropriation in the 2003 budget. That dollar amount has
been increased by about $20 million. Those dollars are much
needed at CDC, and we very much appreciate them being in the
President's budget.
There is a number of different activities. One, relating
back to the question that you just asked, is we need to assure
across CDC that we have the technical assistance capability to
make sure that the dollars that are going out to State and
local health departments are spent as wisely as possible. So
some of this money is going to be used to upgrade our capacity
at CDC, to provide technical assistance and to enable contracts
for technical assistance that States can directly access.
In addition, however, there are critical areas of program
and research, not only in infectious disease, infectious
disease is an important part of that, upgrading our laboratory
capacity, upgrading our epidemiologic capacity, but in other
parts of CDC. The Secretary has committed to there be an EIS
officer, or epidemic intelligence service officers, in every
State. This money will be used to make that happen.
In addition, it will be used to upgrade our ability to
prepare internally for chemical terrorist events and working
with NIOSH, make sure that workers that are involved in
responding to these threats are appropriately prepared. There
are long lists of needed activities at CDC that we need to do
internally to make sure that those front line responses are the
best as possible.
Mr. Obey. I have several other questions that I would like
to ask that you respond to in the record at this point, one
relating to the question of what more we need to be doing to
deal with public health infrastructure problems around the
country.
NIOSH
Mr. Obey. But I'd like to turn now to NIOSH, which you just
mentioned. In the years I've been on this Committee, there has
been a distinct pattern, for almost 30 years. That pattern has
been that NIOSH has been attacked by people who don't like the
idea that if NIOSH develops science that indicates that there
are problems with the health of the people in the workplace,
then somebody has to spend money to correct it. So there has
been a concerted lobby effort for over 30 years to squeeze the
NIOSH budget. And I'd like to ask you a few questions about
that.
For NIOSH, the Administration's budget proposes to cut $28
million, or 10 percent below the current year level, as I
understand it. And as I understand it, a huge portion of this
reduction would come in the extramural research program, or
NORA. That would result in a cut of more than half--from $40
million to around $15 million this year. Are those numbers
correct?
Dr. Fleming. Yes.
Mr. Obey. I understand that the NIOSH process for making
extramural grants is very similar to NIH, peer reviewed and all
that. The CDC budget justifications indicate that the proposed
budget cut would reduce the number of extramural research
grants by more than half--from 201 in fiscal year 2002 to just
88 in fiscal year 2003. What would be the impact of that cut?
Would NIOSH be able to make any newextramural grants next year?
Would you have to terminate some existing grants in mid-stream?
Dr. Fleming. Yes. We at CDC realize that we're living in an
era where our needs outstrip our resources. Therefore, very
difficult decisions have had to be made regarding priorities.
We fully support those decisions.
Mr. Obey. But the answer to my question was yes?
Dr. Fleming. Yes, that is correct.
Mr. Obey. To both questions the answer was yes?
Dr. Fleming. Yes.
Mr. Obey. Great. Wonderful. Splendid.
Mr. Chairman, I have a number of other questions that I
would like to ask also for the record, but I don't want to take
up any more time, so I'll submit them. Thank you.
Mr. Regula. We will have another round.
Mr. Wicker.
INFRASTRUCTURE
Mr. Wicker. Thank you very much, Dr. Fleming and guests,
welcome. I think you know that CDC has a lot of support in this
Subcommittee.
We were talking informally with a constituent of yours,
Congressman Linder from Georgia, I guess you're a constituent
of his and he of yours. He just wanted to stop by earlier and
express his interest in continuing to improve the
infrastructure at CDC.
I am quite fond of my minority Ranking Member on this
Subcommittee. Some of the questions that he has asked would
make it seem that the Administration is somehow hostile to
increased spending at CDC. I think you and I would both agree
that that is the farthest thing from accurate. As a matter of
fact----
Mr. Obey. I said the President was opposed----
Mr. Wicker. Mr. Chairman, I think I'm entitled----
Mr. Obey [continuing]. When we were trying hard to raise
this funding, so yes, I do think that's hostile.
Mr. Wicker. I think as a matter of courtesy I should be
able to finish my statement. I waited while the gentleman from
Wisconsin predicated his questions on a----
Mr. Obey. That's inaccurate.
Mr. Wicker. Are we on cross-fire, Mr. Chairman?
Mr. Regula. Mr. Wicker----
Mr. Wicker. I control the time, and I am quite fond of my
friend from----
Mr. Obey. You mischaracterize my words.
Mr. Wicker [continuing]. Wisconsin. I want to pursue a line
of questioning. But I think it's fair to say that the
Administration has been supportive of CDC. As a matter of fact,
has increased funding requests for CDC's budget, is that
correct?
Dr. Fleming. That's correct. Yes, Representative Wicker.
Mr. Wicker. And I do appreciate my friend from Georgia
coming in and pointing out that there may be additional
opportunities for this Subcommittee to look at the
infrastructure at CDC. I've been to Georgia twice to see the
facility, and I agree that there are needed improvements, and
it needs to be long term and we need to continue that. I would
suggest to my Chairman and to my Ranking Member that perhaps we
can tweak the budget and make improvements there.
But I am also appreciative of the Administration for its
advocacy of increased funding for CDC.
In spite of my strong support for CDC, I do have to ask a
question that has become a matter of concern to me over time.
That is, the feeling among many of us who support the Second
Amendment rights, that the CDC is violating not only the spirit
but the letter of the law as set out by Congress. Where
Congress has since 1997 provided, in the law, in appropriation
bills, the following language: provided further that none of
the funds made available for injury prevention and control at
the Centers for Disease Control and Prevention may be used to
advocate or promote gun control.
I think it is fair to say that the CDC is aware of a
firestorm of criticism that has come from time to time based on
apparent violations by the CDC of this express intent of the
Congress as set forth in the law of the land. I'll give you an
example or two, Dr. Fleming. One would be a CDC study entitled
Relationship Between Licensing, Registration and Other Gun Sale
Laws and the Source of Crime Guns. This study espouses
licensing and registration as being effective. Also, it states,
this was released at a time when the California legislature was
expressly debating adopting such legislation.
Also, as you know, in October of 2001, the CDC released a
model State emergency health powers act, which among other
things, advocated legislation to allow a Governor, without any
input or oversight in the State legislature, to control,
restrict or prohibit firearms, including the seizing of private
property. As you are aware, after a public outcry, the CDC
amended their language. But in my opinion, the message was out
there from the Centers for Disease Control and the damage was
done.
Do you agree that these examples violate either the spirit
or the letter of the law? Do you agree that the express will of
the Congress as stated in the appropriations act is what you
should follow? And when a grant application is reviewed, are
you able to tell me what procedures are in place to ensure that
the CDC is in full compliance with Federal law? And what
controls will the CDC implement to ensure that no monies in
whole or in part are spent on studies where the objectives are
to promote or advocate gun control in contravention of the
clearly stated Federal law?
Dr. Fleming. Thank you, Representative Wicker. We certainly
are aware and intend to fully comply with the language that we
have been directed to comply with. The specific examples that
you have raised are ones that I am going to need to go back in
and look into specifically. I would be happy to get back to you
on the record around those.
[The information follows]
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Dr. Fleming. I would like to say that it is important, and
we do believe that it is the intent of the Committee that CDC
still take an active role in looking at issues around the
epidemiology of injury and violence. One of our best strengths
is the ability to collect information that does not take sides
on an issue one way or another, but alternatively allows policy
makers and those who are appropriately, the appropriate
individuals to make policy decisions have the best possible
information available to them.
So in that context, through our various surveillance
systems, looking at injury and violence, vital records, death
certificates, police reports, we do routinely collect
information about weapons that are used, firearms, knives,
etc., and try as hard as we can to compile that information and
make it available to you and others in as objective a way as
possible. We feel that the debate around gun control is
something that is in your hands. Our role in that is to provide
the information that you need to make that debate as
scientifically sound as possible.
Mr. Wicker. Just a follow-up and then I'll take my turn
later on, Mr. Chairman, but Doctor, you are not saying that a
study which provides, which involves surveillance and provides
data in one portion and a conclusion or advocacy in another
portion of that study would be permitted under the express
legislative language that Congress has enacted since 1997, are
you?
Dr. Fleming. Advocacy for a particular position, for a
particular policy, is not something that we would be doing in
this setting. Our role is to gather data so that the policy
makers can set policy.
Mr. Wicker. So if a study involved data in one portion and
conclusions and advocacy in another portion, then that study
should not be funded by CDC under the statute?
Dr. Fleming. Again, I would need to go back, and we will
look at the specific issues that you've raised and get back to
you on the record.
Mr. Wicker. On the record.
Dr. Fleming. I would draw a distinction between conclusions
that can be drawn from the scientific data and then the next
step, which is to advocate for a policy or legislative
decision.
Mr. Wicker. Thank you very much.
Mr. Regula. Mr. Hoyer, and if you'd like to yield a minute
to Mr. Obey.
Mr. Hoyer. I'd love to yield a minute to Mr. Obey.
Mr. Regula. Mr. Obey.
BIOTERRORISM
Mr. Obey. Thank you, Mr. Chairman.
Mr. Chairman, the reason I barked at the comments made by
the gentleman from Mississippi is because he indicated that the
questions that I had asked would lead one to the inaccurate
impression that the Administration was hostile to budget
increases for NIOSH.
Here are the facts. After September 11th, the Chairman of
the full Committee, Mr. Young, and I asked our staff to develop
a bipartisan list of additional emergency requests that had
been made to us by FBI, NSA, CIA, CDC, HHS and any other
alphabet agency you can name that had anything to do with
dealing with terrorism. The fact is, when we went down to the
White House to talk to the President about it, he said to me,
nose to nose, that if we provided one dime more than his budget
called for, he would veto the bill that contained that
increased money.
Now, if that's not a hostile response, I'd hate like hell
to see what was. In fact, we provided ten times the amount for
buttressing public health than the Administration had in terms
of an increase in its own budget proposal. Mr. Daniels, the OMB
budget director, then attacked our package as being laden with
pork. I later said to the Attorney General, if he could find a
single piece of pork in that entire package that Mr. Young and
I developed, that I'd eat his honorary degree from Bob Jones U.
[Laughter.]
Mr. Hoyer. A worthy objective in and of itself.
Mr. Regula. In defense of Bob Jones, they've changed their
policies, if you've been reading the news.
Mr. Obey. Hallelujah. All I would say is that CDC is
getting a billion dollars more today than they would have
gotten if we had listened to the President's threats. Threats
which I did consider to be not only hostile, but totally
irresponsible.
Mr. Wicker. And if I might have a minute to respond----
Mr. Regula. Well, okay, one minute.
Mr. Wicker. I could have just jumped right in and
interrupted.
If the Ranking Member, for whom I have the greatest
admiration, had a heated and pointed exchange about one
appropriation concerning CDC, I wasn't privy to that
conversation, but I think the totality of the record, and it
needed to be corrected this morning, in the face of repeated
statements by the Ranking Member, is that the President and
this Administration have been supportive of increased CDC
funding and they have not demonstrated a hostility toward
increasing this very valuable appropriation. That is the point
that I would continue to insist on.
Mr. Regula. We'll continue this during the markup. Because
that's where the rubber hits the road.
Mr. Hoyer.
IMMUNIZATION
Mr. Hoyer. Thank you very much, Mr. Chairman.
I want to ask some specific questions and maybe go tosome
general questions, see what time I garner here in terms of the
interpretation of who yielded what when.
Immunization, I've been very involved with immunization.
Immunization is flat funded, as I understand it, at $631
million. As you know, Doctor, currently 75 percent, we went
down one point, in terms of percentages of children immunized
in America, fully immunized, from 76 I think in 2000 to 75 in
2001. It may have been 99 in 2000, I'm not sure which are the
figures. We're now flat funded.
What program, I want to know what's the consequence of this
going to be, secondly, I want to know what programmatic steps
do we need to take to raise children from the current average
of 75 percent to what I believe is a much more appropriate, and
I believe our target of 90 percent? The third question in the
immunization area, does the President's budget assume funding
for a six month stockpile of childhood vaccines?
Dr. Fleming. That last question?
Mr. Hoyer. Six month stockpile of childhood vaccines.
VACCINES FOR CHILDREN'S PROGRAM
Dr. Fleming. Thank you very much, Representative.
In the budget, in addition to the dollars that are directly
allocated to CDC, as you know, the vaccines for children's
program, which is administered under CDC, that money also comes
to us. There is an additional $824 million in the vaccine for
children's program for childhood vaccine.
That having been said, our goal is to achieve 90 percent
vaccine coverage for childhood vaccines. They are the really
public health success story of the 20th century, aren't they,
when you look at the reductions in morbidity and mortality from
diseases like measles and diphtheria and whooping cough. CDC's
MMWR today, hemophilus influenza meningitis----
Mr. Hoyer. Is that microphone on? I mean, I can hear you
fine.
Dr. Fleming. I'll speak louder.
I was going to mention that in today's MMWR, there is a
story about reductions in hemophilus influenza type B
meningitis. Twenty years ago, this was the most common cause of
bacterial meningitis in children in this country with the
significant mortality rate and long term neurologic
complications in children who survived. Today's pediatric
residents have never seen this disease, and don't even know
what it is.
Mr. Hoyer. Doctor, if I can interject, if you know, and if
you don't, I'd like you to provide it for the record, what is
the projection that CDC makes of the dollar savings as a result
of an investment in vaccines which are saved as a result of
preventing the illness?
Dr. Fleming. Vaccines are amongst the most cost effective
medical interventions. For every dollar that we spent on DTAP
vaccine, we saved $27 in health costs.
Mr. Hoyer. So there is a 1 to 27 payoff in the investment
in the fund that we have frozen?
Dr. Fleming. Yes, although it depends a little bit on the
vaccine.
Mr. Hoyer. You don't need to put it that way, I just put it
that way. You don't need to adopt my statement. I don't want
Mr. Wicker mad at you. Or Mr. Obey mad at Mr. Wicker because
he's mad at me. [Laughter.]
Dr. Fleming. I don't want to get involved in this, I don't
think.
If I may, though, let me just talk a little bit about the
activities that we can and need to do to improve childhood
immunization rates in this country. First off, we need to make
sure that there are functioning registries across this country,
so that as children come into the health care setting, their
provider knows without having to rely on their memory or the
memory of the child's parents what vaccines need to be
administered. That needs to be an electronic system so that's
available 24 hours a day.
Mr. Hoyer. I want to call to the attention, as a matter of
fact, Mr. Wicker and I have both been very involved in this,
that is a critical problem. When I talk to my local health
officials who interview parents, they can't remember when they
travel from one State to another exactly what the immunization
record of their child was and they may not have the record.
Therefore, what Dr. Fleming is now saying in terms of the
electronic record that can be accessed on the history of
immunization for children that travel readily around the
country, their parents are transferred or whatever, is a
critical element.
Go ahead, Doctor.
VACCINE SHORTAGE
Dr. Fleming. In addition, I think we need to recognize that
there is a relatively new crisis that we're facing today. That
is a shortage in available standard childhood vaccines. The
causes for this are multi-factoral, but essentially revolve
around a diminishing number of manufacturers for vaccine, such
that if one manufacturer has a production problem we're
confronted with a shortage, and difficulties that we've all had
in projecting how much vaccine is going to be used. CDC will be
participating with manufacturers and with a Department-led
initiative run by the Assistant Secretary of Health to look
over the next six to twelve months at how to improve this
problem and how to correct it both in the short term and the
long term.
Stockpiles that you mentioned may be one of the long term
solutions to this problem.
Mr. Hoyer. Doctor, my time is up. Let me ask you one last
question on this round, and I'm going to go to another hearing
on assistive technology for those with disabilities and then
I'll come back. But my question to you is this, if you know,
and if you don't know, I would like it provided for the record.
And I don't want to hear about it being an internal request.
How much did CDC request for this item to the Secretary of
Health and Human Services?
Dr. Fleming. Let me get back to you on the record for that,
Mr. Hoyer.
Mr. Hoyer. I would like that within the next 30 days, prior
to our markup.
[The information follows:]
Mr. Hoyer. How much did CDC request for childhood vaccines
to the Secretary of Health and Human Services?
Dr. Fleming. We cannot provide the specific information you
requested. Per OMB Circular A-11 and OMB memorandum M-01-17
dated April 25, 2001, Executive Branch internal deliberations
regarding the issues and options that were considered in the
process leading to the President's budget decisions are
confidential and should remain a matter of internal record.
Because--and this is not partisan, but when we can devote
$1 and save $27, or some figure thereabout, and keep children
healthy, there is absolutely no excuse for the wealthiest
nation on the face of the earth not to invest that money in
reaching at least 90 percent. Getting 100 percent is difficult
for reasons unrelated to expenditures of money. But there is no
excuse for us not making the requisite investment in making
sure that every child in America is vaccinated against
absolutely, totally preventable diseases.
Doctor, I thank you for the effort you're making. I'll ask
some questions on the next round.
Thank you, Mr. Chairman.
IMMUNIZATION RECORDS
Mr. Regula. I'd just like to ask a question. The only
record of immunization would be what your own doctor keeps, is
that correct?
Dr. Fleming. That in many instances is correct. What people
are trying to do is to have a dual record, so that in addition
to the physicians having a record, that the child and the
parents will have a record. I think many of us grew up in an
era that we had a shot card that we would take around and show
to our provider. That is something we have not paid as much
attention to in recent years. But having patient-held record of
immunizations, where the patient themselves, where the parents
can hold onto, is another way of making sure that information
can be communicated.
Mr. Hoyer. Mr. Chairman?
Mr. Regula. Yes.
PUBLIC HEALTH
Mr. Hoyer. One of the problems is, particularly with, we
tend to know our doctor. People of means and people that have
insurance and all that, they have a doctor. They know how to
contact the doctor.
But a lot of people access public health and access others.
They may not have as good a communication. One of the problems,
in talking to some of my rural area public health clinics, when
new families move into the area, their parents just are not
aware. They may say, well, yes, he or she has had a vaccination
shot, but they're not exactly sure what it was and how
extensive it was, when it was last given, whether it's up to
date. I think that's what Dr. Fleming is talking about and
trying to get some sort of central registry, so that public
health in particular can access what Sally's status is that
relates to vaccination.
Dr. Fleming. If I may add one comment. This problem is
getting worse, not better, because of the success that we've
had, and as progressively more childhood vaccines become
available and can be administered, it becomes even more complex
to keep track of which shots an individual child has received.
Mr. Kennedy. If I could ask, in Rhode Island, we have a
thing called Kids Net. It tracks all the kids and their
immunizations up to age three. I don't know whether that's
national or not.
Mr. Regula. Let me suggest, you might suggest a program
that we could look at. I think this is a very important point
that's been raised here.
We're going to have to move on. Ms. Pelosi.
WORK-RELATED DEATHS
Ms. Pelosi. Thank you, Mr. Chairman. Thank you, Dr.
Fleming, for your testimony. I hope you will convey my own
thanks and appreciation to Dr. Koplan. I want to wish much
success to him in his future endeavors. We will miss him and
appreciate the testimony you have presented here today.
I have some concerns. I'm reading from the Department of
Health and Human Services, CDC, your own book. It says here,
each day 16 workers die from an injury sustained at work, and
137 workers die from work-related diseases. The annual costs of
occupational injuries and diseases are estimated to be over
$171 billion. The annual costs of occupational injuries and
diseases are estimated to be over $171 billion, annual, per
year.
For that reason, I have very serious concerns about the
cut, $28 million cut, in NIOSH. We have all agreed here that
any initiatives or proposed solutions to the challenges we face
should be scientifically based. You referenced it as
scientifically sound as possible in another reference here
earlier. But basing how we proceed, whether it's prevention,
whatever it is, has to be scientifically based.
I guess we are in another meeting of the flat earth society
here when the Administration has decided to cut off the
science. How are we going to make the decisions if we insist,
and correctly so, that to be scientifically based, and then we
take $28 million out of the science that would enable us to go
forward and make those decisions, in an area that costs us $171
billion to our economy, not to mention what it means in those
people's lives each year? So I would put that as my opening
salvo to you.
I had hoped that we could talk more about my next question,
which is, yesterday I introduced a bill to create a nationwide
health tracking network--following up on just tracking and
networks, not the immunization side of it, though--that will
identify the links between chronic disease and exposure to
environmental pollutants. Last year I worked with my colleagues
to include $17.5 million in the public health improvements
account for a pilot project to explore the development of such
a network.
Can you provide the Subcommittee with an update on the
status of those pilot projects?
Dr. Fleming. Yes, thank you, Representative Pelosi. We
appreciate your support over the years. I will convey to Dr.
Koplan your message.
Ms. Pelosi. Thank you.
ENVIRONMENTAL ISSUES
Dr. Fleming. The environmental health tracking system that
we're working on is a critical system to better understand the
environmental health that this country is facing. The short
answer to this is that a lot of information is being collected
at the State and local level about environmental issues. But
we've done not as good as job as we should in linking that
information.
So in one place, people may be collecting information about
where toxic sites are, or what kind of chemicals may be in the
environment. In another place there may be measures of the
extent to which those toxic chemicals are getting into people.
In yet a third place, there may be registries of illnesses that
are potentially caused by environmental agents like cancer or
asthma. Then in a fourth place, there may be prevention
programs targeted.
The basic thing that needs to happen here is to invest the
resources that this Committee has allocated to allow the
linking of those different sets of information that are out
there, so that we have a coherent loop of information that
ranges from where chemicals are in the environment to how much
they are getting into people to what potential illnesses are to
what the prevention programs are, and then that feeds back on
our basis.
The dollars that we are using are dollars that will be
going to States, a small number of States around the country,to
begin to explore the best methodology for, number one, linking the
already existing information that we do have, and then second,
identifying whether or not after information is linked there are still
any gaps in our information for which we need to invest in additional
programs.
The environmental issues certainly are national issues. But
having worked at a State health department for about 15 years,
I can also assure you that they are State and more importantly
local issues. And for that reason, the information that we
gather cannot be a representative sample only that allows us to
garner national estimates. But we need to have sufficient
information such that every community in this country, to the
extent they are concerned about environmental issues, has
information that directly relates back to their community.
Ms. Pelosi. I don't remember ever having a hearing in this
Committee, except in our oversight hearings, but Chairman
Porter, when he was Chairman, did have a hearing on
environmental health. We were very grateful, that was before
our new distinguished Chairman came on board. It was an
exception, in all the years I have been on the Committee. It is
a very important issue, as acknowledged by our previous
Chairman.
I want to just say that I was pleased to see the release of
the National Exposure Report last year that provided the
detailed information on human exposure to 27 toxic chemical
substances. What is the time line for expanding the number of
toxic substances? If you have that information you could submit
it for the record, because my time is blinking away here.
Dr. Fleming. Sure.
[The information follows:]
Ms. Pelosi. The National Exposure Report last year provided
the detailed information on human exposure to 27 toxic chemical
substances. What is the timeline for expanding the number of
toxic substances?
Dr. Fleming. The National Report on Human Exposure to
Environmental Chemicals will be released in late fall of 2002
and will provide detailed information on at least 75 chemicals,
including additional data on the 27 chemicals that appeared in
last year's Report. New categories or classes of chemicals that
will be in this next Report include polycyclic aromatic
hydrocarbons (PAHs), polychlorinated biphenyls (PCBs),
persistent organochlorine pesticides, organophosphate
pesticides, dioxins, and furans.
CANCER SCREENING PROGRAM
Ms. Pelosi. And I also wanted to express my concern about
the fact of the meager resources that are put to the National
Breast and Cervical Cancer Screening Program. Congresswoman
DeLauro, Congresswoman Lowey and I have worked on this for
years and years and years. It took us a long time to get it
over $100 million, we were hoping to get it over $200 million.
But only 15 percent of eligible women are served through
the screening program. We think we could reach up to 70 percent
but we certainly can't do that with the $9 million that the
Administration has put into the program. So I want to register
my concern about that.
And I have some questions about the more difficult and more
expensive challenges we have in treating the declining rate of
TB and some questions about AIDS, which I will submit to the
record, both domestic and international. The red light is
blinking, I will submit those for the record.
Ms. Pelosi. Thank you, Dr. Fleming. Thank you, Mr.
Chairman.
Mr. Regula. Thank you. Mr. Miller.
ORGAN DONATION AND LIVER ISSUES
Mr. Miller. Good morning. I want to convey my thanks to Dr.
Koplan for the great job he's done. He will be missed. Tough
shoes to follow here.
I have a couple of questions. An area that I've developed a
special area of interest in is organ donation and liver issues.
My daughter donated half her liver to our son last October. So
all of a sudden, it becomes personal, certain things.
I'm curious what CDC does in the area of--I know there's
work being done in organ promotion donations and living donor
donations. I don't know if it's in CDC or not, so I'm curious
about that. And then would you comment what, in the liver area
in particular, in hepatitis, what the CDC does?
Dr. Fleming. Sure. CDC does participate with the Department
in developing recommendations for donor transplantation. Our
particular expertise is more in the infectious disease arena.
So what we bring to the table are recommendations around
standards and practices that can be used to minimize or
eliminate the risk of transmission of infectious disease in the
process of donor transplantation.
We also have a major technical role in looking at issues
around blood safety, blood transfusion. People oftentimesdon't
think of that as organ donation, but in some way it is. And we have a
role there.
You're absolutely right, though, that one of the most
concerning and to a large extent silent epidemics that we're
facing right now is epidemic liver disease, liver disease in
particular caused by hepatitis C. There was information even on
the Today show this morning about that. But probably close to 2
million Americans in this country have hepatitis C infection.
Approximately 20 percent of those individuals are going to go
on and develop chronic cirrhosis. Many of them may well wind up
needing liver transplantation.
CDC has an aggressive program to try to deal with this
problem. First, many of the people who are infected with
hepatitis C in this country don't know that they're infected.
So we are working as hard as we can to encourage hepatitis C
testing. In particular, implement it in health departments
around the country in settings where testing for other
conditions like HIV is being done, to have this test also be
available. We fund hepatitis C coordinators in every State to
try to make this increase in testing happen, and also to work
with the private sector.
A second aspect of control of hepatitis C has to do with
prevention to chronic liver disease in people who have that.
CDC is active with NIH and other Department agencies to try to
define what's the best treatment for hepatitis C. Because in
fact, there has been substantial improvements in our ability to
treat hepatitis C, even over the last year or two, such that
now, individuals, if they're diagnosed, have a reasonable
chance with medical therapy, of being able to clear that
infection.
So we're working to try to increase public awareness of
hepatitis, particularly hepatitis C, increased testing and then
increase the likelihood that people that test positive can be
connected with the medical system.
COLORECTAL CANCER AND HEPATITIS TREATMENT
Mr. Miller. It's been brought to my attention that
something you all have is a national colorectal cancer
roundtable that has been very effective at bringing all the
different parties together on that subject. Would you describe
that and see whether this would be applicable in the whole
issue of hepatitis, to have CDC help organize all the different
parties involved in the issue, for communications of prevention
and treatment of hepatitis?
Dr. Fleming. Right. What we've learned with cancer in
general, and colorectal cancer in particular, is that it's
important not only to deliver programs that are specific for an
individual cancer, but to mobilize community and mobilize
providers around the general issue of cancer prevention. So CDC
is currently funding approximately 20 States around this
country to develop comprehensive cancer programs that include
colorectal cancer and colorectal cancer screening, where you
can engage the community and you can engage providers.
I think it is possible that that same kind of methodology
could be used effectively for hepatitis.
Mr. Miller. When they have the cancer roundtable, is that
in each State or one that's national?
Dr. Fleming. My understanding of this is that there is a
national group, but that in addition, we encourage at the State
and local level a similar kind of activity, such that people
who are involved, be it providers or patients or advocates, can
get together at the same place at the same time and work
together. That kind of strategy really is what drives all
public health. It will be a good strategy, I think, to think
about for hepatitis C as well.
When you think about it, hepatitis C in many ways from a
prevention standpoint and a testing standpoint, and linking to
cure standpoint, is not dissimilar to HIV. We can and are
working on better ways to integrate those programs and engage a
larger cross section of the community.
HEMOPHILIA
Mr. Miller. I would be interested in learning about this,
to encourage that type of roundtable for the whole area of
hepatitis, mainly C, because that's the large one.
One brief last question is, hemophilia. I don't know if you
know much about the program. Are you at all familiar? It's not
a big part of CDC, I know, but they really do a lot of good
work, for a long number of years. Their treatment centers and
funding, I don't know if you know much about them, I don't mean
to put you on the spot.
Dr. Fleming. That's fine. I do know that CDC has a close
association with the Hemophilia Foundation and we work
collaboratively with them to develop educational programs.
Mr. Miller. They've been flat funding their treatment
programs ever since I've been on this Committee, which is not
still a big program, but I know the work they've done in
different States has been very productive, mainly in medical
institutions and schools where they have them around the
country. So thank you, thank you for the good work and thank
you for standing in for Dr. Koplan.
Dr. Fleming. Thank you.
Mr. Regula. Mr. Kennedy.
Mr. Kennedy. Thank you, Mr. Chairman.
Welcome. I have a number of questions and a short amount of
time to fit them all in, spanning from oral health to asthma to
diabetes to heart disease and a whole host of things. So I'll
try to get through what I can.
Mr. Regula. We'll have another round.
CHRONIC CHILDHOOD DISEASE
Mr. Kennedy. That will be great. The Surgeon's General's
Report on Oral Health states that the dental decay is the most
prevalent chronic childhood disease, five times greater than
asthma. Furthermore, it also reports that dental decay is the
most frequently named unmet health need of children. It is my
understanding that generally speaking, pediatric dentists treat
the most severe cases.
But there are only 3,800 pediatric dentists in the country.
In my State, there are fewer than 10 pediatric dentists for
25,000 children who lack basic dental care. We literally have
kids in the Blackstone Valley whose mouths are rotting out.
Your budget justification says that the CDC is the Federal
agency with the primary responsibility for supporting State and
community efforts to prevent oral disease. It also mentions
that five States receive core funding and seven additional will
be added. I'd like to know what you are planning to do to do
more about this real crisis in child health in the area of oral
health care.
Dr. Fleming. Thank you, Representative Kennedy. I
appreciate very much your bringing this issue up.
Mr. Kennedy. You can comment briefly and then I can get
more for the record.
DENTAL CARE
Dr. Fleming. Okay. What I'd like to just mention then is
that we are going to be funding 12 States and one territory,
focusing on not only provision of dental care, but also from a
prevention standpoint, more importantly, fluoridation,
sealants, so that our children can be prevented from getting
into the position where they need dental care in the first
place.
Mr. Kennedy. Super. I look forward to working with you on
that. My State has a particularly critical problem there, and I
want to work with you there to get that problem addressed.
Given that many of our negative health behaviors escalate
in times of stress, could you comment on what the CDC is doing
to increase potential increase of chronic health problems
related to stress and negative health behaviors?
Dr. Fleming. This is an area that is one that we're just
moving into. You're absolutely right, mental health and
physical health are very closely correlated with each other at
all stages of life, particularly in the elderly. It's important
to recognize that mental health is an important aspect of
overall health. We're working primarily within the context of
our chronic disease programs in diabetes and cancer control and
heart disease to assure that as people work to attend to their
physical problems that they're also attending to the very
important issues that you're raising.
Mr. Kennedy. I'd like to get a detailed brief from you in
terms of what you're actually doing and where it is in the
budget and what programs you have out there to address this
area.
Dr. Fleming. I'd be happy to give that to you for the
record.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
CHRONIC DISEASE
Mr. Kennedy. I also want to comment on your bringing up the
subject of the chronic health, because as you know, the chronic
health disease prevention and health promotion line is cut by
$57 million in your budget. This is the line that deals with
such things as nutrition, physical activity, obesity, etc., all
things which are key to dealing with the epidemic unmet needs
around chronic diseases. So I just ask you also to comment
briefly about how you plan to make up for this unmet need of
chronic disease prevention by cutting the $57 million that
you're cutting in the chronic disease prevention line.
Dr. Fleming. The primary reason for that cut is the youth
media campaign. The President's budget does propose almost $700
million for chronic disease control, and that includes very
active and vigorous programs in diabetes prevention,
cardiovascular disease, obesity and nutrition. So we can do a
great deal with the resources that we're asking for.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
ASTHMA
Mr. Kennedy. Well, super. I look forward to seeing some of
those ads in Rhode Island. We'd like to see the media budget
when you put it together.
Asthma is of course growing at epidemic proportions,
particularly within the inner cities. It's becoming a very
serious health problem. So I'd like to ask you what it is that
you're doing to address this treatable chronic condition, which
is really just a question of getting the resources to where
there's the least insurance, I guess.
Dr. Fleming. Asthma is an epidemic disease in this country.
Its incidence has increased markedly in the past several
decades. We have cooperative agreements with approximately 30
States currently to work on asthma prevention strategies.
Asthma is preventable, you can't prevent someone from
carrying a diagnosis, but what you can do is control the
disease through environmental modifications in their home and
through assuring that they're educated on how to treat
exacerbations. We are working in these cooperative agreements
to do that, particularly in poorly served inner city areas.
DIABETES
Mr. Kennedy. Again, I look forward to getting into more
detail with you on it.
Finally, about the diabetes, do you think that there ought
to be a diabetes comprehensive program in every State, because
of the growing epidemic in diabetes, particularly as it relates
to the obesity question that you talked about earlier?
Dr. Fleming. Diabetes is epidemic in this country. The
cooperative agreements that we currently have in States that
have comprehensive care are showing unbelievable results with
as much as 35 percent reductions in hospitalizations for
diabetes, 30 percent reductions in incidence of amputation.
These are highly cost effective programs.
Mr. Kennedy. So if you had additional money, could you roll
it right out to the States for their comprehensive diabetes
control programs?
Dr. Fleming. There are additional States that do not have
comprehensive programs who are ready to do them.
Mr. Kennedy. So we'll look forward to working with you on
that.
Thank you, Mr. Chairman.
Mr. Regula. Thank you. Mr. Istook.
Mr. Istook. Thank you, Mr. Chairman.
Dr. Fleming, happy to have you here this morning.
Dr. Fleming. Good morning.
Mr. Istook. One of the things mentioned in the budget
justification for CDC talks about the problems of the emergency
personnel, the first responders at the World Trade Center
attack. And the challenge with having protective breathing gear
for them, certainly that's something we saw with the attack on
the Federal building in Oklahoma City. We've seen it in the
terrorist attacks. We see it in the concerns regarding
potential anthrax or other chemical or biological agents that
could be used in an attack, the need for respiratory
protection.
Your budget justification, of course, talks about NIOSH
becoming a part of trying to make sure that protective gearis
supplied. I'm concerned, however, that NIOSH for some years has been
the source of the problem, rather than the source of the solution.
Efforts to get them to certify the protective masks and separately the
variable filters that can be involved in different types of masks seem
to have gone nowhere. I guess they want a perfect scheme and the
perfect becomes the enemy of the good. Even emergency funding,
directions from Congress seem to have done no good.
Our first responders, police, fire and other emergency
personnel, as well as people doing everyday jobs where they
might be subjected to some other airborne agent, their lives
are at risk, their health is at risk. And NIOSH is dragging its
feet.
My question is very simple. Would you please tell us who at
NIOSH is responsible for this blockage and how do we get them
out of their positions?
Dr. Fleming. Thank you, Representative Istook. The
responsibility is CDC's, and we will work very hard, I'd be
happy to work with you individually to address your concerns. I
couldn't agree more with you that there is a critical need to
assure that our front line responders are protected as they are
protecting the health of others. We need to make sure that part
of that is effective respirators.
NIOSH has, over the last two years, as you know, created a
special part of the institute to deal with this issue. There is
substantial progress that is being made today, and I'd like to
get back to you on the record for that progress. I think you'd
be pleasantly surprised.
Mr. Istook. Well, I'm not, excuse me for interrupting, but
I'm not pleasantly surprised, because I hear they're saying,
well, we'll have something by the end of the year. That's not
the satisfactory time frame in my book. Even if they want
something that may have a longer time span, I would think they
could do some things on a provisional or emergency basis,
rather than saying by the end of the year.
Now, perhaps you're talking about a different time frame
than I've heard.
Dr. Fleming. We certainly will be working to speed that up.
In addition, there is substantial work right now looking at
collaborating with the Department of Defense, so that we can
take advantage of the mutual expertise that exists in both
places, to make sure that the process is as efficient, as
speedy as possible.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
ANTHRAX
Mr. Istook. I appreciate that, and I appreciate your
sharing the concern with the people that are on the front lines
of these situations and the risks that they face. Let me ask
one other question that relates to the overall airborne
contamination issue on this. I chair, for example, the Postal
Service Subcommittee. Certainly we're both familiar and CDC has
been very cooperative in working with the Postal Service on the
anthrax threats.
Part of the challenge that we have in trying to allocate
resources is assessing the level of that threat. You can talk
about the number of deaths, that each one was unfortunate and
horrible. Nevertheless, when we look at a perspective with what
percentage of the mail is contaminated, what sort of threat is
there, what are the vectors whereby somebody might obtain
anthrax or any other substance, part of the challenge we have
is in correctly assessing the level of the threat, so that we
can allocate resources to where the threats are the greatest.
Can you give us your best estimation of just how severe is
the threat or absence of threat of any future anthrax
contamination instances? I know you don't have a crystal ball,
but your best assessment is valuable to us.
Dr. Fleming. I'm not going to be able to do as good a job
on that as I would like, or as I'm sure you would like. I think
what we learned from these anthrax attacks is that mail is a
very efficient way to disrupt a system. The spores that got
sent through the letters, when you look, were very effectively
distributed. That's a great concern to us as far as threat is
concerned. Until the people or person, the people who did this
are caught and brought to justice, I think we need to be
prepared for them to do it again.
We are working closely with the Postal Service, given that
that's what we need to be planning for, to try to address the
issues that you're raising, what are the most appropriate
places to invest to provide the best possible protection for
the most people.
Mr. Istook. How much knowledge and control do you believe
that we now have over the places in the United States or with
access to the United States that have access to anthrax spores?
Dr. Fleming. I think through select agent and through
activities that many of the regulatory and law enforcement
agencies are taking, that we're doing close to as good a job as
can be done. But we need to recognize that with agents of
bioterrorism, and anthrax is an example, that these bacteria
exist in the environment. So there is never going to be a way
for us to absolutely preclude someone from obtaining these
agents and working in laboratories to make potential
bioterrorism agents. We can work as hard as we can, but that
threat unfortunately just cannot be eliminated.
Mr. Istook. Right. And it's tough to evaluate, as we both
know. Thank you, Dr. Fleming.
Mr. Regula. Mr. Sherwood.
FLUORIDATION
Mr. Sherwood. Thank you, Mr. Chairman.
I have two thoughts I'd like to get into today. One is a
follow-up on your discussion with my colleague Mr. Kennedy on
dental care, oral care. And you talked about the veryobvious
value of fluoridation.
I had an experience a couple of years ago of being in the
bush in northern South Africa for about two weeks. We had some
Zulu trackers and spotters and guides working with us,
remarkable men who had never lived anywhere where there was
running water, never been to a dentist, lived in a society that
by everything we would think was very, very primitive. These
men were in their 30s and 40s and early 50s, and they had
absolutely perfect teeth. White, sparkling, and they had never
been to a dentist, they had never owned a toothbrush. They had
never done any of the things we do, and they didn't have any of
the problems we have.
So fluoridation, unless there's naturally occurring
fluoridation in northern South Africa, wasn't their answer.
Dr. Fleming. I don't know whether there is naturally
occurring fluoridation in South Africa. There are many water
systems that do contain fluoride naturally. So that may be an
explanation.
In addition, though, I would point out that maybe what you
didn't see were the children or adults who did not have teeth
in that condition, and as a result of illness or infection had
died. In some ways, many of the health conditions that we're
seeing, we don't want to let natural selection be the process
by which we see healthy adults. I know that you weren't
implying that by any means. But there are differences, I think,
between the circumstances in South Africa and the circumstances
in this country.
Fluoridation in particular is one where it may not be
appropriate in every community. It needs to be a decision
that's made by community values. We need to assess the level of
natural fluoride in the water. But it's just one of those
things we need to have in our tool box.
Mr. Sherwood. And of course, you're correct, I was
interacting with the ones who had come through the system very
well. But I think a great deal of the problem, or the answer,
is diet. I don't think that they drank three Cokes a day or ate
all the sugar. So I think health care in this country and
dental care is to a large extent public information, changing
public behavior. I don't think with all our wonderful
discoveries, the thread we've had in these hearings the last
few days is that it takes 15 or 20 years to get out new
discoveries into the market place and being practiced. I just
wanted to emphasize that fact, that I think public health is
public education.
The other thing I'd like to ask you about, I represent a
community, a nice residential community that lives alongside a
huge landfill. They've asked your office, the Borough of Old
Forge, Pennsylvania, the officials of the Borough of Old Forge
have petitioned the Centers for Disease Control for a public
health assessment. Could you describe this process for the
Subcommittee, and maybe provide me with a little information on
the time frame for such a study?
Dr. Fleming. Sure, thank you, Representative Sherwood. I'm
aware of the request. We received it in the first week of March
of this year. This is a process that is actually done by CDC's
sister agency, ATSDR. The Director of CDC is also the director
of ATSDR. Dr. Henry Falk is the administrator there and is
currently reviewing the request.
Basically what it involves is first an assessment by ATSDR
of the specifics and then depending on what those specifics
are, working with appropriate members of the community and the
health community to take the appropriate steps. I'm being
vague, because without knowing the results of that initial,
preliminary assessment, what subsequently may happen could take
a whole wide range of different avenues. But we will make sure
to keep your office apprised of how that request is proceeding.
Mr. Sherwood. I would appreciate that, if you would get
back to me about it.
Dr. Fleming. Absolutely.
Mr. Sherwood. Thank you.
Mr. Regula. Ms. DeLauro.
Ms. DeLauro. Thanks very much, Mr. Chairman.
Thank you, Dr. Fleming. I'm sorry that I didn't hear your
testimony. The Subcommittee on Ag is meeting as well this
morning, so I'm kind of going back and forth.
If I can, I'd like to pick up on something that my
colleague just mentioned, and that is, public health is public
education. I think there has been some discussion of the
obesity epidemic in this Nation. In 1999-2000, 71 percent of
African-Americans, 59 percent Hispanic, 53 percent of whites in
the State of Connecticut were overweight. Long and the short of
it, and we know what the risk factors are involved,
cardiovascular, diabetes, cancer, to name a few.
We also know that this is a problem particularly among
youngsters. Let me just make a couple of points. The former
Chair of the Appropriations Committee, John Porter, said, ``If
advertising can influence decisions about what cars we drive
and what cereal we eat, why can't it persuade children to make
healthy lifestyle choices? Just as corporate advertising sways
young people to drink a particular brand of soda, it makes
perfect sense to harness the power of the media to convince
kids to eat right, to stay physically fit and drug free.''
OBESITY
When Dr. Koplan was here a while ago in response to the
testimony on the epidemic of obesity among children, which he
said was the obesity rate has increased by 100 percent since
1986, Chairman Porter allocated resources to the CDC for a
youth media campaign. He talked about unleashing the magic of
Madison Avenue to increase kids looking at healthy lifestyles.
In any case, that campaign was a partnership between CDC,
SAMSHA, HRSA, the NIH. Healthy diet, exercise, dangers of
tobacco use. Every day, 3,000 young people take up smoking.
Participation in high school in physical education programs
dropped from 42 percent in 1991 to 27 percent in 1997. Almost
three-fourths of young people do not eat the recommended number
of servings of fruits and vegetables. As many as 15 percent of
our young people age 6 to 17 years are considered overweight.
The youth media campaign, getting to my point, price tag,
no more than what Mattel spends on marketing the Barbie doll,
about $125 million. Not a high price to pay to curb an obesity
epidemic which costs this Nation every single year $100 billion
annually. That program, and I ask how can it be justified to
eliminate a campaign, even though when the odds are stacked
against our kids.
Let me just give you another point. We had, I think it was
the Department of Education, the physical activity program in
our schools has just been dropped. It's eliminated from the
budget. Physical activity dropped for kids, no campaign to deal
with lifestyles about the three Cokes a day, the candy bar with
the vending machine right there. Why are we pulling back on
those things that we thought would be responsive?
So again, why has this program been dropped from the CDC?
Dr. Fleming. Let me talk a little bit about the youth media
campaign. Thank you for raising it. I know at the last
appropriations hearing, we went through those charts showing
the obesity epidemic in this country. The only little point I
would take would be to say that it definitely is a problem in
children, but it's also a problem in adults. So we need to make
sure that we're attacking this across the board.
Ms. DeLauro. Amen. I concur with you.
TWEENS
Dr. Fleming. The youth media campaign is a program that's
designed to target behaviors in our kids, and particularly what
we call ``tweens,'' children between the ages of 9 and 13, of
which I have two.
Ms. DeLauro. Middle school kids.
Dr. Fleming. That's right. It's the formative years, that's
the point at which we can make the most difference.
And you're absolutely right, that there's a lot of
expertise out there on how to do this. What we've tried to do
with the youth media dollars is to take advantage of that
expertise and not have this be a Government program, but have
this be a program that represents the best of what the private
sector can contribute, not have it be a program that
immediately starts sending messages out that may or may not be
effective, but to take the 12 to 18 months that the private
sector takes to develop messages and make sure those messages
are message kids will respond to, and make sure that those
messages are integrated with community events. Because the
public media campaign alone can only be so effective. The
community needs to be involved as well.
That's what it is we're trying to do with the youth media
campaign, it's going to be launched in June of 2002. It will
get to full gear in October of this year, and it will continue
through the 2003 cycle.
Ms. DeLauro. It's going to be a private program versus any
kind of Federal resources?
Dr. Fleming. It will be paid for by the dollars that this
Committee has appropriated, but we're taking advantage of the
private sector expertise that exists out there to make the
efforts as effective as possible. Because of the fact that we
have taken this industry standard of 18 months to gear up to
figure out exactly what is going to be most effective, the
dollars that the Committee has already allocated will allow us
to continue the activities of this campaign in 2003.
Ms. DeLauro. How much money are we talking about?
Dr. Fleming. The first year's appropriation I believe was
about $125 million, and last year was $68 million.
Ms. DeLauro. So that $125 million is going to pay or to get
the private sector to develop a program?
Dr. Fleming. It is going already to get them to develop the
program. But then it also is going to be used in the coming
months to pay for the commercial air time to add the media part
of this and also to pay for the community involvement in the
cities that this program will be visiting.
Ms. DeLauro. How will that work? I don't understand. Tell
me how that is going to work and what will be our connection
with it. We've appropriated the money for the program, it's
going to go to, and I think we ought to think out of the box on
these things. If you've got commercial advertising, they know,
all of us like to think in our own efforts that we can design
the jingle, design the slogan, but we can't do that. I believe
in looking at it.
Just explain to me how this works and what our efforts
continue to be with it, and how does it get to the community
involvement piece. What's that process about?
Dr. Fleming. I'd be happy to provide you with a more
detailed answer on the record.
Ms. DeLauro. Please.
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Dr. Fleming. Basically, we are approaching this just as any
media campaign in the private sector. So the way that folks get
you to eat Cheerios in the morning or to buy a refrigerator of
a given brand, we are tapping into that expertise and into that
methodology to make these behavior messages get to our kids. As
a result, there is going to be a combination of innovative
media messages in venues that ``tweens'' watch, Nickelodeon,
for example, taking advantage of the private sector. There are
many in the private sector who know this is a problem and are
anxious to work with us.
Ms. DeLauro. Are they going to contribute dollars to the
programs?
Dr. Fleming. There will be in-kind contributions.
Ms. DeLauro. Is that in terms of buying the time and doing
things like that?
Dr. Fleming. I can get back to you.
Ms. DeLauro. If you can, right. If you can just lay out,
because I also am anxious to find out how you deal with the
community involvement in this local area, what is that going to
include. So if you could just lay all that out and when it will
start, what's your sense of its duration, so that we can be
thinking about what our obligations and responsibilities are.
Dr. Fleming. Absolutely. I'd be happy to.
One last point is that the key audience here are kids. So a
key part of our development process has been accessing those
kids in ways that are friendly to find out from them what are
the messages that are going to work. So kids to a large extent
are helping us design the effective messages.
Ms. DeLauro. That's great. I believe that kids can lead us
to adults. I think our kids did that on the environmental
issues, I think they'll do that on the smoking issue. If you
could just pass on to Dr. Koplan our regards, thank him for his
very, very good work. It was really a pleasure to work with him
over the years. Thanks so much.
Dr. Fleming. You're welcome, thank you.
Mr. Regula. Ms. DeLauro, you'd be interested to know that
two of our staff have looked at the media campaign and came
back very impressed.
Ms. DeLauro. That's great.
Mr. Regula. So I think you're off on the right track, and
of course, my staff has five teenagers or thereabouts. If she
thinks it will work for them, it must be good. [Laughter.]
Not that they necessarily need it, but she knows kids, what
they respond to.
I yield two quick minutes to Mr. Wicker.
Mr. Wicker. Thank you, Mr. Chairman, for your indulgence.
Just to echo what Mr. Sherwood and Ms. DeLauro have said, I
think you are going to find bipartisan support in
thisSubcommittee for this campaign. And I appreciate your answer to Ms.
DeLauro's question about doing it right and taking the time and
involving everybody. There is the other model, and I asked the director
of CMS about this yesterday. He decided that they needed an education
program about Medicare and Medicaid and found some money in his budget
and came up with a program in a matter of months which he feels is
effective.
So I just want to ask you and point out that this is taking
an awful long time. We're ready to go with it and I think we're
ready to support you on this. Ms. DeLauro is right, and you are
right, it is the children and it's also the adults,
particularly in this obesity question. It sounds so touchy-
feely for me to be saying the Government ought to be helping
people get the weight off. But it is an epidemic health
problem, all across the country. And I've seen the charts about
where it started and where it's expanded. It causes so many
other problems that we've just got to get a handle on it.
So I would urge you to speed up the process if you can.
Maybe get back to me on the record about the different
approaches that you took and that your agency took as compared
to CMS, where they got a program up and running real quick and
where we've taken a whole lot of time, maybe it is a little
frustrating to some of us on the Subcommittee.
Dr. Fleming. Thank you. I'd be happy to do that.
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Dr. Fleming. We are as anxious, I think, if not more
anxious than you are, to get this out. We want to make sure
that we're doing it right.
Mr. Regula. Mr. Obey.
NIOSH
Mr. Obey. Mr. Chairman, let me return to NIOSH. I was
observing earlier that yesterday we passed a brigadoon budget
under which our ability to meet all of our obligations in the
health area, education, DOD, science and the rest, under the
discretionary dollar limit imposed by the budget resolution
yesterday, disappeared into the mist as soon as it was voted
on. We're going to be left with the reality on this
Subcommittee and others that health education and worker
protection and a number of other areas are going to get
crunched. It seems to me that NIOSH is as good an example as
any.
My understanding of your responses, I should say my
understanding of the budget that the President submitted, is
that NIOSH would not be able to make any new extramural grants
under the NORA operation and that they would have to terminate
some existing grants in mid-stream. I'd simply like to note for
the record three examples of the kind of research that's done
under NORA.
There's research at the Washington State Department of
Health on improving the quality of data used in tracking
pesticide illnesses. Coming from a farm area, that's very
important to somebody like me. The research at the University
of Louisville on fertility problems in men working in polymer
production may not be very important to somebody who puts the
budget together at OMB, but it's pretty important to somebody
who is exposed to the problem.
Another example is research done by an organization called
Technological Systems Research on developing a device
preventing electrocution by mobile cranes. My grandfather died
of an electrocution. So I think that could be fairly important
to people who work around those things. I just think it's
important for us to understand what some of these numbers mean.
And then I would simply like to note again for the record,
in light of the discussion that occurred between Mr. Wicker and
me a few minutes ago, here's the record. On bioterrorism
preparedness funding, Congress provided $2.5 billion in fiscal
year 2002 in the emergency supplemental for bioterrorism
preparedness at HHS. That was in the DOD appropriations act and
was carried by that vehicle.
That was $1 billion more than requested by the
Administration. It was $250 million less than the amendment
that I had originally offered and had hoped to provide. And
here are some of the differences. In funding for State and
local health departments, we wound up providing $865 million
for grants to upgrade those capacities, as opposed to $65
million in the Administration's budget. For grants to upgrade
hospital planning and preparedness, this Committee provided
$135 million in comparison to the $50 million requested by the
Administration and the $200 million which we had wanted in our
original amendment.
For funds to upgrade in-house CDC capacity, $100 million
was provided by this Committee as opposed to the $50 million
requested by the Administration. For accelerated NIH research
on vaccines and treatments, $85 million was provided. The
President requested no supplemental funding for that purpose.
We had wanted to provide $115 million, so $85 million wasn't a
bad compromise.
In addition, that supplemental provided $70 million for
construction of high biosafety level labs at NIH to do that
kind of research, compared to zero requested by the President.
I simply wanted that in the record to again make clear what the
story was last year in terms of the resistance that we received
from the White House budget office and the President himself to
our efforts to react to what we had been told were emergency
needs by CDC, by HHS, by the FBI.
The FBI would still be clunking along with computers half
of which couldn't even send to another city a picture of a
suspected terrorist. We've now got the FBI up and running so
that their new computer system will be up and running
thissummer, rather than waiting the years we would have had to wait if
the White House had had its way.
So if I keep beating a dead horse, it's because I think if
we make enough noise about the nature of the disagreement last
year, maybe we won't have a disagreement this year, because
everybody will recognize the necessity for these kinds of
expenditures. So I'm really not asking you to comment, but I
wanted that spelled out in the record.
And I simply also would like to say, it will be interesting
to see who will in fact be appointed to fill the vacancy at
NIOSH. It is often possible to frustrate the ability of any
agency to defend the public interest by appointing a fox to
guard the henhouse. I recall years ago when Ray Bliss was the
Republican National Chairman under Eisenhower. I don't actually
recall it, I'm not that old, but I certainly read about it at
the time. There was that famous remark where he told the
members of the caucus, he said, look, fellows, you don't have
to vote against this stuff, we can just administer it to death.
And that was true, unfortunately. I think that I would hope
that whoever is appointed to run NIOSH will be someone who is
not seen as having been resistant to the past efforts of NIOSH
or OSHA to protect workers. That would be a prescription for a
lot of nasty fights and that would be a prescription that would
not be in the public interest. I don't have a whole lot to say
about that, but I think it's worth noting.
Mr. Chairman, thank you for the time.
Mr. Regula. Thank you. I have a couple of questions, then
we'll go to you, Mr. Jackson.
What's the status of your management reforms? Are you
making any progress?
Dr. Fleming. Yes.
Mr. Regula. I think the Secretary is very interested in
that.
Dr. Fleming. Absolutely. You know, effective management and
administration are a key part of any agency. I think being in
the Government both at the State and Federal level, it's
impressed me that for our trust and credibility, we just
absolutely have to have as effective management and
administration as possible. In that context, we are fully
supportive of both the President's and the Secretary's
initiatives on increasing management efficiencies. We're
working closely with the Department. Currently they've been
down, we've had really good discussions with them for how to
begin these changes, and we're excited about them.
IMMUNIZATION
Mr. Regula. Last year we provided over $85 million increase
for immunization. You've heard the discussion here. What are
you doing with that money, the increase and the money on
immunization? Are you trying to promote using it to get more
vaccines out?
Dr. Fleming. Yes. As we've talked, because of our success
in immunizations reducing disease, people have forgotten how
horrible these illnesses are. It's becoming harder and harder
to make sure that kids get the vaccines that they need. We need
to therefore work to implement a more systematic approach
through the registries that we talked about, through providing
increased dollars to State and local health departments to do
work at the local level.
In addition, we cannot forget that many of the vaccine
preventable diseases that have been eliminated in this country
are still causing devastating illness overseas. So for example,
$25 million of the dollars that the Committee allocated last
year went for the eradication of polio worldwide. I'm pleased
to report that we've made dramatic improvements in reaching
that goal.
There are only now about, as I recall, 10 countries in the
world in which polio exists. The number of cases has dropped
well over 99 percent since the 1980s. We're in that last mop-up
phase with polio eradication. But we need to make sure that we
have the resources to finish the job. The places where polio is
right now in the world, in places like Sudan and Afghanistan,
are going to be the most difficult places to finally, to
finally eliminate it.
Mr. Regula. It's remarkable what's been accomplished, when
you read the history of even our own society here, back a
couple of hundred years ago. My case in point, President
William McKinley used to represent the 16th district prior to
being Governor, then President. He and his wife had two
daughters, one was two and one was four, that died, I don't
know, some type of fever, both of them. Obviously with
vaccines, they would have survived. That's just a good example
of how that was, it was about 100 years ago.
POLIO
Dr. Fleming. Even in the early part of this century, the
leading cause of disability in this country was polio. And we
haven't had a case of polio in the U.S. for several decades.
Mr. Regula. We are so fortunate. Are you doing anything on
the registry? I'm intrigued by this idea. We are such a mobile
population, and people change doctors, we don't have the old
family doctor any more. It isn't part of our life as it used to
be, where you could call up and find out, gee, did I get a
vaccine when I was 10 or whatever. And the schools used to,
well, I guess they still do, it's very useful information.
There ought to be some way to have a data base on this.
Dr. Fleming. CDC, and we'd be happy to get that information
back to you on the record, in detail. But it is working with
many States to do this. The State that I used to work in, in
Oregon, in the old days, people would only have a single
doctor. But in the 1990s, the average kid had three, over three
providers that gave them immunizations at some point during
their first three years of life. It's that switching of health
care systems that makes it almost impossible to track, in the
absence of a select----
Mr. Regula. My granddaughter is seven weeks old, she's had
three doctors already. It's just a changing world. I think it
is something that would be very useful to pursue.
VACCINES FOR CHILDHOOD DISEASES
Dr. Fleming. Let me just mention one other point, which is
that as some of these new vaccines have become available, for
example, vaccines to prevent chicken pox or more recently, a
vaccine to prevent what's called pneumococcal disease, which is
a major cause of pneumonia and meningitis in children. The
costs of the vaccine themselves, of the routine vaccine series,
are going up.
So one of the things also that we've done with the money
that the Committee has provided us is use that money to
immunize the same number of kids, but those kids are now
costing more per child to immunize because of the fact that
there are these new vaccines out there.
Mr. Regula. Mr. Jackson.
Mr. Jackson. Thank you, Mr. Chairman.
And welcome, Deputy Director Fleming. I want to thank you
for your testimony and apologize for being a bit tardy.
Yesterday, the Institute of Medicine released a report that
this Subcommittee commissioned entitled UnequalTreatment. The
study found wide discrepancies in the health care received by whites
and by members of minority groups in this country. The report says that
health care gaps persist even when different racial groups have similar
incomes and insurance coverage.
For example, while 71 percent of white patients received
breast cancer screening, only 63 percent of black patients did.
For every 100 white patients who had a procedure to clear an
artery, only 74 black patients did. Black patients are over
three and a half times more likely to have a limb amputated as
a result of diabetes.
Director Fleming, on page 199 of your justification, at the
very bottom, you acknowledge many of these facts. Nowhere are
these interventions needed more than among our Nation's
communities of color. You cite several facts with respect to
cardiovascular disease and with respect to diabetes.
But on page 207, where it really matters--you've got the
facts on 199--but where it matters on 207--fiscal year 2001--
the request was at $37,810,000, for 2002, essentially level
funding. There is a small cut in 2003, if not level funding. In
light of the report by the IOM, my question to you, Dr.
Fleming, is why is the REACH program, that is, eliminating
racial and ethnic disparities, cut slightly from $37.81 million
to $37.55 million?
Constituents of mine, like Access Community Health Care
received a REACH grant two years ago and are working to
eliminate these disparities in my district and in Chicago. We
obviously need more organizations like this to do this kind of
work. But how can they do it when the program is essentially
flat funded and even experiencing some reductions in light of
the facts?
REACH FUNDING
Dr. Fleming. Thank you very much, Representative Jackson.
The specific answer to that remedy question about REACH funding
is that management deficiencies are the reason for that modest
reduction, and should not affect the amount of dollars that are
going out from CDC to your constituent groups.
Having said that, I could not agree more with you about the
need in this country to more directly attack health
disparities. The IOM report was only one part of that. That
said, holding level access, holding level cultural differences,
even when somebody gets into the system, we still have a
problem in this country where your race or your ethnicity in
fact predicts the level of care that you're getting. CDC I
think can contribute in that area, in the role that we do best,
which is providing more data to say, are there best practices
that will prevent that, are there areas in the country that are
doing a better job, are there health plans that are doing a
better job.
But that's only a part of the problem. Access to health
care is a second important part. And the third perhaps, from a
public health perspective, most important part, is making sure
that in our community program, independent of whether they're
REACH or HIV or diabetes or asthma, that we have programs that
reach those individuals that are affected, regardless of their
race or ethnicity, that we've taken the time to make sure that
those programs are culturally appropriate. We know that the
people who are delivering the messages to those communities are
respected by the communities and they oftentimes are perceived
as peers.
So I would not want you to take away from this that the
only part of CDC that is attending to the issue of health
disparities is the REACH program. That's a critical program,
but we are as hard as we can trying to make this issue of
health disparities in minority communities in this country one
that all of our programs are directly addressing with the
resources that are allocated to those programs.
MANAGEMENT EFFICIENCIES
Mr. Jackson. Would you care to explain to the Committee
what you mean by management efficiencies? The IOM study is
pretty clear in terms of what their recommendations are. We
need broader participation in terms of minorities participating
in health professions. Minority schools obviously need broader
participation from both Federal and State governments. They've
given a number of very, very important recommendations.
But you talk about management efficiencies. What does that
mean in terms of level funding? In light of the facts, which
your own report suggests are clear, that cardiovascular disease
is responsible for coronary disease and that death rates are 40
percent higher among African-Americans than the white
population, that the diabetes issue is 1.7 times greater among
African-Americans, 1.9 times greater among Hispanics, 2.8 times
greater among Native Americans.
I mean, I understand the rhetoric of, we're all for health
disparities. But on page 207, it's real specific. Eliminating
racial and ethnic disparities, 2001, $37.8 million, 2002, $37.8
million, 2003, $37.5 million a reduction of $259,000, when in
fact I believe this program, and I'm making it clear to the
Chairman, because I obviously plan in light of the IOM study to
fight for significant increases in light of the facts, what a
management efficiency is. What does that mean?
Dr. Fleming. I appreciate your comments. If you look at
across all the budget categories at CDC, not by any means
singling out the REACH program, you will see that there are
similar reductions in programs for reducing administrative
layers. So this is a Presidential initiative that we will fully
support that says we can do our job better than we're doing by
across the board, not just in REACH, but all the CDC programs,
look at ways to more efficiently manage and administer our
programs. Again, it's not something that's specifically
targeted at the REACH program. But it is across all the CDC
programs.
REACH PROGRAM
Mr. Jackson. Mr. Chairman, I know my time has just about
expired. I'm not suggesting that the REACH program isn't one
that's obviously worthy and deserving because of the facts. The
Nation's top scientists and doctors have come together in their
report and said that treatment is unequal. But it appears that
the President's approach for efficiencies across all of CDC is
running contrary to what the medical community is suggesting.
It is a significant problem that requires investment by the
Federal Government and the State to address a profound problem
in a way that it has not addressed it before.
So in the name of efficiencies, what you're suggesting to
me is that there will be less funds available to address the
profound problem that the medical community is suggesting needs
to be addressed in a forthright and very aggressive way. Is
that kind of what I'm hearing?
Dr. Fleming. We are going to work as hard as possible to
make it so that the dollars that go out from CDC are not
changed as a result of these changes. These are internal
efficiencies that we're going to effect within CDC.
Mr. Jackson. Thank you, Dr. Fleming. Thank you, Mr.
Chairman.
Mr. Regula. Mr. Hoyer.
Mr. Hoyer. Thank you.
Doctor, I presume what you're referring to in the
management efficiencies, I forget, what's the three word--we're
going to find out pretty soon, because I've been asking
agencies about it, in effect, what the Administration has done
is ascribed to all the agencies across the board a percentage
of savings that they are expected to accomplish. Is that what
you're referring to?
Dr. Fleming. That's correct, yes.
BSA
Mr. Hoyer. We'll get the phrase in just a second, but Mr.
Chairman, I think you've probably been hearing it as well.
As I understand it, when I asked the agencies on the
Treasury Postal Committee on this, these are assigned to you
and to the agencies across the board, business strategy
adjustment is what they call it, BSA.
But that it is essentially saying, look, we don't have
enough money so we're just going to take an arbitrary figure
of, I don't know what percentage it is, and ascribe that to a
savings. I think we obviously need to reinvent, Gore wanted to
reinvent, do more with less, I think businesses need to do
that, Government needs to do it. And we need to do it, frankly,
so we have more resources to help those people who are eligible
for programs but we don't have resources for.
As I understand it, those are not yet identified. Those are
simply targets given to you. I wont' ask you to write them as
arbitrary, but a number that you're supposed to get to.
Dr. Fleming. Our share of the amount is $27 million across
CDC and 125 FTEs.
Mr. Hoyer. And Jesse, that's referred to as business
strategy adjustment. Essentially what it means is, we've got X
number of dollars, we're going to effect savings, and you find
it in your budget. Most businesses do that, and I understand
that. But from our standpoint, the problem with that is, again,
it doesn't say, if we give you an objective, what it costs to
get that objective. It's an arbitrary savings.
Let me go to the continuation of my questions . I
understand somebody, Congressman Kennedy may have mentioned it,
but the National Center for Health Statistics, obviously
located in my district and therefore I have an interest in it,
but also I think critically important, because it is the agency
on which we rely to give us statistical framework within which
to make decisions, figure out what's going on. We reduced it by
$1 million. Now, is that a business strategy adjustment or is
that a judgment that has been made that we can save $1 million
because we found some better way of doing something?
Dr. Fleming. That's in the business strategy adjustment.
INFRASTRUCTURE
Mr. Hoyer. I would like, without going into detail on that,
when you answer my question on the overall CDC request, matter
of fact, I don't think I asked that. I'd like your overall
request for CDC, then the particular request for the
immunization.
By the way, when you talked about the children's, that
money does not provide for help with States' infrastructure,
does it?
Dr. Fleming. The children's--I'm sorry?
Mr. Hoyer. You referenced----
Dr. Fleming. No, that's money that goes directly to
purchase vaccine.
Mr. Hoyer. Right. So the infrastructure, which is part of
the problem, part of the challenge in getting immunization, the
State's infrastructure?
Dr. Fleming. That is correct. Now, just to be clear, the
other monies that go to the immunization program in fact do go
out to support State and local immunization programs.
Mr. Hoyer. I understand that. But my point is, you
referenced that in answer to the question, but those funds are,
we've got a freeze on the 631, they're not available for the
infrastructure.
Dr. Fleming. That's right.
CHRONIC DISEASE
Mr. Hoyer. If you could provide me with both the CDC, the
immunization and also for the health statistics fund.
Now, let me talk briefly, or ask you questions briefly
about chronic diseases. Essentially, Mr. Jackson has been
referring to that, and he's referring to it in the disparities
between the racial disparities and health consequences and
health research. Mr. Stokes, who was one of the finest members
that has ever served on this Committee and I in particular were
very concerned about the disparities at NIH, in terms of
cohorts, when we left our minorities and women. Jesse, in a lot
of instances, we had cohorts that we were doing research on
which did not include at least the percentages of women or
minorities that were necessary to get valid results for those
minority and women cohorts.
But chronic diseases. I want to focus on what you think CDC
is doing to ensure that we address chronic disease as
effectively as we can in light of the high proportion of
morbidity that relates to chronic diseases. In addition, if you
could reference obesity as it relates to the onset of so many
different chronic diseases, and what we're doing on that area.
If you travel in Europe, I presume you've been to Europe,
at conferences and things of that nature, the discrepancy
between obesity in the United States and in Europe is stark. I
don't have any study on that, there have been a lot of studies
on it, I know. But you just have to walk down the street and
see that to be the case. I'd appreciate your comment on that.
Dr. Fleming. Thank you. In this 2003 request, we're
requesting almost $700 million to effect chronic disease
control in this program. Chronic diseases account for about 75
percent of our $1 trillion national health care expenditure. So
in addition to it being a huge cause of illness and death, and
they are very expensive as well, and as all of us in this room
are getting older each day, those expenses are going to do
nothing but go up.
Mr. Hoyer. That's a vicious attack. [Laughter.]
Dr. Fleming. But you know, there's good news. Let me just
respond to that. With effective prevention programs, none of us
need to be looking at our old age as a place where we are going
to fall infirm and have many years of disability. In fact,
there are a number of studies that have shown that with
strategies that we already know and are already implementing
that we can significantly compress that window of morbidity
that maybe many of our parents have faced before they died.
That's a major goal of our chronic disease program. We
basically have two strategies. One is to directly attack the
diseases themselves, be it cancer, through our breast
andcervical cancer program, as an example, or diabetes, through the
programs I mentioned before, that are wonderfully effective, or heart
disease and the steps we can take there.
But in addition, we need to take a step back and look at,
what are the underlying risk factors that are present in us, in
this country, that we can influence so that people never get
that heart attack or that amputation from diabetes. So many of
our programs are also directed at issues like tobacco
reduction, improved nutrition, physical activity. The latter
two in particular are the strategies that relate to obesity.
You're right, we have an epidemic in this country.
I was just at a conference in Europe, however, that was
addressing this issue. And we are not alone. We're just leading
the charge here. The same transitions that have occurred in
this country with respect to obesity are now occurring in many
other parts of the world as well.
So programs that we're doing today to figure out how to
address this problem in this country will be programs that
we're going to need to do the technology transfer in the future
overseas. Having said that, we have pilot programs in a number
of States specifically targeting research and surveillance and
best practices to reduce obesity. There are proven programs out
there that represent a combination of improving diet and
nutrition, so people get the nutrition they need without the
calories, and increasing physical activity through school-based
programs, through urban design that makes it conducive for you
to go out and walk or ride your bike, through programs on the
work site and schools, that kind of thing.
Mr. Hoyer. Thank you. Thank you, Mr. Chairman.
Mr. Regula. Ms. DeLauro and Mr. Jackson would like to get
some----
Mr. Jackson. I don't have any more. I'll provide mine for
the record, Mr. Chairman.
Mr. Regula. Okay, Ms. DeLauro.
WISE WOMAN PROGRAM
Ms. DeLauro. Thank you, Mr. Chairman.
I just have really two questions. One has to do actually
with the breast and cervical cancer program and its extension,
if you will, to the Wise Woman program. Some women are very
interested in that. With that extension of Wise Woman is an
opportunity to look at a whole variety of other illnesses and
risk factors, if you will.
My understanding is that CDC currently funds ten ongoing
and two new Wise Woman projects in twelve States, tribes and
territories. How much would it take to fully fund the Wise
Woman program, so that all States and the women who live in
them will benefit? I have always been of the view that
geography shouldn't be the determinant of whether you live or
die, with some of these illnesses that they do uncover.
Dr. Fleming. The Wise Woman program, as you've said, is a
program that's designed to take advantage of the breast and
cervical cancer screening program, having women come into their
provider and then extending to them a range of other needed
health services that they need. And yes, there are 10 programs
currently where we are learning how best to do this.
In that context, they are almost demonstration projects. We
are right now, right now in the phase of evaluating how
effective those programs are and understanding the elements of
the program that would be amenable to a broader implementation.
So we will get back to you for the record on what that looks
like.
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Dr. Fleming. But it may in fact be, oh, six months to a
year's worth of additional evaluation of what's working and
what's not working with this program before we would be
prepared to say, here's the model that we think would be able
to be mass produced everywhere.
Ms. DeLauro. But it's six months to a year before you have
the information that you need to be able to make a----
Dr. Fleming. That's correct, yes.
BREAST AND CERVICAL CANCER PROGRAM
Ms. DeLauro. And the breast and cervical cancer program is
in every State?
Dr. Fleming. Yes, that is correct.
Ms. DeLauro. How long did it take us to get those programs
across the country?
Dr. Fleming. That was before my time at CDC, but I was in a
State at the time, and I think it was on the order of three to
five years, with the gradual implementation, each year, as you
remember, of the program into additional States.
Ms. DeLauro. What I'm saying is, I understand, my hope is
that we would, with understanding the success of the breast and
cervical cancer program in every single State, we've now just
expanded the capacity to deal with the cardiovascular and the
heart disease, high blood pressure, cholesterol efforts, it
would just seem to me, my hope is that we don't have to take
the same amount of time to do what we did.
We do have a model, it's working, we've added these
otherpieces. We ought to be able to pretty quickly tell whether or not
we're succeeding at this and be able to implement this statewide much
more quickly than we were as if this were just a brand new startup. It
is not a brand new startup, I think you would agree with me on that.
Dr. Fleming. Absolutely.
OVARIAN CANCER
Ms. DeLauro. So if there is something that we can do just
to make sure that we move more quickly on this follow-up. Thank
you.
And if I could just ask, on ovarian cancer, if you could
just tell me about the work that's being done through the
ovarian cancer control initiative, and where you go from here,
what kinds of additional funding do you need to help move this
effort. We don't have an effective screening tool yet.
I just left the Ag Committee where they talked about, the
FDA has talked about their work with NCI, and looking at new
potential tests and so forth and so on. So I just want to get a
sense of where you are.
Dr. Fleming. Sure. Well, as you've said, there is no
primary prevention strategy for ovarian cancer. So the
intervention rests on us identifying earlier women who have the
disease so they can be appropriately medically treated.
Currently, we have projects funded at about $4.6 million, and
they're designed to enable us to figure out how better to do
that targeting, by looking at the characteristics for example,
of women with ovarian cancer who've been diagnosed early and
diagnosed late, and say, what's the difference here? What was
the critical, in retrospect, element that allowed for that
early diagnosis?
Then second, working with, I believe it's Battelle,
conducting a study looking at, what are some of the best
practices out there for physicians? What kind of training is
needed to enable better diagnostic procedures, ultrasound,
pelvic exams, that kind of thing. Then third, we're working
with our cancer registry system to make sure that the
information that we have about ovarian cancer in individual
localities and the country as a whole is being made as quickly
and as easily accessible to the researchers who need to have
it.
Ms. DeLauro. Because the research is proceeding. There are
some very new discoveries, obviously, there's not any date
certain. But I had ovarian cancer 16 years ago, 16 years ago
this month I was diagnosed with ovarian cancer. But we still
have yet to find a screening for ovarian cancer. The research
is getting better and better and better. And what we need to do
is get the information to physicians, etc., and women about
what to look for. Maybe that's the new piece we can add on
these clinics that we're getting across the country.
Another piece, my point is, that that kind of public
education, so that those signs are looked at as quickly as
possible is critical to life and death, particularly with the
new developments. So again, what kind of additional funding do
you need for this effort?
Dr. Fleming. Thank you. I'd be happy to get back to you on
that.
Ms. DeLauro. Okay, please. Thank you.
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IMMUNIZATION INFRASTRUCTURE ISSUES
Mr. Regula. Just a couple of quick questions. To what
extent will the funding provided for State and local capacity
help with the immunization infrastructure issues?
Dr. Fleming. The bioterrorism dollars?
Mr. Regula. Yes.
Dr. Fleming. The dollars will not be used for directly
giving immunizations to children.
Mr. Regula. No, but it will create an infrastructure.
Dr. Fleming. Absolutely. The immunization program in every
State is only part of the health department and relies on that
health department for many of its critical, underlying
services, be it health communication or information technology
or connectivity. These dollars that are being used for
bioterrorism are designed to improve directly bioterrorism
capacity, but also those key underlying critical capacities to
make any health department effective. That will be the payoff.
Mr. Regula. Are State and local health departments getting
beefed up over the past months, working with CDC?
Dr. Fleming. Absolutely.
Mr. Regula. It seems like that was somewhat of a soft spot
in this whole thing, prior to 9/11.
Dr. Fleming. I agree. State and local health departments
responded wonderfully to 9/11 and to anthrax. But what we
learned is that what they had been saying all along is true,
that part of the problem here is just the inadequate
infrastructure and resources to do their job right. These
dollars that have already gone out to them and are in the 2003
budget are going to go a long way.
I can't tell you, Mr. Chairman, how excited State and local
health department directors are right now. It's fun to go out
now and visit.
Mr. Regula. They've been in the wilderness a long time, and
suddenly they're pleased that they're being recognized as an
important element.
Dr. Fleming. Exactly right.
ENVIRONMENTAL IMPACT ON HEALTH
Mr. Regula. I think it's vital we continue to strengthen
them. They're on the firing line.
One last one. Environmental impact on health. We had $17
million, I think. Are you working in that field?
Dr. Fleming. Yes. This is the program to improve, again,
State and local departments' ability to track environmental
figures.
Mr. Regula. Mr. Hoyer raised the question of asthma. That's
got to be an outgrowth of environmental impacts, am I correct?
Dr. Fleming. Right. One of the things that this $17 million
is going to go for is to say, okay, we know something about
where asthma is. But that information has never been linked
with where are the environmental problems in thecommunity----
Mr. Regula. Yes, where they go together.
Dr. Fleming. Exactly right.
Mr. Regula. Any last question?
Mr. Hoyer. Mr. Chairman, if I could, I know you want to get
them out of here----
Mr. Regula. You have two minutes.
CHRONIC DISEASE
Mr. Hoyer. In my two minutes, therefore, there has been in
the chronic disease, there's a $57 million cut, as I understand
it, in the chronic disease area. In Maryland, we don't have a
program for arthritis, we don't have one for cardiovascular
disease, nutrition, physical activity or school health. Maybe
others, but at least those, in terms of CDC's involvement.
Without a $350 million increase to the disease prevention
program at CDC, how will Maryland or other States that are not
included meet the demands of chronic disease? I will ask you to
submit for the record, along with the other issues, a detailed
breakdown of the cuts to these and all other chronic disease
programs that will result from the $57 million cut.
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Mr. Hoyer. If you want to have a general answer----
YOUTH MEDIA PROGRAM
Dr. Fleming. The $57 million is primarily for the youth
media program. So the funding for our programs in arthritis and
cancer, etc., are not being affected by that reduction.
But there is a mismatch, where there are proven strategies
out there that are not being implemented because the resources
aren't available.
Mr. Hoyer. Thank you. Thank you, Mr. Chairman.
Mr. Regula. Thank you. Doctor Fleming, you've done a nice
job this morning. You've had a lot of very useful information.
I wish we had more time. I'm pleased we had a good turnout of
members, given the fact that this is the first day of our
recess. And you remember from your school days what recesses
do. [Laughter.]
PUBLIC HEALTH
Mr. Hoyer. Mr. Chairman, I think it's a reflection, as you
well know, and I think you articulated in the beginning, I
think we dwell perhaps too much on the fact that September 11th
changed the world. I think that is correct, I think it did. But
in fact what it did was it focused us as well on doing some
things that we knew were important.
You referred to public health. I've met, as you have, I'm
sure, with my public health officials in the five counties that
I represent. And all of them were very frustrated that prior to
September 11th, a very important facet of our public health was
not focused on. September 11th brought a focus to it.
As a result, CDC's importance, I think, has also been
emphasized. What we need to do is make sure that it is
emphasized not only from the fact of bioterrorism or the
threats that that causes us, but really the much broader
threats caused to us by non-terrorist activity, but naturally
occurring activity, which when you talk about the millions of
people that are dying daily in the world, in Africa from AIDS,
you know, are really a much greater threat to mankind in the
long term.
The environmental, you mentioned environmental, in the
Baltimore area, asthma is becoming a much more critical problem
and much more higher incidence of asthma in our urban areas,
obviously tied to environmental effects.
Thank you, Mr. Chairman.
Mr. Regula. Thank you.
Thank you, Dr. Fleming. And give our best to Dr. Koplan,
tell him we missed him this morning, and we appreciate all the
good work he's done. As Mr. Hoyer pointed out, you've got a
well kept secret, not so secret any more. But little by little,
the public is getting a growing awareness of the importance of
this agency to their well being.
Thank you for coming. The subcommittee is adjourned.
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Tuesday, March 12, 2002.
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
WITNESSES
CHARLES G. CURIE, M.A., A.C.S.W., ADMINISTRATOR
RICHARD KOPANDA, EXECUTIVE OFFICER
KERRY WEEMS, ACTING DEPUTY ASSISTANT SECRETARY FOR BUDGET, OFFICE OF
THE ASSISTANT SECRETARY FOR BUDGET, TECHNOLOGY AND FINANCE
Opening Statement
Mr. Regula. We will get started.
Carrie, I understand you are going to introduce one of your
constituents. We know you are a very busy and influential
person.
Mrs. Meek. Thank you, Chairman Regula and members of the
subcommittee. Every once in awhile as a Congressperson we get
the unique opportunity to introduce some very outstanding
people to the committee. This is one such day. I am very
honored and proud to introduce to you, for her first appearance
before this subcommittee, a dear friend, a wonderful human
being, and a true champion for the elderly, Ms. Josefina
Carbonell, the Assistant Secretary for Aging in the Department
of Health and Human Services.
Ms. Josefina Carbonell has extensive experience in dealing
with issues of importance to the elderly community. As the
Executive Director and Co-founder of the Little Havana
Activities and Nutrition Centers of Dade County, she is one of
the persons, Mr. Chairman, who has been I think a tireless
worker and a pioneer in providing nutrition and social services
to south Florida's seniors, so she knows about what she speaks.
She is not all theory. She can bridge the gap between theory
and practice in providing health, nutrition and social services
to south Florida seniors.
Her leadership and solid management still has made possible
the diversification, development and transformation of the
Little Havana Activities and Nutrition Centers from one small
site in Dade County to the largest aging, health and nutrition
project in Florida, and the largest Hispanic geriatric health
and human service organization in the Nation.
I can't think of any better suited to be our Assistant
Secretary for Aging than Josefina Carbonell. Her experience as
a care provider and an advocate for seniors make her a
wonderful choice to lead the Administration on Aging and help
us tackle issues facing America's seniors.
I am very privileged and pleased, Mr. Chairman, to
introduce to the committee Josefina Carbonell.
Mr. Regula. You could not have a better endorsement from a
better person. We know that you are good. She is also a member
of the powerful Appropriations Committee.
Mr. Curie, you are the Administrator of Substance Abuse and
Mental Health Services Administration. I assume that you have
support here with the two other panel members.
Mr. Curie. Yes, I do, Mr. Chairman.
Mr. Regula. We are pleased to welcome you. Your testimony
and anything else that you would like will be put in the
record.
Mr. Curie. Mr. Chairman, and Members of the subcommittee, I
would like to take this opportunity to introduce Mr. Richard
Kopanda, SAMHSA's Executive Officer, and Mr. Kerry Weems, the
Acting Deputy Assistant Secretary for Budget in the Office of
the Secretary, Department of Health and Human Services.
I am honored to present the President's 2003 budget request
for the Substance Abuse and Mental Health Services
Administration. Overall, the President has proposed slightly
more than $3.2 billion for 2003, an increase of $57 million
over last year's appropriation.
In the short time since November that I have spent as
Administrator, I have had a chance to begin to learn about what
is happening inside SAMHSA, and its relationship with State and
local governments, consumers, families, service providers,
professional organizations, our colleagues in HHS, Education,
Justice, the Office of National Drug Control Policy, and
Congress.
I would like to take a moment to recognize some of the
leaders in the substance abuse and mental health services
fields that are in attendance today. I am going to read their
name and then the organization with which they are affiliated:
Ellen Garrison from the American Psychological Association;
Julio Abreu from the National Mental Health Association; Jay
Cutler from the American Psychiatric Association; Donald
Whitehead from the National Coalition for the Homeless; General
Arthur Dean and Sue Thau from the Community Anti-Drug
Coalitions of America; Jennifer Collier, who is representing
both the Legal Action Center and the State Association of
Addiction Services; Andrew Sperling with the National Alliance
for the Mentally Ill; Tom Bryant, National Association of
County Behavioral Health Directors; Karen Freeman-Wilson, the
National Association of Drug Court Professionals; Kathleen
Sheehan, the National Association of Psychiatric Health
Systems; Rob Morrison, National Association of State Alcohol
and Drug Abuse Directors; Andy Hyman, the National Association
of State Mental Health Program Directors; Sis Wenger, National
Association for Children of Alcoholics; John Avery, National
Association for Alcoholism and Drug Abuse Counselors; and Dr.
Monica Gourovitch, Distilled Spirits Council of the U.S.
I thank them for being here, and appreciate both their
support and yours for our budget proposal.
As you may know, most recently I served as Commissioner of
Mental Health and Deputy Secretary for Mental Health and
Substance Abuse in Pennsylvania during Governor Ridge's
administration. With that background, I have known SAMHSA from
the outside and from the State perspective. I have also worked
at the community level as the CEO and Director of a Community
Mental Health Center in Carlisle, Pennsylvania and the Sandusky
Valley Center in Tiffin, Ohio. Over the years I have seen many
examples of true partnerships between SAMHSA and its
constituent groups. In the short time I have been atSAMHSA, I
have found a staff dedicated to achieving the vision of providing
people of all ages with or at risk for addictive disease and/or mental
disorders the opportunity for recovery and a fulfilling life that
includes a job, a decent place to live, family support and meaningful
relationships.
Ours is a shared vision of hope and recovery, focused on
providing individuals an opportunity for meaningful life in
their community.
To provide a focus for SAMHSA's activities, on page 5 of
our chart book we have identified a matrix of investment
priorities and cross-cutting principles. The matrix is included
in your handouts, and it helps guide where we want to put our
efforts and resources.
You will see among our investment priorities the
administration's New Freedom Initiative. Its focus is on
providing community-based alternatives for people with mental
illnesses. It is central to SAMHSA's overall vision.
Also within the context of the New Freedom Initiative is
the forthcoming President's Mental Health Commission. The
Commission will develop an action plan for investing and
coordinating Federal, State and local resources to serve people
with serious mental illnesses and children with serious
emotional disturbances.
Another priority for change is eliminating the abuse of
seclusion and restraints. The use of these practices represents
a failure of our treatment system. The President has also
expressed his commitment to reducing drug use, building
treatment capacity and increasing access to services that
promote recovery and help people rebuild their lives. He has
proposed an increase of $127 million in our budget to help
States and local communities to provide increased access to
treatment services.
SAMHSA's National Household Survey on Drug Abuse found in
2000 that approximately 381,000 individuals recognized their
need for drug treatment. About 129,000 of these people reported
that they made an effort, but were unable to get treatment. We
are working with the Office of National Drug Control Policy and
the States to implement a plan to reach out and bring these
people into quality addiction treatment services.
Mr. Regula. Are you saying that there are communities that
do not have facilities?
Mr. Curie. Most communities do have facilities; the issue
is capacity and access. Since the survey was conducted, we have
been honing in on those areas and having States identify areas
where they are seeing lack of access. That is where we want to
direct a major portion of the $127 million.
Another priority includes working within the criminal
justice system. Too often jails and prisons are substituting
for community-based care for far too many people with mental
illnesses and drug problems.
Reentry and diversion programs need to encompass not only
treatment, but also housing, vocational and employment services
and long-term support. Only when we address the issues of
mental illness and addiction will the revolving door between
prisons and life in the community stop spinning.
Some of these very same issues explain why reducing
homelessness is on our list of priorities. We know that many of
the people who are homeless have mental or addictive disorders,
with similar needs for treatment and long-term support.
SAMHSA also has a critical leadership role to play in
addressing the needs of people with co-occurring disorders. A
large number of people who are in our substance abuse or mental
health service systems have co-occurring disorders. Too often
they get care for one disorder but do not get care for both.
That is not just bad health policy, it is bad economic policy.
We could serve more people if we spent that money more wisely
in the first place.
People with HIV/AIDS who abuse substances or live with
mental illness have another kind of co-occurring illness that
remains high on our list of priorities. Our efforts will
continue to grow in the area of HIV/AIDS.
Finally, the terrorist attacks of September 11 put a new
public spotlight on mental health and substance abuse. Within
24 hours both SAMHSA staff and $1 million in immediate
resources were on the way to the State of New York. Within a
week, an additional complement of personnel and an additional
$6.8 million was made available not just to New York but to the
other eight affected jurisdictions. Within a month, another
$21.2 million was awarded to these States.
At the direction of Secretary Thompson, within 2 months
SAMHSA convened a presummit meeting, enabling the nine most
directly affected jurisdictions to share and learn from their
experiences in terms of the mental health and substance abuse
consequences of the attacks. Within 8 weeks, SAMHSA convened a
national summit with representatives from 42 States, the
District of Columbia, five U.S. Territories, two Native
American tribes, and 100 national public service, faith and
community based organizations.
We convened this conference to examine and enhance the
local, State and Federal role in addressing the mental health
and substance abuse needs of individuals and communities
before, during and after acts and threats of terrorism. As a
result, State teams appointed by their respective governors are
refining their current disaster plans to ensure the readiness
of mental health and substance abuse services in their
communities for the ongoing war on terrorism and in the event
of future attacks on the homeland.
An additional $20 million was appropriated in 2002 to
address post-traumatic stress disorders in children. The
President's 2003 request continues SAMHSA's involvement by
proposing an additional $10 million for efforts that focus on
the mental health consequences of bioterrorism activities.
Other activities supported in the budget proposal focus on
post-traumatic stress disorders, the mental health needs of
first responders, and preparation for potential future
bioterrorism emergencies.
To ensure that all of SAMHSA's programs are science based,
results oriented and aligned with the agency's mission, we have
initiated a strategic planning process that will guide our
decisionmaking in planning, policy, communications, budget, and
programs. The process is evolving around three core themes:
accountability, capacity and effectiveness. In short, we are
calling it by its acronym, ACE.
Even before that plan is set in place, we have already
taken steps to expand our partnership with the National
Institutes of Health to produce a comprehensive science-to-
services agenda that is responsive to the needs of the services
field. We have initiated a dialogue with the Institutes, and
have found a common commitment to this agenda. Over the next
year, we will be working together to define and develop a
science to services cycle that reduces the time between the
discovery of an effective treatment or intervention and its
adoption in community-based care. The Institute of Medicine
tells us that that translation can take up to 20 years. With
the near doubling of the NIH budget driving even more clinical
research and development, that gap may grow still greater
unless a fundamental change occurs in how scientific advances
are incorporated into community care.
Mr. Chairman and members of the Subcommittee, our matrix of
program priorities and cross-cutting principles, our strategic
planning process and our commitment to speeding research
findings to community-based care will allow us to see real
progress in the outcomes we seek.
The ultimate measure of our effectiveness will be gauged on
our ability to provide people of all ages with mental and
addictive disorders an opportunity to realize the dream of
equal access to full participation in American society.
Thank you for the opportunity to appear today. I look
forward to learning more about your ideas about how SAMHSA can
achieve its potential, and to working with you during my tenure
as SAMHSA Administrator. I am pleased to answer any questions
you may have regarding our budget.
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SUBSTANCE ABUSE PROGRAMS
Mr. Regula. We will have a number of questions for the
record, of course. Your agency has identified a number of needs
and economic costs; and yet, and I am talking about substance
abuse, your budget is down $25 million. That does not seem to
square.
Mr. Curie. $25 million [clerk's note: later corrected to
$45 million] in the substance abuse area.
Mr. Regula. You reduced your prevention program by $45
million.
Mr. Curie. There is a $45 million reduction in the budget.
As I mentioned in the testimony, one of the basic premises in
this budget is to establish a clear science-to-services cycle.
We are a services administration, and over time SAMHSA has been
involved in research-oriented activities. It is important for
us to be engaging the NIH Institutes on an ongoing basis with
respect to their research agenda.
That reduction in the CSAP budget is related to identifying
best practices through a research modality. What we are looking
to do now is partner with NIH to ensure that the activity
continues within the Federal Government, and that those dollars
are not lost in terms of the overall research agenda. That is
why it is going to be very critical for us as we take a look at
our budget to ascertain that the dollars that we do have in the
CSAP budget continue to support direct services programming,
ensuring that prevention is available in the communities, and
then partner with the Institutes in order to establish their
role. We must work with our constituency groups as well as the
Institutes to define a services research agenda for both
prevention and treatment, and then define our role in
continuing pilot programs based on those research findings with
strong program evaluation components. As we move ahead, we will
utilize the $600 [clerk's note: later corrected to $500
million] million we still have in prevention with the block
grants and capacity expansion programs.
We have had some difficult choices to make in this
particular budget process. Again, we took a hard look at the
appropriate role we should be playing, a hard look at the role
the Institutes should be playing, and really do believe those
reductions are going to be made up in partnership with the
Institutes and not have an adverse impact on the overall level
of services.
Mr. Regula. Walk me through. Substance abuser A in
community X, how does your program reach this individual? What
is the procedure?
Mr. Curie. There are a variety of ways. Our responsibility
for ensuring that both prevention and treatment activities are
supported in the community is accomplished by partnering at the
Federal level with other departments as well as with the
States.
Mr. Regula. Once you partner, then what happens?
Mr. Curie. Then the States, using both block grants as well
as targeted capacity expansion grants, contract with and grant
or allocate dollars to local communities and service providers
to ensure that services are rendered. Where the partnership is
important is in coordinating all the dollars that are going
from the Federal Government in the area of prevention, and
treatment and ensuring that they are working in concert as they
support activities at the local level.
We need to be providing prevention services in conjunction
with schools and other institutions that exist within
communities, including faith based organizations, working with
organizations such as the Community Anti-Drug Coalition of
America that General Dean and Sue Thau are here representing.
We need to ensure that those ongoing partnerships exist and,
through the grant process and State planning, that our
resources are effectively reaching the communities.
Mr. Regula. How do they reach the individual?
Mr. Curie. Through community-based providers.
Mr. Regula. Such as?
Mr. Curie. Such as the drug and alcohol providers which
currently operate in most communities.
Mr. Regula. Are these nonprofits?
Mr. Curie. Many are nonprofit, and many are for profit.
They get funding through block grants, indirectly through the
States, primarily. On the substance abuse side, SAMHSA is a
primary source of State funding. In other words, most of the
funding that goes from SAMHSA to the States through the State
drug and alcohol authorities are combined with State dollars.
Mr. Regula. Do the States pay their fair share?
Mr. Curie. Yes. They have to maintain effort to meet their
block grant maintenance of effort requirement. If one looks at
Pennsylvania, from whence I came, the dollars that we used
included the block grant dollars through the Drug and Alcohol
Authority, Medicaid or medical assistance dollars, and also
State dollars. These were combined at the State level to
contract with providers through county systems of care and
community systems of care. You may have a variety of providers
supporting inpatient services, detox services, outpatient
services, prevention services provided in schools, and services
in other institutions in the community.
Mr. Regula. I know you are new on the job, but do you look
at these programs and say is there a real cost-benefit here?
Are we changing behavior in the U.S.A. because of what we do?
Mr. Curie. Yes. In fact, we have been able, over a period
of years, to define most of those factors and principles which
do make a difference in terms of preventing substance abuse, as
well as assuring positive treatment outcomes.
Mr. Regula. How do you translate that into an individual
who has a problem?
Mr. Curie. Again, the treatment needs to be individualized.
We rely on the expertise of the providers who receive funding.
We have also been able to isolate factors which contribute
to ensuring that children do not begin to take drugs, or
diminish their drug abuse once they are in treatment programs.
We have identified model programs of prevention which have
decreased substance abuse by as much as 25 percent.
Mr. Regula. You are saying in the United States it is down
25 percent?
Mr. Curie. Not overall, but those are programs that we have
been able to identify as highly effective. What we need to do,
Mr. Chairman, is to make sure that as we identify such model
programs--and we have identified 39 in the prevention arena
that have demonstrated outcomes of reduced substance abuse with
young people not initiating drug use in the first place--our
goal now becomes ensuring that those factors are at play and in
place within programs throughout the country.
Mr. Regula. Do you pass this information on through some
sort of a Web site or bulletin to agencies across the country?
Mr. Curie. Absolutely. We have a Web site that receives
thousands of hits on a daily basis. Also, we have an ongoing
dialogue with State drug and alcohol authorities, and State
mental health authorities to communicate to them the latest
findings.
Mr. Regula. Overall do you think we are making progress?
Mr. Curie. I think we are making progress in understanding
what works. Where we need to make continued progress is
applying what we know and realizing the restructuring benefits
in the service delivery system. Our biggest challenge at this
point is moving systems in the direction of implementing known
best practices.
Mr. Regula. Do you think you are going to meet that
challenge?
Mr. Curie. I think we are. We will be working in
partnership with ONDCP, and the only way we are going to meet
the challenge successfully is through that type of partnership.
I mentioned work with the Departments of Justice and Education,
our other Federal partners, whose cooperation is going to be
critical. They work with institutions which impact the lives of
virtually every American in some way. SAMHSA needs to be about
leveraging those relationships and partnerships.
Mr. Regula. Mr. Sherwood.
Mr. Sherwood. Thank you, Mr. Chairman.
It is good to see a fellow Pennsylvanian.
Mr. Curie. It is good to see you, Mr. Congressman.
DEMAND FOR SERVICES
Mr. Sherwood. As appropriators, we understand that
everybody who works in your field has superior expertise and
the best motives in the world, and we understand that there is
tremendous demand for your services, but I would like to follow
up on the chairman's question.
How do we measure that we are making progress? Other than
we are just trying to do good, how do you justify to us that we
are going in the right direction and we are making progress? In
other words, what figures do we use or what information do we
have to tell us that we are reducing demand and we are helping
the overall problem, because as we look at it from a
layperson's point of view, that does not seem evident.
Mr. Curie. Understood. I believe that is a responsibility
of SAMHSA to disseminate information about effective services
and quantify service improvement as best we can. It is very
important to assess outcomes. Again, that is part of our
strategic planning process. SAMHSA must focus not just on
ensuring that treatment is available, but ensuring that
treatment works and that it translates into the people in the
community breaking the cycle of addiction, and being able to
manage their mental illness.
As I mentioned earlier, we know more about what is working
now through a variety of programs we have had in place with
strong evaluative components. Within the last two weeks we
released a study of the high risk youth program conducted by
our Center for Substance Abuse Prevention. We found that there
were interventions which brought down drug use substantially.
If one compares the control group that was not involved in the
program with the group that was, after an 18-month period the
people who went through the program abused drugs 28 percent
less than the control group. We were able to isolate factors
regarding how to tie programs into families and strengthen
families, how to work with children and adolescents, how to be
involved with schools and institutions.
That is an example of a program that works, consistent with
the model programs that I mentioned earlier. SAMHSA's
responsibility is to examine what is working in particular
situations and begin to focus on those services as part of the
overall system of care.
We can assess overall progress through the National
Household Survey. We also have an early warning network through
emergency rooms, and we use these systems to assess overall
ongoing usage. On page 21 of the chart book is an example of an
impact that we have seen on marijuana use. We noted that the
mid to late 1990s, marijuana use among those in the 12 to 17
age group increased. We are beginning to see that come down
now, achieving specific goals that we have set in partnership
with ONDCP. It will be very important for us to ensure that we
are implementing effective programs and documenting what works.
The bottom line is that we know much more about what works
today. It is a matter of seeing that knowledge applied.
Expecting results from the delivery system is going to be a
major focus in the future. We owe it to you to be able to not
only demonstrate and implement programs which work, but also to
work with you to determine how SAMHSA can invest our existing
resources in those programs that are showing positive outcomes.
That is going to be a major planning priority for SAMHSA in the
coming year.
Another CSAP example, is in the workplace. We are seeing
appropriate drug and alcohol treatment interventions that, for
every dollar invested in treatment, prevention and Employee
Assistance Programs, have resulted in a $1.40 to $13 return on
investment. They result in lower medical bills and improved
productivity for the employers that we have studied over a
period of time.
That type of effectiveness will be important to document on
an ongoing basis as we work in partnership with the States and
providers to implement effective models and interventions.
HOMELESS PROGRAMS
Mr. Sherwood. Judge Barrasse from Lackawanna County has
just reiterated to me his serious concern with the lack of
available treatment programs for drug and alcohol. I think
probably the blight on the U.S. that it is so hard to
understand or explain is that we have probably the best economy
in the world, and yet so many homeless. I think there is a
great tie-in. How do you think we are doing there?
Mr. Curie. I think that is an excellent example. If we look
at a variety of programs that SAMHSA has implemented over the
years, we have been able to determine which programs are
effective in addressing homelessness, especially those
individuals with mental illness as well as addictive disease.
In the Center for Mental Health Services budget we have
requested over a 17 percent increase in PATH funding. This
program funds States to ensure that there are supports in place
to address the needs of homeless people. It not only provides
them a place to live, it helps them gain the skills that they
need to be part of the community.
The reason that funding for homeless programs is increasing
is because SAMHSA is achieving results from that funding, and
we want to continue to foster them. We are concerned about
homelessness in light of the fact that the economic times are
harder now. The Department has made homelessness a priority.
The Deputy Secretary, Claude Allen, is chairing a work group of
which SAMHSA is a very active participant. We are looking to
partner with the Centers for Disease Control and HRSA in this
regard. In fact, we just supported a summit in San Antonio a
month ago where SAMHSA brought those agencies together,
including their directors for HIV, to address the HIV problem.
We look to establish the same type of partnership in addressing
the homeless issue.
We are adding $22 million in 2003 for homelessness
programs. The same principles apply whether you are bringing
people out of institutions into the community, or bringing them
out of homelessness into participating in the community. We
need to not only focus on treatment and access to care, but
also examine the skills they need in terms of a job and the
skills they need to navigate in the community. Those supports
are very important.
Mr. Sherwood. Mr. Chairman, thank you.
POST-TRAUMATIC DISORDERS PROGRAM
Mr. Regula. Mr. Hoyer.
Mr. Hoyer. Mr. Curie, I serve on the Treasury-Postal
Subcommittee, which oversees ONDCP; and obviously for a decade
now, and General McCaffrey does not like to call it a war, so
whatever it is, an effort to prevent and cure is probably not
the proper word, but at least to wean off substances.
I have got some questions about traumatic abuse that I am
going to ask, but if I have time left, I want to get back to
that because it seems to me that your Department, working very
closely with ONDCP, is critical, both in your prevention and
education efforts.
Let me ask you about the National Child Traumatic Stress
Initiative, which you are familiar with.
Mr. Curie. Yes.
Mr. Hoyer. It is good Ms. DeLauro is here because we have
been working very hard on that. In the Children's Health Act in
2000 we authorized $50 million. We put $20 million in the bill
last year, and then we added $10 million to it in conference.
The chairman was very helpful.
First of all, you probably do not have it now, and it would
take longer than the 5 minutes I have, but Congresswoman
DeLauro and I would like a progress report as to where we are
in the expenditure of that money.
Mr. Curie. We can give you more specific information, but
we have made progress. The good news with these particular
dollars is that the Center for Mental Health Services has begun
setting up an actual networks around the country to make
resources available to States and localities to address trauma
in children. Obviously there are mental health consequences,
and that effort was underway even before September 11. That
puts us in a good position to address the new trauma associated
with the ongoing war on terrorism and the aftermath of the
attacks.
We are establishing that network and working with
universities across the country. We have received many
responses to our grant announcement, and are adding 25 projects
this year. So things are well underway. I can give you a more
in-depth progress report at a later time regarding where in the
country and how we see those post-traumatic stress projects
linking with State mental health authorities and local provider
networks.
POST TRAUMATIC STRESS DISORDERS FUNDING
Mr. Hoyer. I am pleased to hear that.
I was not pleased, however, that the $10 million that we
added in conference was not added to the base. So as I
understand it, we are back at the lower base. With respect to
the $10 million extra, will that be incorporated in these 25
projects? Or is that part of the $20 million?
Mr. Curie. We are looking at utilizing those dollars to
build further capacity through those networks. There is an
additional $10 million requested for bioterrorism, around which
we are building an agenda to address needs in our public mental
health and substance abuse system, but that is separate. In
fact, 5 of the 25 projects are proposed as 3-year awards. We
are going to be using that mechanism.
Mr. Hoyer. I am concerned about the 3-year awards because
it looks to me like we are stretching out the dollars because
we have frozen at the $20 million. In other words, the $10
million in the supplemental was not added to the base.
Now, it appears that you are stretching out the $10 million
to cover 3 years of grants, as opposed to $10 million per year
with the expectation that we put 10-10-10. Am I correct? Is
that what we have done?
Mr. Curie. Yes, that is correct.
Mr. Hoyer. I would presume that Congresswoman DeLauro and I
are going to try to work on that. I don't know whether you will
be allowed to answer this question. Was that what you requested
to the Department or OMB?
Mr. Curie. The budget process is a process that we all must
work through.
Mr. Hoyer. I know the process well.
Mr. Curie. We had some tough decisions to make in terms of
the budget priorities.
Mr. Hoyer. I understand that. My question is: Is what you
got what you requested either from the Secretary or from OMB?
Mr. Curie. Yes.
Mr. Hoyer. In other words, you did not in making your
request to the Secretary, and that which was relayed to OMB,
did not include the $10 million in the base?
Mr. Curie. Right. This was consistent with our request.
Mr. Hoyer. There seems to be some consternation on your
right. I speak not politically but geographically. You may not
be able to answer the question, but the answer ought to be
accurate. Let me tell you why. It is a difficult question for
people to answer working within the administration. I
understand OMB may have said we only have X dollars available.
As a program administrator, your shop may have concluded we
cannot spend the $10 million. There is a difference. One is
that the $10 million, if appropriated, could not be effectively
spent. The other is, we do not have the money so we cannot give
you the money.
That is why I asked that question, which I think is a fair
question for Members of Congress who have a responsibility for
appropriating the money to ask, so we have an understanding
what those who are on the front line and responsible for this
objective feel.
Mr. Curie. I understand, Mr. Congressman, and I definitely
appreciate your support and leadership in this area because it
is very important to the mental health of children. Trauma is a
very important issue that we are committed to addressing.
To answer your question, we did have some tough decisions
to make in terms of a tight budget year. We attempted to
stretch resources where we could yet still move ahead.
Obviously, in many situations if there were additional dollars,
we would be in a position to use them wisely and move ahead
with this type of agenda.
Mr. Hoyer. There is no doubt you would spend them wisely.
If the committee gave you $10 million for this program, and in
effect gave you the same level or higher, you have $30 million,
we are authorized at $50 million, you got $20 million from the
committee, $10 million in thesupplemental. The question is if
you got an additional $10 million, would that money be used effectively
in this program?
Mr. Curie. Yes, it would be used effectively.
Mr. Hoyer. I think that is the best I am going to get, and
I will take it.
Let me go back then to my last question, Mr. Chairman.
As you may know, the ONDCP has a number of HIDTA centers
around the country. We have spent over $200 million on these
centers. They serve a law enforcement coordination aspect.
There were five initial, and then the Baltimore-Washington was
added on as the sixth essentially at the beginning. There was a
unique status in the Baltimore-Washington HIDTA in that there
is a prevention component. The University of Maryland is tied
in with that prevention component. You have prevention as a
very important part of your aspects.
In your work with ONDCP, I would hope that you would stress
the importance of prevention. I do not want to say what the
Director believes or does not believe, but in the past the
prevention component was not a priority for him. My point being
every law enforcement official I have talked to, every medical
professional says if you do not invest significantly in
prevention, you will never have enough money on the law
enforcement or jail space, and you will never stop the demand
side. Therefore, the farmers of the world who are poor will
produce a product that they can sell high. That is just a fact
of life. Do you agree with that?
Mr. Curie. I think it is well stated, Congressman. I agree
that it is critical for SAMHSA, in partnership with ONDCP, to
ensure that prevention is a very important priority of the
demand reduction program of ONDCP. I have had some productive
meetings with Director Walters as well as with Dr. Barthwell,
who is Deputy Director for Demand Reduction, and I am confident
that we will be able to craft a strong prevention agenda
together.
Mr. Hoyer. Thank you.
POST-TRAUMATIC STRESS PROGRAM
Mr. Regula. Ms. DeLauro.
Ms. DeLauro. Thank you, Mr. Chairman.
I am sorry I missed the opening testimony.
If I might, let me just follow up on some of the questions
that my colleague from Maryland has posed. It is true that we
are very much interested in this area. We spent a lot of time
last year discussing the issue of post-traumatic stress in
children, and the incidence prior to September 11, and the
greater incidence after September 11. There are some pieces
here. Let me put this in a context, and maybe I am misreading
numbers.
I just find overall that the administration's mental health
budget as it relates to children, I find it troubling and let
me just tick off why. Take a look at children's mental health
program, no change. There is a $63,000 addition. For all
intents and purposes, it is level funded.
Child and adolescents PTSD, it is $20 million, although
basic understanding, the chairman, ranking member, Mr. Hoyer,
myself, I don't believe there was a committee member who was
not aware that we were talking about $30 million to be expended
this year. That was clear. I don't believe there was any
fudging, any confusion at all in that number. Now we are
looking at $20 million plus 10 over 3 years.
Youth violence prevention, no change.
Mental health block grant, no change. Again, that in and of
itself is very, very troubling to me about what direction we
are going in looking at one of the most serious problems that
this country faces. That is complicated as well by what is
happening in States. I will give you Connecticut, which has
cutback substantially on mental health programs, and
particularly as they relate to children, at a time when we are
seeing the need for increased assistance and treatment.
So we at the Federal level are compounding what is going on
in our States and leaving at the mercy of these illnesses
thousands and thousands and perhaps millions of children. In
terms of where our overall priorities lie, I think we are
failing with what we ought to be trying to do.
Now I want to go back to the post-traumatic stress program.
Your understanding as well as our understanding was that we
have a program that is authorized up to $50 million. We were
able to get $20 million. We got an additional $10 million from
the supplemental, but we were all on the same page, including
you at SAMHSA, that we were talking about $30 million to be
expended this year?
Mr. Curie. Speaking as the new Administrator, that was not
necessarily my understanding of the situation.
Mr. Kopanda. The emergency appropriation actually came to
SAMHSA and we became aware of it after we had submitted our
budget request to the Department and OBM. So in terms of the
answer to the former question, no, we did not request
continuation funds, but that was because that was not part of
our base at the time.
Ms. DeLauro. I would be happy to go back to all of my
colleagues, and the chairman and I spoke many times about this,
and the ranking member spoke many times about this, so there
shouldn't be any confusion about what the legislative intent
was in terms of the use of this funding.
What we ought to do is address that issue and make sure
that in fact we are spending those dollars this year so that in
fact we can build on a program that is authorized at up to $50
million for a very critical program.
Let me ask you a bunch of questions. $30 million, as a
result of that an increase if you had the $30 million, how many
more centers? You talked about the network that has been set up
around the country. That is about 18 centers, as I understand
it, at the moment. What can you do with the additional money?
How many more centers?
Mr. Curie. The average cost per center is between $300,000
and $400,000. With that average cost, you can get an idea what
the additional dollars would produce in additional centers.
Ms. DeLauro. Can you get back to us as to what the $30
million gets you in terms of additional centers?
Mr. Curie. We can do that.
[The information follows:]
Question. If you had the $30 million how many more centers?
You talked about the network that has been set up around the
country. That is about 18 centers, as I understand it, at the
moment. What can you do with the additional money? How many
centers? Can you get back to us as to what the $30 million gets
you in terms of the additional centers?
Answer. In FY 2001, SAMHSA established a network of 17
National Child Traumatic Stress Initiative (NCTSI) centers with
a primary responsibility for providing effective treatment and
service delivery approaches for child trauma in community and
speciality services settings and one National Center for Child
Traumatic Stress to provide national leadership and focus. With
$30 million, SAMHSA would be able to award approximately 18
additional NCTSI centers plus supplement 4-6 existing centers.
These funds would also support the continuation of 17 NCTSI
centers and the National Center for Child Traumatic Stress.
Ms. DeLauro. I want to know where they are now, where they
are located, what we can do, what your intent is, and where to
locate them.
I yield to the Chairman.
Mr. Regula. Is there any evidence as to what the success
rate is at the centers? Are they making a difference?
Ms. DeLauro. They are working, Mr. Chairman.
Mr. Curie. We do not yet have outcome data as we are now
establishing the centers. We just started awarding them in
September.
Ms. DeLauro. When will the new programs be notified of
their selection?
Mr. Curie. This month.
Ms. DeLauro. You know what those centers are?
Mr. Curie. Yes.
Ms. DeLauro. With your potentially doubling the number of
centers receiving the grants, what are the internal mechanisms
that you have to deal with in terms of your own resources and
personnel to administer these programs? Do you have adequate
personnel and resources to be able to administer?
Mr. Curie. We utilize both staff and contractual services
to ensure that these centers are set up and monitored on an
ongoing basis. That will be structured into the process.
Ms. DeLauro. And there is also a proposal that exists to
extend the authorization of the program for 2 additional years
to 2005. Do you support that effort?
Mr. Curie. Absolutely, in light of the current landscape.
From my perspective, seeing this was a program already under
development, we felt like we had a running start on addressing
the new type of trauma we must deal with. Obviously, there is a
lot of bad news in terms of trauma and the environment that
kids must cope with today.
The good news is that the vast majority of children in this
country are resilient and have good families that will help
them through this crisis. But we need to make sure that these
centers are established and the resources are available because
there are clearly vulnerable children who became more
vulnerable because of the events of September 11, and because
they must cope with ongoing trauma already in their lives.
Ms. DeLauro. The fact of the matter is that oftentimes with
this level of trauma, the symptoms of the trauma can show up
soon after the event, but the trauma may not show up until
months later, or maybe years.
With all due respect in terms of resilient families,
resilient families need access to resources to be able to help
youngsters who find themselves in real difficulty. We saw
tremendously outrageous numbers of children whose lives are
filled with violence, either experiencing violence themselves
or witnesses to violence, and this was long before September
10. That is why it was a good judgment in terms of people
trying to put this program together. They saw a need and
responded to it; and everybody responded after September 11 to
say we now have a much more serious problem here.
Let us appropriate 20 plus 10 so that we can really truly
make a difference in this effort by setting up more of these
centers around the country. I beg of you, please do not
shortchange these youngsters. I see a budget about mental
health that is so troubling with the scale of the problem that
we have today, that I don't believe as a Nation that we--we are
irresponsible if we do not do something about this issue. We
will fight for this $30 million this year.
Mr. Regula. Mr. Kennedy.
CHILDREN'S MENTAL HEALTH
Mr. Kennedy. Thank you, Mr. Chairman.
I think Congresswoman DeLauro hit many points that I also
want to make. I concur with her opinion, and with the ranking
member, Mr. Obey, who has made children's mental health a real
priority, and has worked diligently to ensure that it is
reflected in the budgets.
In that regard, we obviously need to do so much more than
we are doing. I had a meeting with the Business Education Round
Table, of RI, all senior executives of every major corporation
the other day, and to a person, all of them understood that our
special ed population is exploding in our schools because we
have not done enough to intervene early in children's lives to
ensure that we shape and mold them in a way that gives them a
positive trajectory.
I am working on this through the Department of Education
and Department of Justice with the title V funds and I like
programs like Safe Schools, Healthy Students which combine
funding from all of the various agencies. Unfortunately that is
being underfunded with certain agencies.
I want to emphasize what Ms. DeLauro is talking about and
the need to intervene early. Otherwise we pay for it through
the rest of our lives. To this point, we have a budget where
the administration has correctly requested almost $100 million
for children's mental health services because an estimated 21
percent of children in the U.S. have a diagnosable addictive
disorder, yet 66 percent of those with a diagnosable disorder
do not expect to receive mental health services. In short, the
government has made children's mental health a priority because
we recognize this as a vulnerable population in need of health.
The irony is that while children's mental health is
relatively underfunded our seniors are far worse off. And we
always talk about how kids are underrepresented in all of our
budgets because they do not have a voice, and seniors have more
of a voice, but it is not reflected in thesenior mental health
budget. Statistically 21 percent of children have diagnosable disorder,
and we have $100 billion for them, but we have over 26.4 percent of
seniors with mental health disorders, and only 3 percent get treatment,
leaving 97 percent untreated.
So 21 percent of children get $100 million and yet there is
26 percent of seniors, and they get $5 million. And the only $5
million they get is the $5 million that we worked in this
committee to put in last year.
I would just say, and I spoke to the Secretary about this,
we are going to have a baby boom generation that is going to
retire. We are going to bust the Medicare budget. We better be
smart about the way that we treat diseases, otherwise we are
going to pay for it through the back door.
SERVICES FOR THE ELDERLY
Over 70 percent of the Medicare admittances in emergency
rooms are drug and alcohol related for senior citizens, 70
percent because of the abuse of prescription drugs, we have a
big problem and we do not have any money for it. I think this
budget certainly does not reflect that we have got a growing
baby boom generation that is going to demand a lot of services.
I have spoken to you about this in my office and I know
that you appreciate this issue. I just want to say on the
record this is something that definitely needs more attention
and I hope you can comment about your feelings about the need
for more senior mental health treatment.
Mr. Curie. Mr. Kennedy, I appreciate your remarks and
observations. You have just described what I would consider an
historic issue regarding the public mental health system in the
country.
In my experience as Commissioner of Pennsylvania, if you
look at the priorities that State mental health authorities
have placed on core populations through the years, not
necessarily senior adults, or children with serious emotional
disturbances, I think what you are identifying is an existing
need which is only going to become greater. Clearly it is an
area that must be addressed as a major first step by not only
SAMHSA, but also by State mental health and local authorities.
We do have an aging workforce in the population. State
mental health authorities and local authorities must consider
how to work with the administration to not only address the
fact that people with serious mental illness are living longer,
but as people live longer more mental diseases evidence
themselves.
So we are now developing a plan with the Administration on
Aging to address this issue long term. We must engage the
public mental health system at the State and local level, where
the seniors are located. We have identified prevention efforts
and we are dedicating resources in prevention, not only in the
area of children but also in the area of seniors because of the
growing problem with abuse of prescription drugs and alcohol.
And as we know, our physical chemistry of us changes as we get
older.
In fact, we have examined recent reports from our Household
Survey identifying the substance abuse disorders in older
adults and treatment needs. This is another example where we
are more clearly identifying what the problem is. For years the
seniors' problems were not even recognized. Now we are
identifying what works. We need now to go about the process
that you are talking about, how do we integrate services as
part of a real system of accessible care. It is a clear
priority.
I appreciate the $5 million that this committee
appropriated for services for the elderly in the 2002 budget.
SAMHSA needs to partner with AOA, CMS, and all of the entities
that take care of our seniors. We need to leverage our
resources because we are actually a small player in terms of
funding, but we still can provide leadership and leveraging in
that area.
MENTAL HEALTH PARITY
Mr. Kennedy. I look forward to working with you in that
area. One way to pay attention to that area is to provide
parity in insurance coverage under Medicare. It is
discrimination. It is flat out discrimination. It is a
violation of people's civil rights, as I see it, because if you
have a mental disability you are discriminated against. If you
have cancer, you are not discriminated against, and God bless
it, I want to support funding for cancer. But we get nothing in
mental health. 50 percent co-pay for mental health, but that
does not hold true for all of the other physical ailments.
We have the World Health Organization, the Surgeon General,
everybody saying it is physiological. All of these smart people
coming up here know better, but yet our country's policy is
still in the dark ages. Can you comment on that?
Mr. Curie. I think you are reflecting what we are so far
learning from the data. We need to study the impact where
parity is in place. This has been a long standing debate,
whether to achieve parity for mental health coverage for
Medicare and in the private sector.
Mr. Kennedy. Secretary Thompson supported parity when he
was Governor of Wisconsin. How do you feel about it?
Mr. Curie. I think that the data are indicating to us, as
we look at preliminary findings and States that have passed
parity laws, that with a managed care overlay, you can actually
control the costs. We need to examine the outcomes in
situations where we have parity. Are people really gaining
access to care, and are people really being treated in ways
that we anticipated under the parity laws? We are in a
situation right now where we are able to get more data to
inform us of the decision. Federal employees are now under the
second year of their mental health parity plan. We should
examine the track record of Federal health care benefits, and
determine what are the real costs. We also need to look beyond
the cost, at whether people are really receiving quality
treatment. Are the earlier interventions with treatment and
diagnosis because people have access to care; are they helping
lighten the burden on the public system of care?
We have not had very complete information. Part of what we
need to do at SAMHSA is help complete that information and
continue to paint that picture.
Mr. Kennedy. I respect your answer. I think the
administration is very lucky to have you as Director of SAMHSA.
I think your hands are tied because the administration has not
chosen to step up to the plate yet. I hope that they do. They
have said enough about the NewFreedom Initiative, and the
President's father doing the Americans with Disabilities Act, and he
wants to be the one that follows through on that implementation.
If he wants to be the President that follows through on his
father's legacy, this is going to be the barrier he needs to
break. I know he has a commission that is studying mental
health. I hope that they come up with a recommendation that we
do go to parity.
The question should not be the cost. If the question is
cost, we should not have coverage for cancer, heart ailments.
We should not have insurance at all. Insurance costs money. So
let us block it out. If that is the reason we do not have it,
let's not have insurance. We should look at it on a basic
fundamental scientific level. Is it physical? Yes. Then it
deserves coverage.
If your company does not want to pay for it, then we have
the problem with insurance for all Americans. That is another
issue, but the premise is that we should not mix the two. We
should say we know it is physical. It needs to be covered. If
it costs money, let us go to the health insurance side and
worry about it on that side, end of story.
I appreciate your input, and I would certainly like to get
some more feedback from you as we move forward in this
Congress, and hopefully pass parity.
MENTAL HEALTH SERVICES
Mrs. Northup. Thank you, Mr. Chairman.
I think this is a good example of people who can look at
exactly the same facts, have the same wish for the same
outcomes, and come to different conclusions about how we best
get there. I, too, am very concerned about the issue of
treating mental illness. I would disagree that the place to
start fixing the problem is in the private insurance market,
but in the public insurance market, which is what you are
responsible for.
I think our public community mental health centers are a
failure. I can see the results of it in my district, and I see
the signs of it all across this country. When we decided to
deinstitutionalize people with mental illnesses, I think we
assumed that the community mental health centers would pick up
and provide for people the necessary opportunities for
interventions that would allow them to live more fully in their
communities.
What has happened is that as we increase the dollars, and
it is certainly not in your budget, but it is all of the
Medicaid billing that they are in charge of doing. I am sure
the committee knows that mental health centers are given the
responsibility and opportunity to draw down almost unlimited
Medicaid dollars for mental health benefits for people in this
community. They can contract out with different providers,
whether it is homeless centers or veterans organizations that
provide mental health services. And increasingly what I think
we see is that the community mental health services are
skimming off the top by servicing the easy-to-treat clients and
failing to address in a comprehensive way those that most need
the services.
So what we have are those that are more deeply affected,
those that are often pointed to in the course of this debate,
and I would like to work with my colleague because I think we
can profoundly change the opportunities that are available for
people that have the need for services both in the public and
the private sector.
But the people, especially in the public sector that are
the most profoundly afflicted, are the least likely to have
insurance. They are dependent on the public system. The problem
is if you have a stress class or a weight control class--which
our mental health centers are now conducting--those people tend
to show up at 1 p.m. every Wednesday. They are functional. They
may have some mental challenges. The homeless do not show up at
1 p.m. on Wednesday. The services that are delivered to them
need a profound level of care. You have to meet them where they
are. You have to provide the food and the shelter.
What we find is more and more of the homeless services that
really fall in the category of mental health are being asked to
be provided through HUD because Health and Human Services has
done just a disastrous job in providing services for these
people.
Primarily we see these centers contract with the homeless
centers for small amounts of billing opportunities to provide
for mental health services, and then they walk away from those
hard-to-treat services. We hardly have any outcry from the
homeless groups and the other groups that provide the best
services because they are afraid that the community mental
health service will cut them off entirely if they raise their
voice against the local community health services.
Do you have any comment or can you give me any reassurance
that things are going to get better?
Mr. Curie. You have described a scenario with which all of
us in the field are familiar. We have seen situations where
people who have been a core responsibility of the public mental
health system, with serious mental illness, would have lived
most of their life in an institution. You are right, many
lessons have been learned through the process of
deinstitutionalization. We have found that when people have
been outplaced into the community with only minimal treatment
support, they have inevitably failed, especially if the
responsibility was placed on that individual to keep seeking
care.
We now know that there are interventions and model programs
which actively reach out to such individuals and engage them in
treatment.
In Pennsylvania, my most recent experience, we had the
CHIPS program, Community Hospital Integration Projects Program.
I think Mr. Sherwood is familiar with that up in Lackawanna
County. It is very active; we created a video depicting the
successes out at Clark Summit State Hospital.
What we found was as we downsized State institutions,
public mental health systems needed to keep the money in the
system and transfer that money into community-based models. It
cannot be just given to an outpatient clinic, as you described,
but must provide those supports and services in the community
which bring people a life. This is consistent with the
President's New Freedom Initiative and will be an area of focus
for the President's Mental Health Commission.
The President's Mental Health Commission is going to
examine those interventions which have worked, rehabilitation
interventions, and interventions involving case management.
Community treatment models will be examined which have kept
people successfully living in the community.
Mrs. Northup. First of all, I don't think what works for
one person necessarily works for another. We need different
models.
Mental health centers are both the planning agency and the
delivery agency. And so what they tend to do is givethe harder
to deliver services to a nonprofit or under contract, and I might say
at minimal dollars. They give away minimal dollars and then they cherry
pick. They keep internally the services that are the easiest to
deliver. I think we know in many of our communities where the best
providers are. I think you have to hit the community health centers
over the head with a bat to free up the dollars so they go to the most
effective organizations, albeit they may look different and have
different models--just as we raise our children differently. Every one
of us are motivated by different things. They do not all have to look
alike, but we have to get the dollars away from the organizations that
are cherry picking and paying exorbitant salaries to the people that
work for them, while they are giving pennies to the organizations that
are having the biggest benefit.
Mr. Curie. I would agree that we need diverse providers,
that we need to work toward not just relying on one kind of
provider because many types of needs exist. We are working with
the State mental health authorities to develop performance
partnerships which will define improvement outcomes for
people's lives, not only to keep individuals out of the
hospital, but to provide them a healthy life in the community.
We have found if people get a job and a decent place to
live, have meaningful daily activity and maintain strong social
relationships, they do succeed in the community. That is what
our array of services needs to be doing.
Mrs. Northup. And the organizations that provide those are
getting pennies from our community mental health block grants.
Mr. Curie. The President's Mental Health Commission will be
looking at offset analysis. In other words, they will consider
what we know works, what are we now spending our money on now,
and how we can put our available resources into what works.
That offset analysis is going to be critical, I think, to
arrive at the very improvements that you are describing.
Mrs. Northup. If I can just follow up with one more
question.
Whether we are looking at the big system or whether we are
talking about family members of someone that is suffering,
generally that child of theirs or that family member does not
have coverage. We should talk about the sort of comprehensive
intervention that ought to be available. In my district, my
friends here might be shocked to know, our community mental
health services drew down $60 million last year. And the
homeless are not being served. None of that is equal to the
kind of services that HUD provides through their homeless
grants.
If this is not a waste of money and cannot be better spent,
to me, the whole system is broken. We ought to start there.
Quite honestly, you could probably give us better information
of how to get dollars, mental health dollars, to the harder-to-
treat community than any other group of people. It may not
always be as rewarding to service the hard-to-treat because it
can be two steps forward and a step back. Ask any of their
families, they will tell you.
Mr. Curie. What you just described is definitely a core
mission of SAMHSA in terms of address the hard-to-treat
population. In Pennsylvania I remember sitting down at what is
called a drop-in center, which is a consumer run service that
seems to work well for consumers and their families.
I asked the question around the table as I was sitting
there, they fixed breakfast for me that morning, I asked them
how many of them had been in a partial hospital or day
treatment program which for years had been funded in
Pennsylvania as really the only day treatment option.
One gentleman spoke up and said he was in a partial
hospital program for 16 years, and I looked at him. I asked him
how long he had been coming to the drop-in center, and he said
for 2 years, and it is the best 2 years he had ever had. He
does volunteer work, he has some part-time jobs, he is involved
in church. He is working with Goodwill. He has made friends. He
seemed genuinely content and proud. He said for the 16 years he
was in the partial hospital program, I asked him what did he
think of that experience. He said there are only so many ways
you can learn to brush your teeth over 16 years.
Mrs. Northup. I am not advocating going back to a hospital
model. I am just talking about shaking the dollars.
Mr. Curie. I think some of the resource investments give
people activity, but they are not bringing real improvements in
people's lives. I appreciate your support.
Mr. Regula. Was the $60 million you mentioned Federal
money?
Mrs. Northup. The majority of it is Medicaid dollars that
they bill for mental health. In every one of our areas is a
community mental health organization that has the billing
rights for all mental health services in Medicaid. They
basically allocate a particular nonprofit so many dollars but
they will be the only billing agent for mental health services.
Mr. Regula. Who delivers this service?
Mrs. Northup. In my district they keep internally the easy-
to-deliver services.
Mr. Regula. Your agency does not deliver these services?
Mr. Curie. The agencies you are describing may get some
funding through the State. You are correct in your assumption,
ours would be a very small amount because the mental health
block grants are small, as are the block grants to the homeless
groups and others. State and local organizations must
prioritize the most serious needs in the community.
Homelessness is always at the top, and they provide a few
dollars to the homeless organization to cover that
responsibility. Then they hire counselors on staff and bill
Medicaid for the easier to treat afflictions, where the people
are able to show up every Wednesday.
MENTAL HEALTH COMMISSION
Mr. Regula. Will the President's Commission address the
issues that have been raised by my colleagues?
Mr. Curie. The President and the Commission need to set
that full agenda; and I would anticipate so. My understanding
is that CMS will be engaged in the President's Commission, and
I think the types of issues that Mrs. Northup described clearly
are ones that will need to be addressed in the action plan that
the President is expecting. The Commission will identify what
is needed to make the public mental health system work,
especially for people with serious mental health illness.
Mr. Regula. This provoked a lot of discussion. But,
unfortunately, we have another panel and we have to move on.
PARITY IN BLOCK GRANT FUNDING
Ms. DeLauro. Mr. Chairman, one piece of this you can get
information to us on, my question is parity between the
substance abuse block grant and the mental health block grant.
The substance abuse block grant got a $60 million increase, a
request from the administration, and the mental health block
grant was flat funded. Quite honestly if you do that in terms
of the block grant program, you are going to see the States
that will lose funds under the administration's proposed freeze
are: Ohio, Pennsylvania, Kentucky, California, Wisconsin, and
Mississippi. It is a serious issue here. I don't know what your
view is on that.
And can you supply the subcommittee with the amount of
additional funding needed for the mental health block grant to
hold all States harmless?
Mr. Regula. Let us put all of these questions in the
record.
Ms. DeLauro. I want to know why we do not have parity
within the effort in terms of substance abuse and mental
health.
Mr. Curie. I will follow up.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Hoyer. Mr. Chairman, may I make an observation? This
document, page 13, I found to be interesting. It is the
projection of SAMHSA as to the cost of mental health substance
abuse, crime, criminal justice and premature death. The
interesting thing is that they project about a $310 billion
cost of all of these. We invest in SAMHSA to overcome this loss
of 1 percent.
Ted Agnew was elected governor the same year I was elected
to the State Senate in Maryland, 1966. I think it is
appropriate of that chart and our discussions. Ted Agnew said
in an excellent inaugural address, he said that ``The cost of
failure far exceeds the price of progress.'' That is what this
chart shows, and that is what this discussion is all about, and
I think it is what Mrs. Northup's discussion is all about. If
we effectively use dollars, we are going to save a lot of money
by investing in prevention as opposed to paying the price of
failure to prevent, failure to cure, failure to intervene.
Mr. Curie. Well stated.
Mr. Regula. Thank you for coming.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Wednesday, May 1, 2002.
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
WITNESSES
CAROLYN CLANCY, ACTING DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND
QUALITY
LISA SIMPSON, DEPUTY DIRECTOR, AHRQ
RITA KOCH, DIRECTOR, DIVISION OF FINANCIAL MANAGEMENT, OFFICE OF
MANAGEMENT, AHRQ
KERRY WEEMS, ACTING DEPUTY ASSISTANT SECRETARY, OFFICE OF BUDGET,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Regula. We'll get our second panel, Agency for
Healthcare Research and Quality. We're sorry we're holding you
up as much as we are, but this is important stuff.
Well, we'll get started here. Thank you for coming. I do
want to express the Committee's condolences on the passing of
Dr. Eisenberg, who was obviously a leader of great insight.
It's been a bit of a challenge for your agency to lose a leader
like that. Leaders make such a difference. But I'm sure that
you're all carrying on very effectively.
You have an important role to play, and so Dr. Clancy,
you're going to speak and then the others will add to it. Thank
you.
Opening Statement
Dr. Clancy. Thank you, Mr. Chairman.
I know I speak for all of my colleagues in saying that we
feel very fortunate to have worked with Dr. Eisenberg for the
past five years.
Mr. Chairman and members of the Committee, I'm pleased to
be able to be here today to present the President's fiscal year
2003 budget request for the Agency for Healthcare Research and
Quality, or AHRQ. With me today are Dr. Lisa Simpson, the
Deputy Director for the Agency, Rita Koch, who directs our
Division of Financial Management, and Kerry Weems, who's the
Acting Deputy Assistant Secretary of the Office of Budget, from
the Department of Health and Human Services.
AHRQ'S MISSION
AHRQ's mission is to conduct, support and disseminate
research to improve the quality of health care, reduce its
costs, improve patient safety, address medical errors, and
broaden access to essential medical services. A primary focus
of this mission is to ensure that the research we support is
translated into research that can improve people's lives.
This mission, to which the Committee has provided guidance,
is driven by the needs of the users of our research, patients,
doctors, nurses, health system leaders and policy makers.
IMPROVING HEALTH CARE
Let me be concrete and describe just some of the ways that
AHRQ is already improving health care. I see examples of this
in my own practice as a clinician and supervising medical
residents. When a patient with pneumonia is seen in our
practice, the resident goes immediately to their hand-held
computer and checks a tool from an AHRQ funded study that helps
them know which patients should be hospitalized.
But the impact of AHRQ's research goes beyond improving
care in our clinic to improving the Nation's health care. As
was just mentioned in the previous hearing, an AHRQ supported
study that was published today in the Journal of the American
Medical Association demonstrated that one can actually improve
the delivery of a drug called beta blockers to improve outcomes
for patients who are having coronary bypass surgery, a very
common procedure in this country.
Another example, AHRQ provides the Center for Medicare and
Medicaid Services with evidence-based information to inform
technical assessments for their coverage decision. Based on a
recent assessment that we supported, Medicare now covers the
treatment of actinic keratoses, a important precursor to skin
cancer.
In another study, an AHRQ-funded study found that many
breast fed non-white infants developed nutritional rickets, a
very rare bone disease that most doctors have never seen. The
results prompted the State of North Carolina to provide vitamin
D supplementation to all breast fed infants in the State
through WIC.
In yet another example, AHRQ's research has led to the
development of patient information materials on prostate cancer
screening that help men make informed decisions about
treatment. This information has been used widely to help
improve patients' understanding of the prostate specific
antigen test, or PSA.
Finally, another trial that was funded by AHRQ and HRSA
found that bag valve mask ventilation used by EMTs works as
well for young children who stop breathing as does putting a
tube down their throat, without the risk of subsequent injury.
As a result of this study, the L.A. County and Orange County
California medical systems have ordered all their paramedics to
begin using the less invasive technique, because it is just as
effective. In addition, the American Academy of Pediatrics has
modified its educational programs to encourage the use of the
bag valve masks.
AHRQ'S FY 2003 BUDGET REQUEST
I'd now like to present AHRQ's 2003 budget request. For
2003, we are requesting $252 million, which is a decrease of
$49 million, or a 16 percent decrease from fiscal year 2002.
The request will enable us to focus on four areas: patient
safety, development of ground breaking reports on quality and
disparities in health care, translating research into practice
and helping Americans make more informed decisions when
choosing a health plan.
INFORMED DECISIONMAKING
Mr. Regula. How do you help Americans to make more informed
decisions?
Dr. Clancy. We do that through research that actually
identifies their concerns, that also identifies the most
effective strategies for presenting the information in ways
that's comprehensible and relevant to them, and then by
evaluating whether or not in fact they're using that
information effectively.
Mr. Regula. How do you communicate that to them?
Dr. Clancy. A variety of tools. Most Americans are just as
diverse as the members of this body,members of any large
organization. Some patients want to get this information from the web
and they want graphs and charts and lots of details. Some patients want
a much more simplified paper version.
Mr. Regula. The web is a very important tool to you, I
would assume.
Dr. Clancy. Absolutely.
Mr. Regula. Both from the standpoint of the medical
profession as well as the public.
Dr. Clancy. Without question.
Mr. Regula. In fact, it is your tool.
Dr. Clancy. It is a very important part of what we do. But
we also need to recognize that some patients don't have access
or aren't yet computer literate. So we make sure that we
provide information for them that they can get as well. But
we'd be happy any time to show you some of these tools.
To focus on the four areas I just mentioned, we're going to
need to cut some of our existing programs. We estimate that
we're going to need to cut non-patient safety grants by 46
percent, and non-patient safety contracts by 31 percent. In
addition, we're not going to be able to fund any new grants not
in patient safety in 2003.
Our request also includes $10 million to cover the
continuing annual costs of the sample expansion of the
Department of Commerce's current population survey.
PATIENT SAFETY
The first area for AHRQ is patient safety. In 2003, AHRQ
will be able to contribute its ground breaking work on
improving patient safety and reducing medical errors. Very
early, AHRQ-sponsored research on medical errors and patient
safety laid the groundwork for current efforts to address this
critical health care problem. According to 1999 estimates from
the Institute of Medicine, medical errors in hospitals alone
claim between 44,000 and 98,000 lives every year.
In fiscal year 2001, for example, AHRQ funded research at
the University of California, San Francisco and Stanford which
outlined evidence for 79 patient safety practices. A number of
these are already being adopted by purchasers. In 2001, the
agency also funded $50 million worth of research in patient
safety that will yield evidence based practical tools and
strategies for settings as diverse as intensive care units,
community health centers, nursing homes and patients' homes.
The fiscal year 2003 budget request includes an increase of
$5 million, for a total of $60 million, for improving patient
safety. Our additional investment in 2003 will have two parts.
First, we'll implement local safety improvement priorities
through grants that will provide incentives to put systems
based interventions in place in health care organizations. As
you just acknowledged, Mr. Chairman, these grants will include
an emphasis on the use of technology and informatics.
As a physician, I trained in the era of index cards and
clipboards. The residents I train, as I mentioned a moment ago,
all use personal digital assistants.
Second, we will develop a program to train patient safety
experts who will enhance patient safety efforts in local
communities and organizations by providing technical
assistants. These experts would be something like the
Congressional fellows and scholars that your offices often
host. You benefit from their expertise during the time they
spend with you and your staff, and they leave behind knowledge
that you and your staff can use as needed. This program was
developed in specific response to the express needs of States.
NATIONAL REPORTS ON QUALITY AND DISPARITIES
The second area of our request will support the development
of two unprecedented reports on quality and disparities in
health care in the country that have been mandated by the
Congress. First, we will spend $53.3 million to support the
medical expenditure panel survey, or MEPS. This $4.8 million
increase from 2002 will allow us to survey more people and to
ask more in-depth questions about such issues as racial
disparities, chronic illness and quality of health care. One
million dollars of this increase will improve the information
available in insurance offering by employers and the cost to
them and their employees.
HEALTH CARE COST AND UTILIZATION PROJECT
Second, the 2003 request provides continuing support for
the health care cost and utilization project, or HCUP. This is
Federal-State-industry partnership to develop information used
by hospitals in States to compare quality of care in hospitals
and emergency rooms. HCUP will be funded at $4.1 million in
2003.
TRANSLATING RESEARCH INTO PRACTICE
The third area is translating research into practice. TRIP,
as we call it, is a very important step of AHRQ's research
focusing----
Mr. Regula. Research into all areas?
Dr. Clancy. We focus on translating evidence that we have
developed as well as developed by NIH and other agencies as
well. And it's focused on closing the gap between what's known
and what we actually do.
We know that all too often, patients receive care that is
not based on the latest scientific evidence. And we take the
challenge of promoting evidence-based practice very seriously
and believe that our work is not complete until the research we
sponsor is translated into improved health care. However, since
we don't regulate provider purchased health care, we don't have
these levers available to improve health care quality. So we
rely very critically on partnerships to achieve our goals.
For example, the article I mentioned a few minutes agothat
was published today was achieved because of a very important
partnership with the Society of Thoracic Surgeons. They collect data on
over half of the coronary artery bypass surgeries done in this country,
and they use that data to feed back information to their physicians, so
that they can improve the quality of care.
In 2003, we will fund translating research into practice at
$7 million.
CONSUMER ASSESSMENT OF HEALTH PLANS
The fourth area is to ensure that Americans have evidenced
based information to make health care decisions. In 2003, we
will continue to fully support the consumer assessment of
health plans, or CAHPs, as it's called. You or your staff may
have used CAHPs, a section of the Federal Employee Health
Benefits Program book to make choices about health plans.
In this year, we're going to move beyond simply reporting
differences in plans or giving patients report cards about that
to using that information to improve the quality of care that's
provided.
Mr. Chairman, I'd like to thank you and the Committee for
giving me the opportunity to present the President's budget
request of $252 million for AHRQ in 2003.
[The justification follows:]
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INFORMATICS
Mr. Regula. Dr. Simpson, did you want to make any comments?
Dr. Simpson. Thank you, Mr. Chairman.
I would just add that your question about informatics and
the web is really an exciting opportunity for the kind of work
that we sponsor. One of the programs, for example, is the
National Guideline Clearinghouse, which is a web-based tool
that provides information about clinical practice guidelines
for doctors, health plans. It's on the web so you can actually
look at it yourself, and is used very widely in this country,
over 94 million accesses.
It's a partnership, again, as Dr. Clancy said, with the
American Medical Association and the American Association of
Health Plans. That's a critical example, as well as the
consumer types of tools that we sponsor.
Mr. Regula. I am concerned about the half of the American
public that does not use the web. How do we get to them with
all these useful tools?
Dr. Clancy. It seems to me that there's two strategies that
we pursue. One is having paper based and other sorts of tools,
at least for people who can read. An area that we are growing
increasingly aware of is the problem with literacy in this
population, and one that is of deep concern to us.
A second strategy that has been used in some of our
projects has been to develop programs to make computers
available for populations that don't have them at home, for
example, through libraries or other community organizations.
That has been remarkably successful.
Mr. Regula. So you distribute to the public libraries, for
example?
Dr. Clancy. In some cases, investigators have been able to
get computer companies to donate them.
Mr. Regula. Mr. Istook.
HEALTH CARE COST
Mr. Istook. Thank you, Mr. Chairman.
Dr. Clancy, I appreciate your being here. Mr. Chairman,
this is one of the greatest areas that I have with the proposed
Administration budget. Dr. Clancy, I know, did not stress it,
but we have a major problem, because I believe the most
important work that this agency does is exactly the work that
OMB decided should be deleted from their budget. And that's the
research to help find more affordable ways for medicine to be
practiced, and to translate medical research developments into
action.
Their budget includes something like $83 million of cuts to
wipe out this entire effort. You may recall, Mr. Chairman, that
last year, I posed this question to Acting Director Kirschstein
of NIH and to HHS Secretary Tommy Thompson, about the need to
be having greater research into making health care affordable.
And they both said that was a very important initiative that we
should have underway.
We have double digit inflation in health care costs and
health care insurance, rising prescription drug costs, billions
of dollars going into research, to find more ways to provide
treatment. But it doesn't make it affordable. In fact, we had
the survey that was presented by Blue Cross last year that
showed, of the health care costs escalation, about a third of
it is attributable to being driven by new research that showed
new ways to do things and therefore, people wanted it to be
done, but it wasn't affordable.
I don't believe that they've sought to make it up any place
else in the budget, the effort to put significant resources
into making medicine that's practiced affordable. Not just
telling people, we're going to reduce your reimbursement rates,
not telling people we're just going to try to control
administrative overhead, but actually helping them find more
cost effective ways to treat people. Because it does no good to
have marvelous new research procedures of treating people if
those are not affordable, if you cannot translate it into
action.
And the Administration proposal, and I have some insight
into perhaps why it came about, but it's one of the most wrong
headed things I've seen. If anybody is here from OMB that is
the individual at OMB that was responsible for that, shame on
you. When health care costs are getting out of sight and we say
that the only agency, which is under-funded to begin with, that
is charged with trying to make health care affordable and
helping the health care community do it, and that's what we
wipe out of the budget, it's a pretty sad chapter.
Dr. Clancy, I won't ask you if you necessarily endorse
everything that I've said, that way I won't put you on the
spot. But my question, simply put, is where in the budget, if
it's not in your agency's budget, where in the budget are we
pursuing ways to make health care affordable, as Dr.
Kirschstein has said we need to be doing, and as Secretary
Thompson has said we need to be doing? Who's doing that?
Dr. Clancy. Let me just say, Mr. Istook, that a very
important part of our research portfolio in the past, and we
think a unique contribution that the agency can make, is in
complementing the work done by NIH and others in trying to make
sure that the return on investment for developing new treatment
or diagnostic interventions is achieved, by making sure that
those most likely to benefit receive the intervention, and
those who will not benefit or may even be harmed do not.
COST EFFECTIVENESS RESEARCH
Mr. Istook. That's the TRIP, the translating research
into----
Dr. Clancy. That's part of it. We also have a very specific
initiative focused on research on cost effectiveness. One area
where we've been able to make someinroads in there is looking
at the use of pharmaceuticals.
Mr. Istook. But Dr. Clancy, my question is, and I
understand you're Acting Director, and you're presenting the
budget that's been provided for you. My question is, if you are
not providing, if AHRQ is not providing the resources to
translate research into affordable patient care, is there any
place else in the Administration budget that we have resources
allocated for that mission?
Mr. Weems. Mr. Istook, AHRQ would be the main place where
that would occur.
Mr. Istook. So in other words, if we take it out of AHRQ,
it ain't going to happen, despite the need expressed by the
Director of NIH and by Secretary Thompson, certainly with which
I agree?
Mr. Weems. AHRQ is the place where that mission directly
happens. There are other places in HHS where one might see work
on that occurring. But AHRQ is the main place where that
happens, sir.
Mr. Istook. And that is what is de-funded under the
Administration's proposed budget, that particular portion, the
major portion of AHRQ's mission, that's what's being de-funded?
Dr. Clancy. Yes.
Mr. Istook. Okay. I appreciate that. I think the point is
made. Thank you, and I'll work to see that doesn't happen.
Thank you, Mr. Chairman.
FY 2003 REDUCTIONS TO EXISTING PROGRAMS
Mr. Regula. A couple of questions. You're going to have to
manage these severe cuts. Are you going to do it across the
board with your grants, or are you going to selectively look at
grants that have a higher or lower priority?
Dr. Clancy. That's a really good question, Mr. Regula, and
one that we're struggling with. We have not come up with a
final decision yet in terms of how we'll do it if this proposed
budget is enacted. We will be doing it based on broad
consultation with our advisory council, with our stakeholders
and the users of our research, and also following the principal
of maximizing return on Federal investment in the research
that's already been supported.
A little over half the grants that would need to be cut
under this budget have already been up and running for a couple
of years, and others are newer. So that's going to be the sense
of tradeoffs that we need to make.
Mr. Regula. So you'll have potential loss, because of lack
of continuity in your grants you will to some extent lose what
you've already invested?
Dr. Clancy. Yes.
RESEARCH RELATED TO NURSES
Mr. Regula. Well, if Mr. Istook prevails, it may not
happen.
But we are concerned, because it's an important function.
We've heard in our public witness testimony from nurses who
have stressed the importance of nurse working conditions on
patient safety. Have you done any studies and if so, what's the
result?
Dr. Clancy. Last year, we were given an very important
opportunity to invest in research related to working
conditions, much of which was focused around nursing issues.
There's a number of laws that you've heard about at State
levels, for example, that are looking at ratios of staffing,
how many nurses to patients and so forth.
These grants actually are a very important complement to
that approach by looking at how nurses are organized. For
example, does it make sense if you are taking care of patients
who are HIV positive to have them in a dedicated unit where the
nurses have a lot of expertise, or does it make more sense to
have them spread across different floors in a hospital? In the
case of that particular study, it turns out that the dedicated
AIDS units actually do make a lot of sense in terms of the cost
of care and patient outcomes.
So we've funded that kind of work. We've also conducted
some internal studies to show that staffing ratios are indeed
associated with avoidable errors, so the fewer nurses that are
available per patient, the more avoidable errors you see.
Mr. Regula. Last week we had a witness testify who works
with nurses who is a sociologist, and said that stress is a
factor in nurses leaving the profession, that the workload, the
stress of being put into very responsible decision making
processes, would that be your experience in the research you've
done, that stress is a significant factor? Because we are
losing a lot of individuals from the profession, and there's a
looming shortage.
Dr. Clancy. It's certainly been my personal experience as a
clinician, and it is something that we are also focusing on in
some of the studies in this program, as well as trying to
identify strategies to help people deal with that stress. If
you're stressed, for example, because you're worried about the
potential for errors, evidence-based information technology can
help reduce that chance of errors, and that's going to reduce
stress. But those are precisely the types of issues that we're
examining.
MALPRACTICE
Mr. Regula. You deal with what I guess would be malpractice
issues. How do you get those brought to your attention, that
there is a problem of faulty diagnosis or faulty practices? How
does that actually come to your attention?
Dr. Clancy. We don't deal directly with malpractice. We do
study factors that are associated with increased liability and
so forth. Interestingly, there's some overlap, but not as large
as you might think, between actually providing negligent care
and having a lawsuit. You would think that they would be one
and they same, they're not. Not all patients who receive poor
care sue.
Mr. Regula. But how do you learn about the negligent care
is really what I'm asking. Forgetting about malpractice.
Dr. Clancy. In one instance, we actually sponsored a study
where we looked at the relationship between physician-patient
communication patterns and malpractice. How we did that was to
work with a physician's malpractice insurer to identify
physicians who had two or more claims against them as opposed
to those who had had none. Then the investigator, with in the
physician and patient permission recorded the encounters in the
offices, and found that there were significant differences in
how physicians communicated with patients between physicians
who had been sued and those who had not.
Mr. Regula. And you share that information with the medical
community and hope that better communication will result in
better services?
Dr. Clancy. Yes. In fact, some health care systems have
made this a big priority. They've used the findings from this
study to develop their own programs and follow how their
clinicians do over time.
DEPARTMENT OF COMMERCE'S CURRENT POPULATION SURVEY
Mr. Regula. With your tight budget, why are you being asked
to contribute to the Department of Commerce's current
population survey, I think $10 million? It seems to me that
only exacerbates the problem you have on the shortfall.
Dr. Clancy. It makes $10 million less available for the
other research that we support, yes.
Mr. Regula. Why would your agency be even considered to be
involved?
Mr. Weems. Mr. Chairman, AHRQ participated in a couple of
the large surveys which have been mentioned before. They can
best help us frame the questions and analyze the information
that comes back as we work with the Department of Commerce and
the Census, too.
Mr. Regula. Commerce gets information flow that would be
useful in their studies?
Mr. Weems. Yes, and we're also going to ask them to augment
the questions that they ask to be able to provide the State
level data that we need.
Mr. Regula. Mr. Istook, do you have anything?
Mr. Istook. No further questions, thank you.
Mr. Regula. Well, thank you very much. We'll have questions
for the record to be submitted, and we'll certainly take a good
look at your budget and the importance that it has to the
delivery of medical services. And most importantly, to the
delivery of high quality services to the patients. I guess your
real mission is to ensure that the patient gets the best
possible care. Is that a fair statement?
Dr. Clancy. That's exactly right. And our mission is to
make sure that what works is what happens in health care.
Mr. Regula. That's a pretty big order.
Dr. Clancy. It is.
BIOTERRORISM
Mr. Regula. Okay, well, thank you for coming. We're sorry
we're short of time, but as you can understand from the
previous panel, bioterrorism is a high priority. I assume you
have some impact on our response to terrorism in your agency.
Dr. Clancy. Yes, actually in 2000 the Congress gave us $5
million to support research that would look at how the health
care system can be critically linked to the public health
infrastructure. For example, very recently, we now support a
web site where doctors and nurses can get continuing medical
education credits in return for learning about anthrax,
smallpox and other potential bioterrorist agents. That was just
expanded to expand the number of clinicians who can get that
kind of credit there.
We're also looking at strategies for trying to use, again,
information technology to identify outbreaks earlier and so
forth, and to enhance hospital preparedness, and are working
closely with our Department colleagues on a number of these
issues.
Mr. Regula. So you have a lot of cross-currents of
communications, NIH, CDC?
Dr. Clancy. Absolutely.
Mr. Regula. The military, all the players in the health
care delivery system.
Dr. Clancy. Yes. And as Mr. Allen mentioned in the prior
hearing, we also have the lead for the Department on something
called the Council on Private Sector Initiatives, where there
are representatives across the Department of Health and Human
Services from the Department of Defense, from the FBI, the
Office of Homeland Security, and the Office of Emergency
Preparedness, FEMA, excuse me, is what I meant to say, trying
to make sure that when private sector entrepreneurs or
companies have a good idea that they think might be helpful in
the fight against bioterrorism, that they are routed to the
right agency, so that we're aware of everything that's going on
in the private sector as we begin to get our arms around this
problem.
Mr. Regula. Well, thank you very much for coming.
Dr. Clancy. Thank you
Mr. Regula. The Committee is adjourned.
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PUBLIC COMMUNICATION
Mr. Regula. I would like to ask you at this point, do you
get a lot of hits, as they say, in the parlance of the Web
sites? Are people using it?
Ms. Duke. People use our Web sites, and we do get--thank
you so much. It helps to turn on the mike. Yes, we do get a lot
of hits on our Web site, and we are in the process of
modernizing our Web site right now. And we are working on a
low-income portal to allow people not only to get to our Web
site, but to get to all services that are provided across
government. So we are doing a lot with our Web site.
Mr. Regula. What kind of information? I wake up in the
morning with an ache and a pain. Can I call them and say, this
is what is bothering me? What would you recommend?
Ms. Duke. You are not going to get medical care in the
direct sense, but you are going to get sites. For example, you
might get the numbers of people to call. For example, through
our Maternal and Child Health Bureau, we have worked with
Hispanic organizations to set up an 800 number that people can
call to get services provided by native speakers. So, for
example, you would be able to get to a doctor who would provide
certain kinds of services or could find those services in a
culturally competent way. So there is a lot on our Web site.
Our rules are on our Web site, and I could ask each of my
colleagues if you would like to sort of summarize some of the
things they have put on their Web sites, if you would like.
They have just emerged from the George Washington Parkway.
Mr. Regula. They look reasonably relaxed.
Ms. Duke. They do. They look pretty good.
Mr. Regula. Well, it seems to me--what was the name of the
group in Ohio that we gave? Net Wellness is an Ohio group that
you can call, and they have doctors who are on call that will
respond to questions.
Ms. Duke. That is right, or various ways to correspond with
them. I don't know if you are aware of this program, but it is
an innovative program started by the State, and we put some
funding in last year.
Right.
Mr. Regula. And I wondered if it was a parallel to what you
are doing.
Ms. Duke. With the program I have just referred to, the 800
number for Hispanic-speaking clients, if they call that 1-800
number, they will get to a central service that will provide
them a Spanish-speaking person who can direct them to the kind
of service they need. They can make the direct connect for
them. So that if a pregnant woman calls and wants services in
her own language, they can connect her with one of over 3,000
providers on that database--and we can get you where you need
to go.
Mr. Regula. How does the public become aware of this? It
seems to me it is a great service, but I dare say that----
Ms. Duke. That is one of the things----
Mr. Regula. A small percent of the public knows about.
Ms. Duke. We are working on that right now. Secretary
Thompson has a great concern to make sure that the public can
know how to get to us, and so what we are building is an HHS
portal that is an entry way to every service that HHS provides
in an integrated way.
Mr. Regula. So it would be one-stop shopping?
Ms. Duke. Yes. That is what is involved and actually HRSA's
IT shop has the lead for the development of that portal.
Mr. Regula. How soon will that be online?
Ms. Duke. Well, I think with Secretary Thompson, it
probably will be online very rapidly. Our aim is to have it up
this year, so they are starting that project right now.
Mr. Regula. Members ought to be made aware of this, because
you could stick a little squib in your newsletter saying, did
you know that you can get this service? And if they put that in
a newsletter, that eventually reaches pretty much the full
population, assuming a member puts it out. And that would be
one way to get it out, because there are so many resources in
this city that people just don't know about.
Ms. Duke. Absolutely.
Mr. Regula. And this would be a vital one for them.
Ms. Duke. Absolutely. And that was one of the concerns,
that we have this wonderful new technology, and to make it
serve people rather than having people have to figure out--the
issue is how to present your services in a way that addresses
why people call you rather than presenting the services in a
way that you are organized to do the work, and that has been a
major change over the last years.
Originally, these services were sort of built in terms of
this is the way we are organized to provide the service, but
that isn't the way people ask for services. So that is what we
are in the process of redoing, is getting it to be a user-
friendly approach that people can come in and simply link
through to the service they need.
Mr. Regula. Let us know when you have got that up and
running.
Ms. Duke. We will do.
Mr. Regula. Maybe I will send a dear colleague to my
colleagues advising them of this, and then they would have the
option of putting something in on a newsletter that could be
very useful to the public.
Ms. Duke. Great. We have a portal now, but it is simply not
what we want it to be. So I will let you know what our
timetable is and also let you know when we are ready to go.
Mr. Regula. Thank you. Sorry for interrupting.
TELEHEALTH
Ms. Duke. Oh, no. Not at all. I was telling you about our
telehealth program, that also does distance learning and
provides medical consultations for people in distant places,
and that is one of the services that now has a grant program,
which we will continue, to provide innovative services, but our
goal this year is to push telehealth availability into every
HRSA program so that we will use this technology to make our
services more accessible and to drive down costs.
HEALTH CENTERS
Mr. Regula. Well, now, you fund the community health
centers; correct?
Ms. Duke. Yes, we do.
Mr. Regula. Wouldn't it be very useful to them to have
this----
Ms. Duke. Absolutely.
Mr. Regula [continuing]. Access contact? How many of them
know about or use it?
LONG DISTANCE LEARNING
Ms. Duke. Some of them do. Actually this is one of those
things where we don't know all the answers, and lots of people
are ahead of us, in the sense that many of them have already
put together distance learning capacities.
Through the innovative program that the Congress has funded
for some years, we have put systems out there. And so States
have been using telehealth already. We have been using some
telehealth, but our goal is to put it in over program because
you are absolutely right. If a health center has access to a
telehealth consultation, when a case presents that is beyond
the immediate--of the folks involved, they could ask the best
specialists in the country to help.
SCHOOL PROGRAMS
Mr. Regula. Switching gears a little bit, many of the
schools are getting wired for this type of thing, long distance
learning. Would it be conceivable that you could offer a course
on good health practices and then a school could plug in, or in
Ohio, we have a central point where these programs come in, and
then schools can pull off of that net.
Ms. Duke. Yes.
Mr. Regula. I mean, it seems to me it would be an
enormously valuable education tool.
Ms. Duke. I think it is. Actually, last week I was meeting
with a group of State maternal and child health directors. One
of them was telling me about a situation where the school had
the equipment, but the school nurse saw a need and got the
maternal and child health director for the State to pull
together a group to use the school's equipment under the
leadership of the school nurse to provide services and
education on oral health. This is really an educational issue.
Teaching about oral health right there was just part of their
ordinary use of the school equipment.
But in addition, they were able then to take the same
equipment they were offering the educational program on, and
were able to set up consults with specialists who are miles and
miles away to save them the distance--you know, their travel
would have been 500 miles to get to the next closest
specialist. These consults were using the camera equipment that
was bought for the school system and were able to provide these
services. They have now set that up as a regular program. She
then was telling this to the other Directors as a way of
enhancing their capacity. So we try to take these good
practices and get them shared with other States.
Mr. Regula. It seems to me it would have a terrific
potential. You have CDC that is trying to teach young people
the dangers in smoking, and this would be a perfect tool,
better, I think, than a billboard.
Ms. Duke. Oh, absolutely.
Mr. Regula. Because you have got a captive audience in a
classroom situation.
Ms. Duke. Right. So we will try to work with more--and in
fact, as we are putting out our grant announcements for next
year, we use a one-time announcement, and it comes out in the
summer that announces all of the grant programs we are planning
for next year.
As we are putting that out, we are going to be telling our
grantees this year that we want them to tell us how telehealth
could increase access to education and to health care, as well
as how it could reduce costs in their grant proposals.
So we are really trying to mainstream this whole use of new
technology.
Mr. Regula. Well, I think it is a great idea and I think if
we can be helpful in any way, because the opportunity is in the
classroom.
Ms. Duke. It really is. It is there.
Mr. Regula. Well, thank you. Go ahead. I am sorry. I keep
interrupting you.
Ms. Duke. Oh, that is okay. This is a wonderful program,
and I am thrilled to have the opportunity to talk about it. I
really am.
HEALTH CENTERS
Some of the things that we know--that we do, you already
know about, but I think to summarize a few of them and to tell
you about what we think we would like to have for a funding for
them, we are asking for 6.1 billion for our programs for this
year. They will help to support the programs in our Bureau of
Primary Health Care, there are sort of the rock of the safety
net program that we had. We will be looking at the second year
of the President's initiative to expand the health center
network to 34--4,400 accesspoints over 5 years. We will move to
3,400 this year.
Many health centers are doing some very innovative things.
We are doing things like trying to control blood pressure by
working with population groups, by working with diabetes, by
working with community groups to try to manage the issue
around----
COLLABORATIVE PROGRAM
Mr. Regula. Okay. Now, if a community health center has an
innovative program that is working well for their clientele, do
they tell you about it?
Ms. Duke. Yes, sir.
Mr. Regula. And do you tell the rest of them about it?
Ms. Duke. That is one of the things we are trying to do. We
are trying to get more health centers to participate in--we
have a program called the Collaborative Program that works
with--well, and actually, we have a new one coming up on cancer
this year, so we actually do try to get that message out. We
have a diabetes collaborative that has been out for a while.
Mr. Regula. Through all the health centers?
Ms. Duke. We have over 300 involved, and we are trying to
get more involved.
Mr. Regula. Do you have a newsletter you send to them?
Ms. Duke. Let me ask Bill Hobson, who is sitting all the
way to my left. Do we have a newsletter that we send that tells
them of these good things we are doing in the collaboratives?
Mr. Hobson. Mr. Chairman, we don't have a newsletter per
se, but we have State associations of Health Centers in all 50
States that profile and promote best practices in their
newsletters. In addition we have training programs and guidance
documents that inform Health Centers on ways to improve. We
make sure that in all Health Center meetings, that we do
profiles of our collaborative program, and some of the benefits
that accrue, both to the health providers in terms of increased
efficiency in providing care, as well as improved outcomes to
the patient.
Mr. Regula. So you really share this good information?
Mr. Hobson. Absolutely, at every opportunity we do. We
consider it to be one of our more effective programs. We
consider it to be groundbreaking. Community health centers have
been noted to be national leaders in this area of improving the
way in which clinical services are provided.
Mr. Regula. Well, so much good gets done that doesn't get
disseminated.
Ms. Duke. That is one of the challenges that I think we
face is getting the good news out about what we can do, and a
lot of the good things that we can do we accomplish because we
are working with other people who share the goals but are
coming at those goals from different point of views and
different places in this very complex government, State
government, local government, faith-based groups.
We are trying to bring them all together to accomplish the
goals, not just talk about accomplishing them.
Mr. Regula. Right.
Ms. Duke. That is where we are.
You know about our health centers, and I can tell you share
the view that--about the good works they do. We are asking for
$114,400,000 additional dollars this year.
Mr. Regula. Saves the emergency rooms.
Ms. Duke. It does.
Mr. Regula. No question.
Ms. Duke. It drives down the cost of emergency rooms, and
it prevents chronic illnesses, and so we do a lot of work that
needs to be done there, and the thing is we need to reach out
and get more folks involved in that work.
Mr. Regula. I agree.
NATIONAL HEALTH SERVICE CORPS
Ms. Duke. We use--in the health centers, we use a lot of
our National Health Service Corps, which is part of the safety
net that has been around for over a quarter of a century, and
this year we are asking for an expansion of the National Health
Service Corps. We have asked for a $44 million increase in
order to allow the National Health Service Corps to grow as we
are growing the health centers so we will need more providers.
Mr. Regula. Are they volunteers?
Ms. Duke. No, they are not. What they are, they come in
sort of two parts. They are scholars for whom we provide
scholarships and loan repayors, until the sense that they are
folks who have completed their training and we engage them for
periods of either 2 or 3 years to work in high-need areas. And
that program produces 2,300 people in the field right now.
Mr. Regula. So they move on from this assignment to----
Ms. Duke. They could move on. I think the nicest part of
that is research we have done shows that we actually have a
retention rate that at the end of the 2 or 3-year assignments,
we have about 68 percent of them, at the end of 5 years, are
still serving in the needed areas, and even after 15 years we
have 52 percent of them still serving low-income populations.
Mr. Regula. That is remarkable.
Ms. Duke. So it is a wonderful story. So this is a very
important program, and it is one that we rely on for direct
health care services.
HEALTHY COMMUNITIES INNOVATION INITIATIVE
We have a very innovative program in our budget this year,
and that is the healthy communities innovation initiative and
this is a new interdisciplinary program--it is a demo program--
that is designed to address three of the most rapidly growing
diseases in the United States, and they are diabetes, asthma
and obesity. And the Secretary feels very passionately about
the need to engage in preventive health care here, because
these are very expensive killers, and weare determined to try
to do something about that.
Mr. Regula. This is where you can use your long distance
learning and your Web site.
Ms. Duke. You bet, absolutely. Because a lot of this is
education, it really boils down to what people can do for
themselves, how can they change their lifestyles, and if they
know the risks, then they have some incentive to make those
extra changes. We are going to try to learn a lot through these
demonstrations, learn what works and see if we can make a
difference. So that is a big program, with a request for $20
million.
SECURITY AND PREPAREDNESS
We are very much involved, as you know, in the security and
preparedness of our public health infrastructure as a result of
September 11th, and HRSA will be directing five programs in
that area. And the request is for $618 million.
Mr. Regula. Well, the Secretary yesterday talked about
making the public health system seamless.
Ms. Duke. Yes, he did.
Mr. Regula. For lack of a better term, where the State and
the locals are coordinated. We had a scare of meningitis up in
my area, maybe a year or so ago, and, you know, they weren't
sure who was in charge, the mayor, the township trustees or the
public health department, the city or the county, and everybody
got in the act and finally CDC came, and that kind of put a
relief valve out there.
But if I understood the Secretary correctly, you are trying
to get these seamless so that they are all working together. Is
that basically----
ONE DEPARTMENT
Ms. Duke. That is basically the idea. The idea is to have
them working seamlessly together and seamlessly we will work
with them, and so this is part of the Secretary's goal of
having one Department of Health and Human Services that works
seamlessly within and facilitates seamless services throughout
the system. And that is what we are trying to do in this
coordinated approach.
And, you know, this is a big project, and it is on a very
fast track, and so this is going to be a management challenge,
and I think we are up to it. But it is going to be a big
challenge.
EMERGENCY/HOSPITAL PREPAREDNESS
Mr. Regula. Do you get the hospitals involved?
Ms. Duke. Yes.
Mr. Regula. Because they tend to each go their own
direction.
Ms. Duke. Yes, we do. In fact, one of our programs is the
hospital preparedness program, and we will be working with CDC
and Office of Emergency Preparedness and HRSA to get the
hospitals involved to work through the State health
departments, the States are involved, and then we have steering
committees that are made up of all of the relevant stakeholders
so that everybody gets in on the takeoff and so that we are
pulling them together.
So, for example, the State Offices of Rural Health,
Emergency Preparedness, will all be sitting at the table as
this money is coming together and helping to develop the plan
that will become a State plan. And that committee structure
will continue and it won't just apply to HRSA's grants, but
rather to HRSA's grants and CDC's grants, so we are trying to
bring it together here and trying to bring it together in
States as well.
HOMELAND SECURITY
Mr. Regula. I assume that Governor Ridge's operation, if
they get it defined clearly, would be in part of this, homeland
security.
Ms. Duke. The Department works closely with homeland
security on this as well.
Mr. Regula. Well, I am going to be in a meeting with him
later on today. I will--anything I should be telling him?
Ms. Duke. Well, I think you can tell him that we are part
of his team.
Mr. Regula. I will.
Ms. Duke. Thanks.
ORGAN DONATION/TRANSPLANTATION
Another part of our program--and HRSA has a very diverse
mission and a very challenging mission, but we are also--we
also are involved in the organ transplant--donation and
transplant program, and this is something, as you know, the
Secretary feels passionately about, because every day there are
60 transplants, but every day, 10 to 15 people die because
there are not enough organs, and the Secretary very much wants
to increase donation in this country. And so we have a major
initiative to increase donation. He announced it last April
17th, and that program we have asked for a $5,000,000 increase.
Mr. Regula. I thought he made a great comment yesterday.
Your heart and your lungs don't need to go to heaven with you.
Ms. Duke. I think that he is absolutely right. You know,
you can do good even after.
NURSING SHORTAGE
Another part of our work has to do with providing health
care providers, and this is an area that we are particularly
concentrating on this year, is the nursing shortage. The
nursing shortage is real. We are all getting older, and nurses
are getting older, too, and retiring. And the pipeline bringing
folks in is not keeping pace.
Mr. Regula. I hate to keep interrupting you, but you keep
bringing up ideas here.
Ms. Duke. It is great.
Mr. Regula. The nursing shortage, I have a friend who is
head of the sociology department, and said that in her
particular school they work with the nurses because one of
theproblems is burnout, stress that is causing people to leave the
profession, because I guess they become the recipients of everybody's
burden. Is that a fair observation?
Ms. Duke. It is a very fair observation. It is a very
stressful work. I think the thing about it is that people go
into it because they love it, and they stay in it because they
love it. But at some point it becomes a threat to your health.
The hours are long. The working conditions are tough. The pay
is low. It is a very, very stressful career, but at the same
time people love it. And I think the thing that many of the
nursing groups are doing is trying to address the issue of
burnout, especially in those fields where you are dealing with
very tough situations day in and day out.
And so the professions have offered seminars on taking care
of yourself as a professional in order to allow people to
survive the stresses and to live full lives that allow them to
contribute still the next day.
Mr. Regula. Do the curricular offerings in the nursing
education field anticipate this? Do they prepare these
candidates up front for this kind of a challenge?
Ms. Duke. I don't know the answer to that, but perhaps Dr.
Shekar might know that. Does the curriculum provide that?
Mr. Shekar. Thank you, Dr. Duke. We have a number of
programs that look at issues to increase the value that nurses
feel being in the profession, such as career ladder programs.
In fact, we have somewhere in the range--the low 50 types of
programs that are scattered through our basic nurse education
program and our advanced nurse education program that allow
nurses to move up the ladder and have greater value and greater
training so they can do more with their nursing degree and
background.
Mr. Regula. So you warn them up front that this is not
going to be a day at the beach, being in the nursing
profession. They are going to be faced with stresses and here
is how you cope?
NURSE TRAINING PROGRAM
Mr. Shekar. It is really multidimensional, and also at
various stages of the training process, as Dr. Duke probably
expanded on, we have a program that we are even looking at,
students in junior high and high school, called kids in health
careers, and we are trying to get folks to think about nursing
and be prepared for what is involved with the nursing
profession, from junior high on.
Ms. Duke. And I know when my own daughter was in high
school and college, she did a lot of internships, so that she
actually was experiencing nursing from the point of view of the
professional nurse an had a mentor, and now as a nurse
practitioner, she now has nurses in training who come and work
with her and she provides mentoring for them.
I also know that in developing her own vision of a career,
she said to me early in her career, I am going to plan to do 3
to 4 years on the floor which is very intensive and I will be
very up to date on what is happening, and then I plan to do
some work in an outpatient clinic, and I will meet patients at
a different stage in the illness, and I think I need to pace
myself through a career.
So she got that from somebody and I am afraid she doesn't
get that from me because I am not a nurse and I don't know how
to counsel. But somebody helped her think through a strategy of
how she should train, but also a strategy for how she should
manage her career so that she could remain at optimum use to
the profession and to her patients.
Mr. Regula. Very interesting. Somebody gave her good
advice.
Ms. Duke. Sounds that way to me, yeah, or else she has good
common sense.
Mr. Regula. Well, they say the apple doesn't fall far from
the tree.
Ms. Duke. Thank you very much.
NURSING PROGRAM/NURSING EDUCATION LOAN REPAYMENT
We have in this budget increases for our nursing program.
We are asking for $99 million for our nursing program this
year, and the distribution will go $1 million toward advanced
nursing, and almost $5 million toward our Nurse Education Loan
Repayment Program, which is a marvelous program that we could
talk about at a later point if you wish.
ABSTINENCE EDUCATION
Another piece of our program has to do with dealing with
the issues of teen pregnancy and out-of-wedlock sexual
activity, and in our budget for the whole department, we have
$135,000,000 for abstinence only education activities.
$123,000,000 of that program is in the HRSA budget, which is an
increase of $33 million. And that will provide for community-
based and State-based programs.
Administratively, we have tried to tighten up our ship and
get as much productivity as we can, and we are supporting the
Secretary's goal of increasing the IT efficiency at the
Department. That is in our administrative budget.
BUDGET DECREASES
We have some major decreases in our budget in health
professions, education, in the Community Access Program, in the
State Planning Grant Program and Children's Hospital Graduate
Medical Education Program have the largest reductions. But
basically, our view of this budget is that it will allow us to
remain the anchor of the health care safety net. We have a lot
to do, and we think we are up to the challenge. And I am
available for questions, and my colleagues have arrived from
the Parkway.
Mr. Regula. Well, would they each like to comment, or would
you like to----
Ms. Duke. I would like to introduce them if I might.
Mr. Regula. Absolutely.
INTRODUCTION OF WITNESSES
Ms. Duke. On my right is Dr. Sam Shekar. He heads the
Health Professions Bureau. On his right is Dr. Peter van Dyck,
and he heads the Maternal and Child Health Bureau, and on his
right is Bill Beldon from the budget office of the Department.
On my left is Deborah Parham, and she is the acting head of our
HIV/AIDS Bureau; and on her left is Jon Nelson, and he heads
our Office of Special Programs that has the organ
transplantation and donation program in it. And on his left is
Bill Hobson, who is acting head of our Bureau of Primary Health
Care.
Mr. Regula. Well, maybe you can respond to questions as
they might involve your particular----
Ms. Duke. I will. I will refer them to them as well.
Mr. Regula. Sir, are you ready to go?
Mr. Miller. Thank you, Mr. Chairman. I am glad to see all
of you here today, and there are so many different programs you
cover, and it is exciting the stuff that we get involved in.
ORGAN DONATION/TRANSPLANTATION
Let me start off--when I first walked in--I am sorry I was
a few minutes late there, but you are talking organ donation,
and I mentioned yesterday that I personally experienced that
last October. Our daughter donated her liver to her son at
Mount Sinai, New York. So I spent a lot of time in the hospital
in New York City, too, during that period of time. And it was
very successful, and they are both doing well, but we are
fortunate for our son's sake that our daughter was able to step
forward. She is the mother of our only grandchild. So it was a
tough time.
So I obviously have a great deal of interest. There is a
Member of Congress who is a living donor--donated his liver in
Massachusetts just over a year ago that, you know, as Tommy
Thompson--they are heroes. So I want to help that area. I mean,
we never talked about it publicly much before the event,
because it was a very personal and private thing to us, but the
Sarasota paper wrote an article on Thanksgiving Day.
We agreed to tell people. Understand that you can make
donations, and it means the difference of a life. And so
whether you are a living donor--a liver transplant, you know,
is still a fairly rare thing, and there has been some problems
with it. You know, it is not like it is a common-type surgery,
like some others, kidneys and such.
So tell me more what you are doing and what can be done to
help make people aware of it, not just the one that you can't
take to heaven with you, but the living donor ones, too. But as
has been reported about some of the problems of living donors,
you know, do no harm, and if a living donor goes out and
doesn't survive, you have taken a healthy person's life away
from them. And so you have got to be cautious as you approach
this. I know the medical profession obviously is very concerned
about it.
So let me hear you talk a little bit about organ donations,
please.
LIVING DONOR
Ms. Duke. I will kick it off a little bit, and then I will
ask Jon Nelson to join in that discussion. Living donation is
actually the fastest growing area, and one which we expect to
continue to grow. We had about 5,000 living donors for kidneys
last year, and about 300 for liver donations. This is an area
of tremendous hope and potential. At the same time, it is one
that is not entered into lightly. We had a recent case in New
York where we lost the living donor, and that is a risk. And so
we are very concerned about informing the public about the
potential about the risks and ensuring that people to make
informed decisions. It is an area I think that we will see more
of, and I think over the next years, we will be seeing more in
donation cadaveric, as well as living donation. The paper this
morning has a story from Saudi Arabia on a uterus donation,
which was a first. So that was an amazing piece of surgery.
So it is an area of tremendous potential. In living donors
there is real risk, but there is real life-saving here, and so
I am going to ask Jon to talk a little bit more about the
living donor program, and then we can talk more about what we
are doing to try to get people to think about not going to
heaven with their organs.
Jon.
Mr. Nelson. Thank you, Dr. Duke. Obviously, the Secretary
is encouraged with your enthusiasm, and he shares that and has
since he was confirmed a year ago. Living donation, as Dr. Duke
said, is not a procedure without some risk. For that reason,
the Department has been cautious in its promotion and support
of living donation. In 2001, just last year, the number of
living donors probably exceeded the number of cadaveric donors.
So as Dr. Duke said, it is the area of most growth.
Notwithstanding that, the number of organs that you recover
from a living donor is limited to one. Whereas the number of
organs you recover from a cadaveric source are about 3.2
organs.
TRANSPLANTATION
So most of the transplants for some time will be from
cadaveric sources, and the Department's efforts and its
promotional activities to encourage donation to get those
people, the 50 percent of the people who when offered it, had
opportunity to donate, who choose to say no, to encourage them
that this is something that out of this extraordinarily
difficult time in their life that something good can come from
it, to encourage them to say yes.
That is the focus of our efforts. At the same time, on the
living donation side, we are working with the clinical
communities, the surgeons and the physicians who are intimately
involved with donation from people who are typically related to
the person who is on the waiting list to receive a transplant.
So that the people who are going to make the decision to donate
to a loved one do so in the most informed way as possible. It
is clearly a procedure that is not without some risk. To ensure
that the donors know what those risks are, are willing to take
it because they think that a greater good can derive from it.
Mr. Miller. Is it regulated at the Federal level?
Mr. Nelson. Transplantation as a medical procedure is
regulated locally through State--within the hospitals--within
the State Health Departments, and regulated also through
medical associates. Our involvement is mostly for operating the
transplant system, the organ procurement and transplantation
system, which is the real-time matching system between donors
and recipients so that when someone dies in Florida, the most
suitable recipients are quickly identified, and that process
occurs as quickly as possible so that those organs are shipped
and transplanted and the people can survive.
Mr. Miller. There is an article--I studied this last year,
obviously, and there is an article about--I think it was a New
England Journal article, I am guessing in May,about the growth
and the number of institutions offering liver transplants growing
faster than the standards, because there hasn't been that much done,
maybe 2,000 of them.
So it is not like it is a very common surgery, and all of a
sudden, dozens and dozens of liver transplant programs were
popping up all over the United States, and there is a growing
demand, and it is going to be growing, especially with the hep
C concern in this country and the number of people, the demand
is going to be far greater than the supply, and so that is the
reason--but you are saying that, for example, if--as these
hospitals keep popping up, even though there is no--I guess
generally--what is it, the medical term, standards of--yeah,
how you do that. There was a concern about that. I don't know
where that stands.
Mr. Nelson. Well, there are over 700 transplant programs in
the United States. Many of those transplant programs will occur
within the same transplant hospital in a transplant center so
that a particular hospital could have a kidney program, a
kidney pancreas program, a liver program, as well as heart and
lung programs. There are real advantages to that, as well as
some disadvantages, as you are clearly aware. The advantages
are that people don't have to travel far from their families
and support systems, who are so important in this process for
receiving a transplant. These are very, very difficult
procedures regardless. They are not--never really entirely
routine.
We encourage in a variety of ways, and I mentioned working
with the clinical societies for establishing standards and also
our contractor, UNOS, and the OPTN, to have the standards,
protocols for transplant as well, and to ensure that there are
standards of practice and training requirements for all
transplant professionals, as well as the hospitals which
provide really the infrastructure for those procedures.
Mr. Miller. What is the most common? Is that kidney?
Mr. Nelson. Yes.
Mr. Miller. And what is next?
Mr. Nelson. Probably liver would be soon after that, and
livers actually travel better than--almost as good as kidneys.
So livers can--it is called ischemic time, from the time it is
clamped and no longer has a blood supply, to the time it is
unclamped and in its new person, can be 12, 14 hours. Kidneys
can survive 24 hours, so they really are much more mobile.
Mr. Miller. What is the ratio of cadaveric versus living
donors?
Equal numbers?
Mr. Nelson. In 2001, there were about 6,000 living donors
and also the same number of cadaveric donors. In 2002, if you
look at the trends, it will be substantially more living
donors.
Ms. Duke. But the issue is that with the cadaveric, you
have the possibility of about three times as many transplants,
because there are more organs.
Mr. Miller. How many organs--you know, how many different
transplants are possible from one cadaver?
Mr. Nelson. Of solid organs, about 3 to 3.2, but typically
there are many other life-saving procedures that derive, their
tissues, their eyes. There are a lot of others with the consent
of the family that can with be life-saving, as much as the
solid organ transplants.
Mr. Miller. Well, we felt very good about the experience,
and thank God it is behind us. I tried to donate and I went
through the testing. And in the very end, I did not. But they
sure did not want a 59-year-old applying. They sure told me up
front. They said you would be the oldest. But I did learn some
more about hospitals because we were in the hospital for a
while there, and I was very pleased with everything.
So at any rate, it was interesting being around nurses for
2 weeks. I think our son was in for 2\1/2\ weeks. You found
some outstanding ones, and you really admire them working on a
Saturday night, a Friday night and the shift changes. I am just
amazed how many have been there 25 years. They are fortunate at
this particular location--I think they are geographically
located convenient to the housing, a lot of the people, too. I
think they could get there easily. That was important. But I
have been concerned--in my area of Sarasota, Florida--am I
taking up too much time?
Mr. Regula. All you want.
Mr. Miller. Lots of senior citizens. Health care is
probably my biggest industry because of all my seniors. I have
got as many seniors as anybody in the Nation, as far as
Congressional district, and so there is a real challenge of
staffing, and it is not just the nurse practitioners which are
there, but it is the nursing assistants. How do we generate the
numbers with all the nursing homes? And nursing homes are 365
days a year, 24 hours a day, and I know the legislature
recently passed, well, we are going to toughen up the standards
and raise the standards.
Well, that is great, but you better find people to work.
Whereas some industries have been able to utilize more of the
immigrant population, when health care you have got to be able
to communicate, and that is a challenge.
So I think we did put language in the bill last year to try
to encourage that. I know we helped States to try to come up.
Talk a little bit more about what can we do--I mean, not just
the anesthesiology nurse, but the one that is working on the--
--
BASIC NURSING
Ms. Duke. Basic nursing?
Mr. Miller. Right.
Ms. Duke. One of the things we are trying to do is to get
more folks into the pipeline into health professions in
general, but into nursing in particular. Just last week, the
Secretary launched a program called Kids Into Health Careers,
and we launched it at a local junior high school, and one of
our messages here is that there are 270 health professions.
Nursing has within it so many subspecialties and so many
opportunities to serve, that we really want to get kids
interested earlier so we can begin to build that pipeline.
Some other things that we have done is we have provided
programs, working with universities, medical schools, area--
health education centers, to help prepare students for the
curriculum that they are going to need to have in order to
train for those professions. So we do some programs, summer
camps, for example, to help kids get more proficient in
science, to help kids master the necessary math skills so that
we are reaching out to try to do two things, to get them
interested and then get them to the basic prerequisites to be
able to participate in the training for the program.
The other thing we are trying to do is to reach into the
support areas of nurse's aides and so forth to try to offer
them the opportunity to have formal training to move into
nursing as a profession, and so we actually have a full step-
by-step bringing people in at the associate level, bringing
them in at the bachelors level, and then the possibility of--
the possibility of going on from there.
NURSING EDUCATION LOAN REPAYMENT PROGRAM
Mr. Miller. Scholarship money fairly, rarely available? I
sense it is. So if somebody wants to become a nurse, they can
find some scholarship, whether--in my case, at a community
college or something, to be able to work--get--I mean, whether
it is the Federal level--I am not just talking about the Pell
grants or the other, but is it----
Ms. Duke. There are a variety of opportunities in nursing.
One of the programs that we have that I am just tickled with
and we have expanded it over the last year, is the National
Nurse Education Loan Repayment Program, which is a program that
allows us--for agreement for the nurse to serve in an
underserved area, we will pay back part of her education loan
for 2 years, and then if the nurse is willing, we will extend
it for a third year.
Last year we had a basic appropriation of about $2 million,
and the Secretary in looking at this same problem said to me,
if I gave you $5 million, could you do something? And you know
the Secretary. You say, yes, sir. And I said, yes, sir, we
could. And we--what we did with that money is for our money
last year, we were able to provide 1,032 nursing years of
service by reaching out to nurses and getting them into the
field.
You know, we have about 500,000 nurses who are trained as
nurses but aren't working as nurses, so we are trying to reach
out and use these as incentives to get people to be involved in
nursing, to go where we need them to be in nursing homes, into
rural areas where we need health care providers.
So using this Nurse Education Loan Repayment Program has
helped people look at the possibility that they are not going
to be in debt for the rest of their lives, and that they can be
in areas to really provide service.
NATIONAL HEALTH SERVICE CORPS
In addition, we have opportunities for advanced nurses in
our National Health Service Corps. We have scholarships there.
The Education Department has nursing scholarships, and some of
the States have scholarships as well. So, I think the main
thing is getting across to the perspective student that--and
this is what I said to the junior high folks last week, is that
we can help you. We can help you find the support you need to
get the prerequisites educationally, and we can help you find
the money. So you are not out there alone. There is a big
infrastructure of people who want to help.
Mr. Miller. And the pay scale is getting up now that it
is--you know, it is like pharmacists are making--coming out of
school, you make a pretty good salary as a pharmacist, and I
think nursing is getting up there.
Ms. Duke. Nursing salaries have improved. It is still one
of the areas that nurses cite when they cite for reasons why
they left the profession, and we have tried to study that
500,000, to understand what they are doing. Many of them have
left because there are greater opportunities for nurses--women
today, and some of--and the profession is still largely women
have simply taken higher paying jobs, but the salaries have
improved. So the loan repayment possibility is an attractive
feature.
Mr. Miller. Well, then, I have another line of questioning
here, unless you want to go and we alternate?
Mr. Peterson. Go ahead.
Mr. Miller. This is another issue about the HIV issue, and
you all do have Ryan White. You don't do the housing here? You
don't have the housing monies. How much is Ryan White, and how
much is----
Ms. Duke. Ryan White is a billion nine, and Deborah Parham,
who heads our HIV/AIDS Bureau, could talk a little bit about
the housing program.
Mr. Miller. How much is housing, do you know? That is in
HUD, I--yeah----
Ms. Duke. It is a HUD issue, and Deborah says that this is
not one we feel qualified to talk about.
RYAN WHITE
Mr. Miller. One of the things when you have large Federal
programs--and I am supportive of Ryan White and the concerns.
We saw this in the National Endowment for Arts, all of a sudden
you get some scandal that is blown out of proportion. I have
seen it in agency after agency, and I don't know--I did see
something about, you know, some problems with Ryan White, how
some monies are being used. And the last thing we want to do is
undermine a program over some, you know, thousand dollar or
$10,000 money. You know, it has happened to agency after
agency. Talk about the controls and how you can--and some of
this--and it may not be all factual, but I am just--you may be
aware of more of them than myself. How do we control or keep
that from happening? I think you may need a microphone for this
lady here.
Ms. Duke. I will hand it to Deborah in a moment. The HIV/
AIDS program has been reviewed by the Inspector General and by
the GAO on several--I think 16 different occasions, and
basically we are doing a pretty good job of policing that
program overall, and it is a large program at a billion nine.
But there are situations that happen, and that is part of our
stewardship responsibility. And we have several programs that
we are working on to try to ensure accountability for the funds
we hand out. I am in the process now of establishing an
integrity unit within my office to ensure that we have a
regular review of our grantees around the quality of their
clinical services but also the quality of their stewardship of
the public's money, and we have otherrequirements, regular
reporting and relationships. We have biweekly phone calls with our
grantees. So we have a relationship with our grantees, but then our
grantees have subgrantees, and that is when it gets more difficult. But
I will ask Deborah to comment further on those works. Deborah.
Ms. Parham. Thank you. Like you, we are very concerned when
we hear that there is money that is being spent not as it was
intended, and like Dr. Duke said, we do have some controls in
place. One thing about the Ryan White Care Act is that a lot of
the money goes to the cities and to the States, and then they
are responsible for monitoring the subgrantees. So what we do
at the Federal level is give them technical assistance on how
they can do that, and how they can improve their monitoring
systems.
For those programs that we directly fund, it is much easier
for us. We can go out and provide on-site technical assistance
to them in the clinical, administrative, fiscal and MIS areas
and we do that. So, yes, there are programs that you hear about
in the news. The one thing that I think that is not said in the
news as much is that where we do find that there is fraud and
abuse, those people are tried, and there are sanctions. Some of
them are in jail now. So the system is working in terms of
finding where those places--where the money has been spent
inappropriately we are able to address those issues.
Mr. Miller. Well, the $1.9 billion program is a lot of
money, and I understand now, you know, a lot of it is, in
effect, block granted to the communities, and then it goes to
the next level, and all of a sudden you have got some dumb use
of the money that embarrasses the whole program, and that is
how programs I have seen get weakened up here is when some
subcontractor--you know, I will use the National Endowment for
the Arts as another illustration. It goes to the museum and
then a museum grants it to the artist, and before you know it,
you have got something that is really dumb, and why are we
doing that, and everybody agrees that it shouldn't have
happened.
So the controls need to be as tight as they can, because
otherwise it has the potential of undermining the program, and
I am supportive of the program, so I wish you well on that.
Ms. Parham. One other thing that I just want to add is
that, as Dr. Duke said, we do have the Inspector General who is
looking at programs right now, and one of the things that they
are going to do is to look and see what we are doing at the
Federal level, as well as what the grantees are doing to
monitor their subgrantees and give us feedback in terms of ways
that they think we can improve the monitoring.
Mr. Miller. Citizens Against Government Waste Organization,
which is a fiscally conservative group, and it lists all these
illustrations of how money is not well spent. So you need to
watch that. So thank you very much. And Peterson, we need to
figure out the vote situation.
RURAL HEALTH
Mr. Peterson. Well, you can come back for another round,
too. Just to follow up on the educational issue, my health care
provider--I serve a very large rural district in northern
Pennsylvania. Providers there are as concerned about employee
availability as they are reimbursements, and that is a big
concern is reimbursements have always been a problem in rural
areas. Has there been any thought of combining with the health
care professions collectively? I scold them all the time that
they don't sell well.
In years gone by, going to health care was where you
could--if you had good health care skills, you could get a job
anywhere in America, no matter where you or your mate went,
there were usually jobs available, and that is still true
today. And the need of health care is going to grow a lot
because of our aging population, especially in rural areas that
I serve. So has there been any thought of having that kind of a
promotion to young people and to maybe people who are going to
be retrained? Health care is a field where, you know, you can
go anywhere in America and get a job. I mean, this is job
security. If there is one field that has job security, I would
say it is health care, but yet I don't see that message out
there.
Ms. Duke. That was one of the messages. The Secretary
talked to the young people about when we launched kids into
health careers last week. He said to them, if you are looking
at having the possibility for mobility, this is a career choice
that offers you that option. So it is one of the themes that we
do strike in our messages out from the Department. I am not
sure that the individual professional groups make that a part
of their campaigns, but I meet with them regularly, and I will
raise that with them at the next meeting.
Mr. Peterson. It would seem like a few Federal dollars
combined with industry dollars could really get the message out
there. We could be sort of the glue that ties them all
together.
In rural areas the technicians are a huge problem,
recruiting docks is always a problem and adequate nurses is
always a problem, but now it is the technicians and the problem
is in a lot of areas within 100 miles--or 200 miles, we don't
have anybody teaching technicians. Do you deal with that issue
at all, trying to get institutions and hospitals to join
together and offer the programs that are necessary in the
hospital setting?
Ms. Duke. We are aware that the--that in the 270 health
professions that make up health care for this Nation, that we
have sub fields that are not plentifully filled, and
technicians are definitely one of the areas. That is one of the
things we have--in the package for kids into health
professions, we actually have a section on lab techs, so that
we are trying to teach young people that health professions are
more than doctors and nurses.
We have documented the shortage of pharmacists, for
example, and making students aware that they too could be a
pharmacist, and that doesn't mean that you necessarily would
practice in the local drugstore. You might be practicing in a
major medical center, or you might be practicing in a rural
health clinic. But that pharmacy is another profession. So we
are trying to get people to look at more than just entry into
the doctor and nurse corps, but rather into the broader
profession.
And we do meet with the associations regularly about how we
can do more linking together to make more out of what we have,
and that is where, again, telehealth is anotherpossibility
where tests can be done in one site, processed in another and results
sent back, so that it is another opportunity for us to help in areas
where having a full cadre of appropriate health professions isn't
there. So this is one of those things where I think telehealth that we
talked about a little earlier this morning is going to make some real
improvements for folks.
NURSING WORKFORCE
Mr. Peterson. Back to the nursing issue, I have seen
where--you know, I think the move towards predominantly
bachelor degree nurses is part of our nursing problem, because
they have a lot of other options. I am not against the
bachelors degree, but they have a lot of other options, and ask
the nurses who can get an 8-to-5 job, doing quality assurance
and all kinds of jobs, and they are not going to nurse on the
schedules that nurses work if they can get an 8-to-5 job and
make as much or more money.
So I don't think you are going to recruit them back, in my
view. But I have seen people enter the field as a nurse
assistant and they were good, and then they go and they become
an LVN, and they were good, appeared then as they get their
children raised and they go and become a nurse.
Ms. Duke. Absolutely.
Mr. Peterson. Not a bachelor degree nurse but an----
Ms. Duke. An associate. Yeah.
Mr. Peterson. And I think that is the track, and I don't
think those are very likely to leave nursing. They are not
going to have the job opportunities doing things that bachelor
degree nurses do. I think that is the problem--that is part of
the problem I think. Bachelor degree nurses, I have two young
ladies who came out of their--their families were in
accounting. Well, they have realized now one more year of
schooling, they can be a CPA, and they said if we are just
going to do paperwork as a floor nurse, we are going to be
CPAs. And they are both going to night school, and are going to
leave nursing, and that is a tragedy to the health care field.
Ms. Duke. This is one of the problems I cited a little
earlier is that there are more career opportunities. Nursing is
still largely a woman's profession. And as more professions
have become available for women, particularly higher paying and
one of the pieces of the working conditions that you have
pointed to is hours, that people have moved out of health
professions in general and in nursing in particular. But I
think that the--there is a continuum of services in nursing,
and that is one of the attractions I think of the field. There
is a continuum. That we need people in all of those levels, and
one of the reasons we do need bachelor nurses is that at the
bachelor's level, they are able to deal with the complexity of
this modern medical system, where a shot isn't a shot and a
test isn't a test. There is a very complex set of tests and a
very complex set of options. So we need associate nurses, and
that is the fastest growing section of our nursing population.
Mr. Peterson. I am going to have to ask you to sit tight
for a few minutes. I have got to run and vote. I am down to the
end, and as soon as somebody runs, we will resume the hearing.
So this hearing is in recess till we get back.
[Recess.]
Mr. Miller. If we could have everyone take their chairs, we
will begin.
As you know, there was a vote that took place, and that is
one reason I got up and left early. A lot of times one will
leave early, cast their vote. We don't expect a second vote,
and then come right back and continue the hearing, because it
happens--you know, yesterday was--Mr. Thompson was here, and
yesterday at the same time Mr. Powell was here. You just have
to interrupt the--the director of the FBI was delayed. So
unfortunately you don't control that.
COMMUNITY HEALTH CENTERS
But I have a couple more questions. The community health
centers, rural health, is that under your----
Ms. Duke. Yes, community health centers.
Mr. Miller. We have an outstanding one in my area, and
there has been a really outstanding director that runs the--I
just use the material rural health. But they have expanded it
in a lot of different areas, and it has been a great asset to
my community. Describe that for me for a minute. Who would--how
is that----
Ms. Duke. That Community Health Center Program?
Mr. Miller. Uh-huh.
Ms. Duke. I will kick that off, and then I will turn to
Bill Hobson, who is the acting bureau head for that program.
The community health center program is sort of the bedrock
of our safety net program. There are about 730 grantees in this
program. They are community-led health care providers. They are
all across the country. About 47 percent of them are rural.
They provide a variety of services, and they have been the
linchpin for health care in the area, often serving as the base
for a network of integrating services within the community
working with hospitals and other providers to make sure that we
have networks of services. And that is one of the things that
we have tried to foster through our work is networking of our
services.
I will turn to Bill Hobson to talk a little bit more about
that health center program.
Mr. Miller. I have two major communities in my area, and
one has an outstanding one with a diverse group of programs and
really nice facilities, as nice as you want, high quality
doctors, and the other one doesn't do that much, and I am not
exactly sure. Is it--I don't want to criticize them toomuch,
but there is quite a contrast. But go ahead.
Mr. Hobson. Sure. We have a wide variety of programs within
the community and migrant health centers and the other-
consolidated health centers that we fund under this national
initiative. We have some programs that have been in operation
for a longer period of time, have a more secure funding base,
have more well-developed service systems and possibly have a
better facility. Other programs, because of some of the
particulars of the neighborhoods that they serve, don't have as
many other resources beyond the Federal grants to take
advantage of or because they haven't benefitted from some of
the very best leadership, aren't as developed. We have a wide
range of programs, given those factors.
However, we insist that all these programs really meet
minimum standards with respect to the quality of care that they
deliver. We do on-site reviews averaging every 3 years
including reviews that focus on clinical services, financial
management, administration and governance, and we leave each
one of those programs that we do a site visit on with a list of
things that they need to improve.
So we feel pretty comfortable that most of the centers
clinical care programs, are very strong. That is not to say
that we don't have a lot to do in terms of bringing all of our
facilities up to speed and fully developing all of our programs
around the country. Approximately 51 percent of the grants that
we have right now are in rural communities. In other words, the
service areas that they have self described to us are for rural
communities. Approximately 47 percent of the users that we see,
and that is of the 9,600,000 users in the program, are seen in
our rural programs as well.
Mr. Miller. Is that funded separately from urban or inner
city type health programs?
Mr. Hobson. No. Basically they are funded under the same
authority. If you look at the consolidated health centers,
there are several components. We have a community health center
program, and under the community health center program, the
sites can be both in urban and rural areas. We have a migrant
health center program, where all of the sites are almost
exclusively in rural areas. We also have a primary care public
housing program that focuses on direct service delivery in
public housing units. We have a very small school health
services program, and we have additional services that are
available to the homeless population, our health care for the
homeless program that was started originally under the McKinney
Act.
Mr. Miller. Well, the one that we have in Manatee County I
have just been impressed with. I spoke at it when they
dedicated the new physician practice area, and it is as nice as
you would want anywhere. Then I went and visited a year or so
ago their facility for family health, and just the--I mean, I
would be very comfortable for my family or me to go to those
facilities, as far as seeing the facilities and the quality of
the people there and the attention and care. And they are
large, not small operations.
So I guess--and part of it I think is local leadership has
taken that effort. That just varies sometimes. I guess that is
true of all kinds of social services a lot of times, if it is
at the local level. If you get a highly motivated, dedicated
leader--I know our head--I mean, our Meals on Wheels program in
one community is really strong, because for many years we had
a--and we still do. But she started it and got it going.
So I think it is--do you see that, too? I mean, how good
that local executive director is or that local board?
Mr. Hobson. That sometimes tends to show up quite a bit as
you look at the facilities and the way the program appears. But
one of the things that we really don't have, is, a lot of
resources that we make available from the Federal program to
focus on developing facilities. A lot of the programs raise
funds in their individual communities to develop their
facilities. What we tend to focus on and we tend to judge the
program by is the quality of the providers that they have, and
by and large the 4,400 physicians that we have in the program
nationally are board certified physicians who have finished an
approved residency program. We feel that the bedrock or the
core of the program is our highly trained, highly motivated and
very committed clinicians that we have been able to employ.
Mr. Miller. Having nice facilities makes it easy to attract
the people, too. So I guess we were very fortunate in Manatee
County.
ABSTINENCE EDUCATION
Let me switch to another subject, and that is abstinence
and education you brought up. That is a politically charged
issue, and I think everybody would agree that is great. So the
goal, I don't think--how does it work at the Federal level as a
Federal responsibility? Is it a Federal responsibility? Does it
really--you know, has it--what studies show from a--that it
really does--is a good use of dollars?
Ms. Duke. One of things that this program has in it is a
3.5 percent funding for an evaluation of the program, including
a longitudinal study. So we are going to know a lot more about
its effectiveness as a result of what we aredoing this year.
The Assistant Secretary for Planning and Evaluation is going to lead
that evaluation effort for us. We are in our second year of that grant
program, and we are seeking funding for a third year of it. As part of
that, we are going to launch a really intensive evaluation that I think
can answer those questions more authoritatively.
Mr. Miller. I am sure it is difficult to measure that
single variable. That is true in any--I guess all--especially
longitudinal studies. How do you----
Ms. Duke. It is sort of like many of the things that we do,
and it is really one of the frustrations, which of many things
contribute to an outcome and sorting out our role is the dicey
methodological chore. But there are specialists who deal with
the subject of social program evaluation who are putting all
their mighty muscles to developing this, including the
longitudinal study; and I think that that is a very important
piece.
Mr. Miller. How much money are we talking about in this
year's appropriation?
Ms. Duke. For FY2003 we are asking for $73 million, and
this year we had $40 million.
Mr. Miller. How does that work? Is it a grant?
Ms. Duke. Well, actually, there are two programs. There is
a community-based program, which is the one I was just talking
about. The community-based program is a discretionary grant
program, and that means that we put out an announcement telling
the world that we want to fund some programs to achieve these
specific goals, and the legislation has within it the specific
eight criteria that these programs must adhere to. Then
applicants send in their applications.
Last year, in the first year of the program, we had 377
applications. We had funding for 20 planning grants and 33
implementation grants. Those funds are now in use in the first
full year of that cycle.
In 2002, we will run another cycle, and we will have
sufficient funding for about a hundred grantees.
COMMUNITY HEALTH CENTERS
Mr. Miller. Does the health--community health centers get
involved in family planning issues?
Ms. Duke. I will hand that to Bill.
Mr. Hobson. Family planning services are considered to be
part of the comprehensive scope of services that community
health centers should provide. They don't tend to focus on
family planning services, per se, but almost all community
health centers would provide those family planning services as
a part of their routine service program.
Mr. Miller. If they offer obstetrical services?
Mr. Hobson. Yes, and that really depends on whether they
have been able to establish an obstetrical care program. You
generally need several physicians capable of doing deliveries
that are part of the nighttime call and the weekend call
systems. Sometimes in order to offer obstetrical care services
that is done in partnership with local hospitals.
Other health centers that have enough of a critical mass of
physicians who are delivery trained will provide that service
themselves. More than 75 percent of health centers provide
[perinatal] care services.
Mr. Miller. Do y'all handle family planning monies?
Ms. Duke. No. The family planning money is handled by the
Office of Population Affairs in the Department.
Mr. Miller. Ours is called rural health, and I don't know
why--maybe that is just a historical name, and maybe it has
changed, and I might be embarrassed by saying it is still rural
health because I have been around for too many years. But--why
is it rural health? Is that how it originally started?
Now, they also have been able to get physicians who
received money for their medical education to come serve a 2-
year period or something to work there, and then they stay. I
mean, ours--it happens to be a nice coastal community that
doesn't seem that rural, but it is.
NATIONAL HEALTH SERVICE CORPS
Ms. Duke. We have sort of two programs that are related
here. One is the National Health Service Corps where we provide
the physician or clinician to come and serve for a period of 2
years or perhaps even with an extension to 3 years, and many of
those providers actually do become residents and remain in
those communities. The retention rate, 15 years after they have
finished their obligation is still over half of them remain
where--serving underserved populations.
COMMUNITY HEALTH CENTERS
We do have community health centers. About half of them are
in rural areas, but we also have a rural health--an Office of
Rural Health that has rural hospitals and rural health clinics
as well. So we may be funding them through different streams,
but they are all within HRSA.
Mr. Miller. I know people go to this facility--I mean, it
is a sliding scale, and so you could--I mean, it is amazing
that, because it is nice facilities and quality care, that they
do have their share of--people pay the full, you know, amount,
because it is so nice.
So there is a lot of programs in the government we should
be pleased and proud about and excited about, and that is the
one I happen to be familiar with.
I will now let Mr. Peterson take back over, and I thank you
very much for the job you are doing.
ORGAN DONATION AND TRANSPLANTATION
If there is anything on organ transplant, obviously, I have
a very personal involvement, and we think we have a liver
caucus in Congress because this other Congressman is a member
of the other party because the two of us are sointimately
involved with this issue.
Ms. Duke. Thank you very much.
PEDIATRIC GRADUATE MEDICAL EDUCATION
Mr. Peterson. I want to shift gears with you here.
Pediatric education money, I guess I was interested in
the--I was surprised at the cut. I toured Pennsylvania's
children hospitals--I chaired Health at the State for 10 years,
so I toured them then, and I have toured two in the last 3
months, and that is one of the most specialized businesses
there is. I mean, they are working on babies about that size
with surgeries in their beds. I mean, it is one of the most
dynamic--and I guess to not treat them equal to other teaching
institutions or other teaching disciplines, I just don't
understand, because it is at the beginning of life. It is where
we really should, you know, have our expertise and train our
pediatricians and our specialists for children. Any thoughts on
that item?
Ms. Duke. This budget reflects the very tough choices that
had to be made as the Department has tried to focus on a series
of priorities. We clearly have a priority in the use of funding
this year for dealing with repairs to the public health system,
to deal with the preparedness issues associated with the
realities of the world after September 11th, and that has been
an absolute priority.
In the Health and Human Services budget, we also have a
priority for funding the National Institutes of Health, which
is a world-class institution that does such important work, a
benefit to everyone. In our budget, we have an absolute
priority on the direct delivery of care to the population; and,
based on those priorities, a lot of tough decisions had to be
made. Among them was the cut in the pediatric GME. That program
has grown sevenfold over a very brief period of time, and the
whole issue of how we deal with residency education in the
United States is one that the Secretary feels needs attention.
But in the variety of unpleasant choices that had to be made,
this is one where the cut was felt to be prudent.
Mr. Peterson. Well, I appreciate your reluctance that it
was a cut. I mean, I can sense your--I have one more question,
and then I will----
Mr. Regula. Take all the time you want.
COMMUNITY HEALTH CENTERS
Mr. Peterson. Community health centers, do you have maps
of, like, where they are at in Pennsylvania?
Ms. Duke. Yes.
Mr. Peterson. Can that information be made available to me?
Ms. Duke. Yes.
[Maps follow:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Peterson. How do you choose a community?
Ms. Duke. Let me answer that in two--let me answer your
question in two parts.
Yes, we do have maps of where our community health centers
are, and we will make sure you have one.
The second thing is one of the things that I am working
very hard on this year is actually, again using the technology
that we talked about a little earlier this morning, is we are
trying to do some geomapping of where all of the HRSA health
care services are. Because one of the things that we want to be
able to see is where we have the opportunities to assist with
the integration of those services at the local level. So my IT
shop is working very hard to pull that data together and use
the new geomapping technology to be able to bring all of that
together, and we are going to use that for the basis of
monitoring our programs to ensure not just integrity but also
the opportunity for pieces of the health care system to work
more intimately together and to stretch those dollars better
because we are not duplicating.
So the answer to your question is, yes, we have some maps
on hard pieces of paper, but what I am hoping to get is the
mapping that will show us those linkings on an Internet site
ultimately.
So I will let Bill Hobson talk a little bit about the
selection process, which is a competitive process. And Bill.
Mr. Hobson. Thank you, Dr. Duke.
Yes, we solicit applications----
Mr. Peterson. A little bit closer to the mike.
PRIMARY HEALTH CARE
Mr. Hobson. Yes. We solicit applications on a competitive
basis, as Dr. Duke outlined. However, we tend to identify areas
of need where there are access problems for primary health care
services in each State, working with our State offices of
primary care as well as the associations of health centers that
we have in each State. We have a process that is ongoing right
now that we term our State strategic planning process that
attempts to identify those areas that would be appropriate for
a new health center site.
Once those areas are identified, we try to assist local
community organizations in developing a good application and a
good service delivery plan for those communities. Or in some
cases we try to interest another community health center in
putting a satellite health center in those areas of need. So
although it is an open competitive process, we try to work to
target the highest areas of need and develop infrastructure so
we can serve those underserved populations.
Mr. Peterson. Having come from State government, would you
say that the effectiveness of the State health department in
that role depends on whether their communities are successful
or not and how much they help them and guide them?
Mr. Hobson. State health departments have been extremely
helpful in a number of States. Quite often the State offices of
primary care are most often located within the State health
department. They provide assistance in attempting to get the
designations that are required for the placement of a health
center. Health centers are located in a geographic area that
has a designation as a medically underserved area or serving a
population that has a medically underserved population
designation.
Those designations have to be applied for, and the State
offices have been particularly helpful to local communities in
preparing the applications that they need and reviewing those
applications and also in identifying areas of high need within
the State.
Mr. Peterson. Okay. Well, thank you. I reluctantly give the
gavel back to the chairman. I was just being funny.
Mr. Regula. Okay. Mr. Sherwood.
Mr. Sherwood. Thank you, and I am sorry that I haven't been
here earlier, but I had other things going on this morning.
NURSING SHORTAGE
What I would like to ask you about, my area in northeastern
Pennsylvania is extremely short of nurses, and everyone tells
me that as the current crop sort of retires and goes--as they
get older, go to working part time, that this situation is
going to get worse, and it is exacerbated by--even though we
are worrying about the economy right now, it has generally been
pretty good and that profession is not as well paid in
relationship to other opportunities as it used to be.
So in line with this and what I am told by all my hospitals
is a great shortage and what they think will be a continuing
shortage, I am very concerned that we have some cuts in the
program for nursing education. In the past, some of the nurses
training universities in my district have got some help out of
that.
I am not just one to ask for more money, but I want your
thinking on how we are going to get around this and how we are
going to have enough nurses to do what we have to do.
Ms. Duke. The reality is that we are facing a nursing
shortage. We have just released our nursing survey, which tells
us that the pipeline of people coming into the profession is
not keeping up with the people leaving the profession. We have
also been looking at the relationship between the supply of
nurses and the growing demand for services within the
population. The bottom line of all of that is that we are in a
nursing shortage.
We have specific studies of specific States. Some States
have been in nursing shortages for quite some time, but we now
have documented a nationwide nursing shortage, and we know that
is very real.
The budget that we presented for this year offers an
increase for nursing education. We have asked for $99 million,
and it is a $6 million increase--is a $1 million request for
increase at the advanced level and a $5 million increase for
the Nursing Education Loan Repayment Program, which is a
program that has grown very rapidly over the last year. It is a
program that really gets nurses on the floor now, because we
can help them pay for their education, but they are fully
educated and ready to be on the floor.
With the increase we had last year, we had a $2,000,000
program. The Secretary directed $5,000,000 for us to expand
that program. We were able to produce 1,032 years of nursing
service with our money from last year by commitments from
nurses who are fully trained for 2 or 3 years of service in
underserved areas. So this is a program into which we plan to
put more attention next year with the probability that the
funding we are asking for would allow us to add 700 nurses in
underserved areas.
So we recognize that we need to go directly into nursing
education, and thus we have the programs I have described.
KIDS INTO HEALTH CAREERS
I also talked a little earlier about a program that I
really feel sort of passionately about, which is our Kids Into
Health Careers Program, which is a program where we are working
with the education world to open up the possibilities to young
people about career opportunities in nursing but also in other
health professions. In that program we put together materials
for children from kindergarten through 12th grade, talking
about what those professions are and theexcitement within them,
and specifically in nursing the multitude of activities that constitute
nursing as a profession.
That is the future, is to attract young people to do two
things, one, be interested in the profession, but, two, to
prepare themselves to have the prerequisites to do the training
necessary to enter the profession.
NURSING AWARENESS
Mr. Sherwood. I think nursing, like being a fireman or a
policeman or an NCO in our military services, has been a great
way up for a great many people, and so I think we have to make
sure that we are putting the good information out about what a
rewarding career it is in the correct communities.
KIDS INTO HEALTH CAREERS
Ms. Duke. That is an important part of what we were talking
about in this Kids Into Health Careers, is getting the idea out
that this is--it is a wonderful set of professions. There is an
opportunity to be of service, to have a life with meaning as
well as to have a career that has great flexibility and
intellectual challenge. So our challenge is to get the word out
that this is an area for intense preparation and a good life.
Mr. Sherwood. I think we need to make sure that a new
generation of kids understand that this is a way to be a
respected member of society.
Ms. Duke. Yeah.
COMMUNITY HEALTH CENTERS
Mr. Sherwood. On another note, I would like to commend you
and the President for the Community Health Center funding
increase.
Ms. Duke. Thank you.
Mr. Sherwood. I have two centers in my district that just
do a great job for the uninsured. They do a great job for
people who really without them would be on the short end on
health care. So I think it is a good program, and I am glad to
see your funding increase.
Ms. Duke. Thank you very much.
Mr. Sherwood. You bet.
Mr. Regula. Okay?
Mr. Sherwood. Good shape. Thank you.
Mr. Regula. You are right on the Community Health Centers.
Are yours both Federal? It is a great way to relieve the
emergency rooms and provide health care for a certain segment
of a population. I like those.
Mr. Jackson.
Mr. Jackson. Thank you, Mr. Chairman.
Mr. Chairman, I have about five questions, and I can ask
them in the first round or try and get them in in the second
round.
Mr. Regula. Your first and second round will be the same
one.
Mr. Jackson. I think you are probably right, Mr. Chairman.
Welcome, Administrator Duke, and thank you for your
testimony. Let me apologize for being tardy this morning.
TITLE VII
Yesterday, Secretary Thompson indicated that the President
chose to eliminate virtually all funding for title VII
programs, in part because the data indicating that only 33
percent of individuals who participate in these programs go on
to practice in medically underserved areas. As I mentioned to
the secretary in the hearing, the subcommittee has received
testimony from a number of witnesses in recent years who place
that number at a much higher figure. I am hoping that you can
provide the source data that supports this 33 percent figure.
Can you?
Ms. Duke. We will provide that for the record for you.
[The information follows:]
The data that support the findings that 30 percent of
individuals participate in our programs practice in underserved
areas come from the Bureau of Health Profession's (BHPr's)
Comprehensive Performance Management System (CPMS). These data
are collected from approximately 1,500 grantees and reported on
an annual basis to our Agency.
Ms. Duke. The question is a relative question. The question
is--I think the Secretary's response was in relation to where
to put money, to put it into direct services where we could
ensure that providers went to areas where they were most
needed. In the National Health Service Corps about which he was
speaking, we can assure that the members of the National Health
Service Corps are serving in underserved areas, and that has
been an area of his particular concern.
Mr. Jackson. I am very interested in seeing the data,
because, for obvious reasons, it has raised great concern
amongst our constituents.
NEWBORN HEARING SCREENING
My second question is about the universal newborn hearing
screening. Your budget proposes to eliminate the dedicated
funding source for universal newborn hearing screening. However
while your budget assumes that these activities will be covered
under the maternal and child care block grant, there is no
increase proposed for the block grant program. Data from the
National Center for Hearing Assessment and Management shows
that only 67 percent of babies are now screened for hearing
loss before one month of age. Of those screened, only 56
percent who need further diagnostic evaluations actually
received them by 3 months of age, and only 53 percent of those
diagnosed with hearing loss are enrolled in early intervention
programs by 6 months of age.
My question to you is, does this data suggest to you that
muchmore work needs to be done by State and local health
officials and providers? Also, do you anticipate that your proposal to
eliminate this funding may have some adverse impacts on the State's
ability to reach the goal of universal screening and intervention, and
might even be a setback in some areas if States have to eliminate the
health personnel work in this critical area?
Ms. Duke. We also believe that the hearing screening is a
very important service for babies who are about to leave the
hospital. Literally today I will become a grandmother for the
fourth time.
Mr. Regula. Congratulations.
Ms. Duke. Thank you. I will leave this hearing and go
directly to assist with that birth, which is a pretty exciting
thing, and----
Mr. Jackson. Maybe I should submit the rest of my questions
for the record.
Mr. Regula. I might add that I just became a grandfather,
well, the third time, but a newborn about 4 weeks ago. But I
didn't assist.
Ms. Duke. I have had the pleasure of helping deliver the
first three. So this is a marvelous thing, and I value that
hearing screening program very much.
We believe that hearing screening program is well
established and that State and local organizations are
committed to that program and that it is growing well. We
believe that the availability of the maternal and child block
grant will continue to assist that.
I met with five directors of the maternal and child health
program last week who are absolutely dedicated to the program.
Clearly, they recognize that they might wish it to be
otherwise, but they are committed to fostering that program and
carrying it forward.
So I do think the second part of your question suggests
that we do have a dialogue with our partners in the States and
the communities, and I do think that program will continue. But
I could ask Dr. Peter van Dyck, who heads our Maternal and
Child Health Bureau, to comment further on it if you would
like.
Mr. Jackson. Thank you, ma'am.
Ms. Duke. Peter.
Mr. van Dyck. We have a set of 18 national performance
measures that all States must meet. One of those performance
measures is the percent of newborns screened for hearing before
they leave the hospital. So State MCH programs are committed to
newborn hearing screening. We have made good progress.
There is some way to go, as you have suggested. I think the
Maternal and Child Health directors are dedicated to doing
that. I think they will continue to advance the programs, even
though there may not be specific funding.
Mr. Jackson. Well, my question hasn't been about their
dedication. It was about whether or not there was sufficient
funding in lieu of the budget request to cut funding for the
program and whether or not their dedication could be
supplemented with additional resources to help them accomplish
their goal. My question was referring to those issues.
Dr. van Dyck. I think the State directors will try to--
because they have this performance measure to meet, will try to
reset priorities in the State if necessary to help them meet
that performance measure and to continue this program which has
had such a nice start over the last 3 years or so.
Mr. Jackson. Thank you, sir.
Mr. Chairman, I have one last question so that the
Administrator can get to a great moment in her life. It is
regarding HIV and AIDS----
Ms. Duke. It is all right.
RYAN WHITE CARE ACT
Mr. Jackson. Similar to many States around the country,
Illinois is facing severe shortages in Medicaid budget cuts
that could affect the reimbursement and/or access to
medications for people living with HIV and AIDS. Cuts in State
low-income programs mean that more people will seek life-saving
treatment for HIV/AIDS through Care Act programs. If Ryan White
Care Act programs are continuously flat-funded, states may be
put in the difficult position of choosing between funding HIV/
AIDS treatment programs and being prepared for other public
health needs. Given no increase in the Ryan White Care Act
fund, how can Illinois and other States be expected to address
the growing HIV/AIDS epidemic while also maintaining a solid
public health infrastructure?
And that is my final question. Thank you, Mr. Chairman; and
thank you, Administrator Duke.
Ms. Duke. The program is level-funded at $1.9 billion. It
is a large program. The program respects the reality that this
is an epidemic that is very difficult to work with, to conquer,
but one that we are committed to conquering. The Department as
a whole has a very large commitment to the AIDS epidemic. We
have a commitment in the Department of almost $13 billion. We
have a funding through Medicare and Medicaid, about half of
that, and then we have discretionary funding at NIH of almost
$3 billion. We have our program at almost at $1.9 billion, and
we have funding with CDC and surveillance and prevention. So,
as a department, we are working very hard on the HIV/AIDS
effort.
The funding for the drug programs, we recognize that the
drug programs for folks on a full regimen of drugs could be as
expensive as $10,000 to $15,000 a person. We recognize that
those expenses exist.
We also have some changes in the medical world about when
people go on those services. They go onto these services later,
which has made some change in the--loosening up some
availability of funds. So we recognize the dilemmas, but,
again, there were some tough choices in this budget with the
priority around the broad requirements to build our public
health infrastructure to deal with the issues after the 11th.
So the level funding has some issues involved, but we believe
that some compensation can be made by this broader association
of $13 billion coming from the whole Department.
I might ask my colleague, Deborah Parham, who heads our
HIV/AIDS Bureau, to talk a little bit more about that, if I
may.
Ms. Parham. Thank you.
The only thing that I would add to Dr. Duke's comments is
that there was a $100 million increase in the Ryan White Care
Act programs between 2001 and 2002, and we are just getting
those dollars out now into the communities. We believe that in
2003--of those new folks that we are getting into care now, we
will be able to maintain them in care.
The other thing I would say is, not only--Dr. Duke did
mention the $13 billion in AIDS and HIV money in the
Department, but when you look across the Department at other
programs, for example, the Community Health Center programs,
there are a lot of people with HIV and AIDS who access care
there. These SAMHSA programs as well, people can get care
there. So the Ryan White Care Act program is the payer of last
resort by legislation. So there are other programs where people
can get services as well.
Mr. Jackson. Thank you, Mr. Chairman.
Mr. Regula. You got everything you need?
Mr. Jackson. I do not want Administrator Duke to be late
for her next event.
Ms. Duke. I will get there in time. They tell me, I will be
fine. Thank you very much.
UNIVERSAL HEARING SCREENING
Mr. Regula. Well, I just wanted to follow up on Mr.
Jackson's comment on this universal hearing thing. It seems to
me that you can't rely on the block grant people to do that. I
would rather take something out of the block grant and earmark
it here so we get a hundred percent of screening.
Ms. Duke. Well, one of the things that we have done in
recent years in this program is--and I think this is really a
model program for the government--is the creation of the
performance standards--these aren't Federally imposed standards
on the States, but rather these standards have been worked out
in partnership with the States and the Federal Government. Each
State has had the opportunity to choose----
Mr. Regula. They could add money to it, I guess.
Ms. Duke. That is right. There is a deep level of
commitment to this program, and the performance standard for
hearing is one that they have chosen to be part of, in the
sense that they participated in putting this together. We
believe there is a high level of commitment here to carrying
that forward.
I did not sense in the--I met with five State Directors in
a small session for about 2 hours last week, and then I met
with a large group earlier this week, and I did not get a sense
of a flagging commitment to this program.
Mr. Regula. But given that only--there is one-third that
are not receiving it, as I understand it, one-third of the
babies do not get screened.
Ms. Duke. That we are making progress, yes, that is
correct. We have about 65 percent who are screened now.
Mr. Regula. It doesn't seem to reflect a high level of
commitment on the part of the States if that many are being
omitted.
Ms. Duke. Well, when we started, it was only 34 percent. So
in the short history of the program, we have doubled it.
Mr. Regula. What do you think it costs per child to do
this? How do they do them? Do they have a machine, or what is
the process?
Ms. Duke. I am going to ask Peter to talk about the actual
specifics of it, if I may. But this is one of these marvels of
modern technology, because the equipment that exists to do this
is in hospitals. It is not in private physicians' offices, and
that is why we want to get the screening done before the baby
leaves the hospital.
Let me turn to Peter.
Dr. van Dyck. Well, we probably all remember, some of us
who are a little older, perhaps seeing the nurse or the
physician clap their hands to see if the baby might startle.
That was newborn hearing screening for a number of years, and
that wasn't very successful, unfortunately.
Now, we do have new technology that is not expensive, can
be done by nonmedical personnel, at least as a screening. The
babies that test positive in the screening in the hospital then
require a more specific otologic test with specific people
trained to do it to make sure that the screening test was
accurately positive.
It is important to get these children, then, into service
by 3 months of age or at least get the second test and get the
service provision started, and we would like to get them into
early intervention and speech training and all the other things
that go with it by 6 months of age.
Mr. Regula. Do we--is the money used to buy equipment for
the hospitals?
Dr. van Dyck. Money is generally not used to buy equipment.
The money is used generally for staff, organizing the program,
facilitating and organizing the follow-up and tracking of
people, training of the appropriate personnel who would do the
screening in the hospital or do the follow-up and then public
awareness materials so parents know that they should be asking
for a screen and know what to do if the screen is positive.
Mr. Regula. It seems to me like we ought to be getting
close to a hundred percent. This is not a terribly expensive
procedure. It is vitally important to that child.
Dr. van Dyck. The program--this is its third year, and when
we began, we were at 34 percent, as Dr. Duke said. So within
two to two and a half years we have made remarkable progress.
Forty-seven States now have grants, and we hope that most of
the remaining States will get a grant this year, 2002.
Mr. Regula. They have to apply for those?
Dr. van Dyck. They have to apply, yes, sir.
Mr. Regula. Well, Congressman Walsh sponsored the
legislation, and he has a deep interest in this. He has a
number of questions I am going to submit for the record on his
behalf concerning this program.
CHILDREN'S GRADUATE MEDICAL EDUCATION
Children's Graduate Medical Education, I see you cut out
the $85,000,000 that we put in last year to get them up to a
hundred percent of the authorization. It seems to me that this
is just as important as graduate medical education for the
other physicians. So why do we want to treat these people
differently? They start at the earliest point in an
individual's life, is the pediatrician and those that deal with
the young children, and on a scale of one to 10 it seems to me
they are more important than the ones over here.
Ms. Duke. The training for pediatricians in the country,
this is an important source for training, and we recognize
that. I think that has been recognized in the sevenfold growth
of this program over the last few years.
As I have said earlier in the day, the budget reflects a
lot of choices around priorities, and in the reasoning here we
recognize that the whole issue of how we fund graduate medical
education is one the Secretary feels we need to take a good
look at. On this one, when they looked at it, the reasoning
basically boils down to this is still a very generous package.
It does provide about $58,000 per resident, and the decision
was that that would probably in the course of things be----
Mr. Regula. Excuse me. Staff tells me that $51,000 is the
number that we got from your budget justification.
Ms. Duke. I think that is actually accurate, and I have
misstated. It is slightly under $20,000 direct and slightly
over $30,000 indirect, and that totals to $50,000. I apologize
for the error.
MEDICARE/MEDICAID
Mr. Regula. What do you suppose we spend under the
Medicare/Medicaid program that funds the conventional----
Ms. Duke. I don't know that answer, but Bill Beldon may
know.
Mr. Beldon. The estimate for 2003 is approximately
$8,000,000,000.
Mr. Regula. That is total.
Mr. Beldon. That is the total for graduate medical
education out of Medicare.
Mr. Regula. How much do you think that--using the $51,000
figure, how does that compare per patient or per----
Mr. Beldon. I think the estimate is about $65,000 to
$68,000.
Mr. Regula. Frankly, I don't think there should be an
administration, because it is just as important to an
individual to have good pediatric care, perhaps more important
than the conventional. Of course, the argument is, well, that
child isn't on Medicare and, therefore, that should not be a
responsibility of Medicare. But that child is going to be on
Medicare some day.
Mr. Beldon. I think the distinction is that the
$8,000,000,000 is on the mandatory side of the budget. This is
in the discretionary side of the budget. The choices she was
talking about were the choices that the Secretary was faced
with, and he didn't have a choice on the $8,000,000,000.
GERIATRICS TRAINING
Mr. Regula. I suggested to Ways and Means that they amend
that, but it should cover across the board, because I think how
well you are at 75 is affected by how you are treated at 12
months, and you are talking about a total well-being of an
individual, which leads me to another question. That is, you
took out the money for geriatric training, and that is--again,
we have an aging population. Demographically, they are going to
be a larger percentage. Doesn't it seem that we should be
making a little more emphasis on giving the physician
population experience in dealing with geriatric procedures and
medicine?
Ms. Duke. While we have not continued the funding, the
generous funding for geriatric this year, we have made a
commitment that in our entire program we will put an emphasis
on geriatric services and the use of the geriatric specialists
that we have been able to provide in order to make that more
widely available. Because we are an aging population, and we
believe that making that commitment throughout our program can
deliver those services.
Mr. Regula. I would just be interested in yourprofessional
opinion. I have suggested that at least there ought to be some course
requirement, maybe just a couple of hours, for every physician on
geriatric medicine. Because if they treat a patient at 45, it may very
well affect that patient's health at 75. It would seem that every
physician should have some understanding of the special problems that
result from geriatric medicine. What do you think?
Ms. Duke. As someone who spends some time in hospitals with
aging parents, you certainly long to make sure that each person
that he or she meets along the way understands the difference
between a 95-year-old and a 30-year-old. And my colleague, Dr.
Shekar, whispered immediately in my ear, we agree. So I
appreciate that we agree.
Mr. Regula. So do I. Well, I think--I am just a layman, but
it would seem to me in medicine you should always be thinking
about the total person. Life is made up of a whole series of
impacts or steps, but perhaps that is one of the things that
concern me is the fewer and fewer what I call general
practitioners, family medicine. I know in our case all three of
our children were brought into this world by the local
physician who did the cuts and the scratches and the whole 9
yards. He was in a small town, and we lived out in a farm, and
he was our family physician, did the whole 9 yards. That is
sort of a passing phenomena, isn't it?
MEDICAL HOME
Ms. Duke. Well, one of the things that we try to do through
our health centers and through a lot of our programs is to
arrive at the concept of a medical home, which is a little more
bureaucratic way of saying we would like people to have an
association to a health-care-providing entity and even a
person, with the idea that there is more likelihood that things
will get treated earlier. Because when we were growing up and
we had that access, things got taken care of in a timely way
and we didn't end up at the emergency room with an expensive
critical illness when it could have been handled a lot earlier
and a lot cheaper along the way.
So one of the things that the Maternal and Child Health
program talks about in its program, in Healthy Start and in the
broader program, is getting across the concept of a medical
home for children.
If you would like, Peter could tell you a little bit about
some of the efforts we are making to try to make that happen.
We can't always change the world of providers, even though we
are trying to do that as well.
Mr. Regula. Well, I think economics and liability, medical
liability, have driven the general practitioner in a way out of
the scene, because--well, enough said about the liability
problem, but if you want to comment.
Dr. van Dyck. There is legislation that talks about medical
home for children in the children's health insurance program,
and for children with special health care needs. We feel it is
a very important concept; and it is not necessarily just a
physician but a clinic, nurse or physician assistant who can
provide ongoing regular care for that particular child and
family.
There are now a number of studies which suggest that these
children are more often insured. They make more appropriate
visits. They get referred to specialists more appropriately.
They have less hospitalization, and they have less emergency
room use. And it is all because they feel comfortable in having
a place to always call, whether they are referred on from that
place is fine, but at least they have a home.
So it is a very important concept, I think. If we can build
it among children, infants and children, and get the family
comfortable with that concept and actually encourage that
concept with them, then it will follow to the next generation.
We have put quite a bit of effort into this.
Mr. Regula. Well, I think that you make a good point there
that--in terms of the well-being of that individual there is
some real value to having one physician who is your hometown
doctor, if you will. But I notice the difference in our own
children which had that and my grandchildren, which seems like,
when they take them, it is a different kind of a specialist
every time they go to the doctor. And I don't know. Maybe that
is a better way. I am not sure. But it has certainly changed.
Ms. Duke. It is a changed world.
Mr. Regula. The medical environment, if you will.
You have all been very helpful. Excellent testimony. I
think your agency has a wonderful opportunity to leave a great
legacy for people in so many different ways, and I am sure you
all respect that opportunity that is yours, and we are going to
do the best we can in funding it and helping you.
Off the record.
[Off-the-record discussion held.]
Mr. Regula. Well, good luck.
Ms. Duke. Thank you very much.
[The following questions were submitted to be answered for
the record:]
Mr. Regula. Do you know if it is going to be a
granddaughter or grandson?
Ms. Duke. It is going to be a granddaughter, and her name
will be Allison Christine, and we hope she will be healthy.
Mr. Regula. That is right. Well, I have got an Olivia
Ireland about 4 weeks ago.
Ms. Duke. That is great. Thank you very much.
Mr. Regula. And this wonderful staff bought me two books
called Olivia. I didn't even know they had a book called
Olivia.
Ms. Duke. That is the fun part of being a grandparent. They
keep forcing you to learn stuff that you didn't think you would
have to learn.
Mr. Regula. How many do you have?
Ms. Duke. Personally, this is my fourth granddaughter. My
nurse daughter has a 3-year-old and a 1-year-old, and my second
daughter has a 2-year-old--little over 2--and the new one who
is to be born today.
Mr. Regula. Someone said if I knew grandchildren are so
much fun, I would have started with them.
Well, thank you. You have all been great.
With that, we will adjourn the hearing and let you be on
your way.
Ms. Duke. Thank you very much.
[The following questions were submitted to be answered for
the record:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
W I T N E S S E S
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Page
Beldon, W. R..................................................... 1683
Clancy, Carolyn.................................................. 1379
Curie, C. G...................................................... 745
Duke, E. J....................................................... 1683
Fleming, D. W.................................................... 1
Gimson, William.................................................. 1
Hobson, William.................................................. 1683
Koch, Rita....................................................... 1379
Kopanda, Richard................................................. 745
Nelson, Jon...................................................... 1683
Parham, D. M..................................................... 1683
Shekar, Dr. Sam.................................................. 1683
Simpson, Lisa.................................................... 1379
van Dyck, Dr. Peter.............................................. 1683
Weems, Kerry...............................................1, 745, 1379
I N D E X
----------
Centers for Disease Control and Prevention
Page
Anthrax..................................................29, 81, 83, 84
Arthritis......................................................174, 213
Assessment Initiative............................................ 115
Asthma........................................................... 26
Autism........................................................... 77
Biotechnology.................................................... 1
Bioterrorism.....................................2, 5, 11, 58, 164, 167
Draft Model State Emergency Health Powers Act................ 9
Birth Defects...................................................86, 150
National Children's Study.................................... 86
Breast and Cervical Cancer Program..............................51, 189
BSA (Business Strategy Adjustment)............................... 46
Buildings and Facilities......................................... 85
Cancer Registries................................................ 80
Cancer Screening Program......................................... 17
Centers for Public Health Preparedness.........................121, 166
Colorectal Cancer................................................ 19
Chron's Disease.................................................. 77
Chronic Disease................................20, 23, 47, 55, 185, 210
Community Preventive Services Task Force......................... 89
Dental Care...................................................... 20
Flouridation................................................. 29
Diabetes...................................................26, 169, 181
Early Childhood Longitudinal Study--Birth Cohort (NCHS).......... 90
Environmental:
Health....................................................... 194
Health Tracking System......................................16, 160
Impact on Health............................................. 54
Epi-X............................................................ 88
Genetic Testing Information Coordination......................... 61
GSA Rental....................................................... 79
Health Alert Network.............................................66, 71
Healthy People 2010.............................................. 189
Hemophilia....................................................... 19
Hepatitis......................................................215, 216
HIV/AIDS...................................................69, 206, 215
HIV/STD Prevention........................................... 158
Global AIDS Programs......................................... 92
International HIV/AIDS Funding............................... 77
Human Papillomavirus............................................. 77
Immunization.....................................................42, 76
Global Immunization.......................................... 77,78
Infrastructure Issues........................................ 54
Polio Vaccination............................................ 42
Records...................................................... 15
Vaccine Availability......................................... 163
Vaccine Purchase.........................................14, 64, 78
Vaccines for Children........................12, 13, 15, 43, 58, 96
Infectious Disease Control....................................... 194
Infrastructure................................................... 7, 46
Injury Control:
Hip Fractures Among Elderly.................................. 98
Intimate Partner Violence.................................... 75
National Violent Death Reporting System (NVDRS).............. 97
Rape Prevention.............................................. 97
Research on Gun-Related Violence............................. 9
Trauma Care Systems.......................................... 98
Laboratory Response Network...................................... 173
National Electronic Disease Surveillance System (NEDSS).........72, 124,
160
National Inflammatory Bowel Disease Epidemiology Program......... 213
National Pharmaceutical Stockpile..............................164, 175
NIOSH........................................................6, 40, 153
National Occupational Research Agenda (NORA)...............100, 201
Protective Gear for Emergency Workers........................27, 58
Work-Related Deaths.......................................... 15
Obesity.........................................................31, 155
Oral Health......................................................20, 87
Organ Donation and Liver Issues.................................. 18
Ovarian Cancer................................................... 51
Polio Eradication................................................77, 93
Prevention Research.............................................. 204
Program Evaluations.............................................. 136
Prostate Cancer.................................................. 177
Public Health.................................................... 57
Improvement.................................................. 123
Training..................................................... 166
Workforce.................................................... 120
Radiation Exposure............................................... 150
REACH............................................................ 44
Management Efficiencies...................................... 44
Repair and Improvements.......................................... 63
Restructuring and Delayering Plans............................... 124
Syphilis......................................................... 93
Tuberculosis...........................................70, 91, 174, 206
Unified Financial Management System.............................. 81
Youth Media Campaign..............................32, 57, 151, 167, 210
Wise Woman Program.........................................48, 157, 189
Substance Abuse and Mental Health Services Administration
Abuse, Neglect, and Civil Rights Violations Reported............. 822
Addiction Technology Transfer Centers............................ 811
Anti-Drug Abuse Education Program................................ 810
Anti-Stigma Initiative.........................................783, 887
Brochures on Drugs and Addictive Substances...................... 797
Building Strong Mental Health Programs........................... 754
Building Substance Abuse Treatment Capacity...................... 751
Centers for Medicare and Medicaid Services....................... 784
Children's Mental Health......................................... 771
Children's Mental Health Services Program........................ 867
Chronic Homeless Population...................................... 855
Collaborations with Other Federal Agencies....................... 827
Community Mental Health Centers.................................. 859
Congressional Justification (Justification of Budget Estimates).. 895
Consolidation of Offices within SAMHSA........................... 828
Co-occurring Mental Illness and Addictive Disorders.......845, 855, 887
Delivering Effective Prevention Service.......................... 753
Demand for Services.............................................. 764
Diaster Efforts Following September 11th......................... 877
Drug Abuse Warning System........................................ 830
Ecstsy Initiative................................................ 879
Elimination of Deputy Director Positions......................... 828
Enhancing Partnerships with Private Sector Organizations......... 828
Evaluations on the Effects of Medicaid Managed Care.............. 785
Expand Capacity for Mental Health Services....................... 783
Faith-Based and Community Initiative............................. 832
Funding for SAMHSA Block Grants.................................. 884
Funding for the Department's IT Initiative....................... 839
Funding for the Mental Health Block Grant........................ 885
Funding for the Unified Financial Management System............829, 830
GPRA Annual Performance Plan..................................... 1089
Health Insurance Portability and Accountability Act (HIPPA)...... 816
HIV/AIDS Block Grant Set-aside................................... 816
HIV/AIDS Programs................................................ 805
HIV Risk in at Risk Populations.................................. 787
Homeless Programs................................................ 765
Homelessness..................................................... 843
Improving Management of Federal Resources........................ 756
Jail Diversion Programs........................................869, 891
Longitudinal Survey of Youth..................................... 826
Mental Health Block Grant......................................864, 892
Mental Health Centers and Care for the Homeless.................. 851
Mental Health Commission.............................778, 784, 785, 848
Mental Health Court Grant Program................................ 870
Mental Health Evidence-Based Tool Kits........................... 789
Mental Health Funding Request (PRNS)............................. 843
Mental Health Parity.......................................77, 875, 883
Mental Health Programs Evaluations............................... 833
Mental Health Services.........................................775, 884
Mental Health Technical Assistance Centers....................... 848
Mental Illness and Disorders (Numbers of Persons Affected)....... 864
Methamphetamine Abuse (Treatment)..............................811, 862
Minority Fellowship Program...................................... 787
Minority HIV/AIDS Funding........................................ 829
Model Prevention Programs........................................ 797
National Clearinghouse for Alcohol and Drug Information.......... 802
National Institute for Mental Health............................. 858
National Summit.................................................. 793
National Technical Assistance Center............................. 793
National Treatment Outcomes and Monitoring System (NTOMS)........ 830
Olmstead Decision................................................ 866
Opening Statement................................................ 745
Opioid Treatment Program......................................... 813
Parity for Block Grant Funding................................... 778
PATH Program...................................................791, 854
Pilot for Reporting Performance (Block Grant).................... 789
Post-Traumatic Disorders Program (PTSD)........................766, 796
National Child Traumatic Stress Initiative................... 881
Resident's New Freedom Initiative................................ 794
Prevention Services Supported by the Block Grant Program......... 808
Programs of Regional and National Significance (PRNS):
Applications received and approved........................... 868
Congressional Earmarks and Budget Mechanism Tables........... 817
Projects Proposed for Discontinuation............................ 790
Proposed Cuts in Mental Health................................... 890
Protection and Advocacy Program................................790, 849
Public Service Announcement Campaign............................. 799
Safe Schools/Healthy Students Initiative/Program...............832, 882
SAMHSA Reorganization............................................ 844
SAMHSA's Strategic Plan.......................................... 831
Scholastic Magazine.............................................. 810
Seclusion and Restraint.......................................... 788
Services for Homeless People..................................... 871
Services for People with Co-occurring Disorders.................. 803
Services for the Elderly/Older Adults..........................772, 804
Staff Funded through the Block Grant Set-asides.................. 826
Staff Transfer to the Office of the Secretary.................... 829
Staff Transferred to the Program Support Center.................. 829
Starting Early/Starting Smart Program..........................804, 823
State Incentive Grants Smart Program............................. 805
State Indicator Pilot Grant Program (CMHS)....................... 787
State Mental Health Agency Budgets............................... 792
State Performance Partnerships................................... 814
State Prevention Data Collection................................. 808
Supportive Housing Initiative.................................... 831
Substance Abuse and Children in the Foster Care System........... 860
Substance Abuse Performance Partnership Grants................... 879
Substance Abuse Prevention Funding............................... 874
Substance Abuse Prevention Programs.............................. 878
Substance Abuse Programs......................................... 762
Substance Abuse Treatment........................................ 872
Substance Abuse Treatment Gap.................................... 816
Substance Abuse Treatment Model.................................. 874
Suicide Prevention............................................... 786
Synar Exemptions................................................. 814
Synar Initiative................................................. 796
Testimony........................................................ 750
Training and Certification of Residential Staff (Mental Health).. 790
Training for Mental Health Professionals in Primary Health Care.. 842
Treatment Capacity Expansion--State Grants Program............... 815
Treatment Drug Court Program..................................... 812
Underage Drinking................................................ 795
Underage Alcohol Abuse........................................... 800
Witness Biographies.............................................. 759
Workforce Planning............................................... 825
Workplace Programs............................................... 802
Agency for Healthcare Research and Quality
Access to Mental Health Services.............................1418, 1421
AHRQ and NIH.................................................1426, 1431
AHRQ's Mission................................................... 1379
AHRQ's Reporting Line within DHHS................................ 1407
Bioterrorism..................................................... 1398
Care for the Mentally Ill........................................ 1417
Centers of Excellence on the Health Care Markets and Managed Care 1415
Community Mental Health Centers.................................. 1424
Congressional Justification...................................... 1435
Consolidation with NIH........................................... 1407
Consumer Assessment of Health Plans.............................. 1383
Cost Effectiveness Research...................................... 1395
Department of Commerce's Current Population Survey............... 1398
Domestic Violence................................................ 1409
Employer-Sponsored Insurance for Mental Health Services.......... 1423
Evidence-Based Practice Centers.................................. 1406
Evidence-Based Research.......................................... 1431
FY 2003 Budget Request........................................... 1380
FY 2003 Reductions to Existing Programs.......................... 1396
Health Care Cost................................................. 1394
Health Care Cost and Utilization Project......................... 1382
Health Care Cost Savings......................................... 1433
HIV Research Network............................................. 1429
Hysterectomy Research............................................ 1432
Improved Health for Priority Populations......................... 1410
Improving Health Care............................................ 1379
Informatics...................................................... 1394
Informed Decision-making......................................... 1380
International Evidence-Based Practice............................ 1412
Malpractice...................................................... 1397
National Guideline Clearinghouse................................. 1412
National Healthcare Disparities Report........................... 1408
National Healthcare Quality Report............................... 1405
National Reports on Quality and Disparities...................... 1382
Other Funding sources............................................ 1400
Patient Safety................................................... 1381
Patient Safety Data Initiative................................... 1408
Patient Safety Initiative........................................ 1426
Patient Safety Research Results.................................. 1400
Patient Safety Task Force........................................ 1402
Quality Measures................................................. 1419
Quality of Mental Health Services................................ 1422
Reductions in the FY 2003 President's Budget..................... 1429
Research on Health Costs, Quality and Outcomes................... 1425
Research Related to Nurses....................................... 1396
Rural Health..................................................... 1413
Translating Research into Practice............................... 1382
Witness List.................................................1379, 1384
Health Resources and Services Administration
Abstinence Education/Programs....................1718, 1730, 1790, 1851
ADAP............................................................. 178
Adoption Awareness Program...................................1285, 1294
Advisory Committees, Councils, Panels, Commissions............1778-1781
AHECs (Area Health Education Centers)........................1832, 1857
Amendment Cost................................................... 1796
Basic Nursing................................................1723, 1795
Black Lung....................................................... 1762
Budget Decreases................................................. 1719
CARE Act......................................................... 1798
Children's Graduate Medical Education........................1743, 1751
Children's Health Fund........................................... 1789
Collaborative Program............................................ 1713
Community Access Program.....................................1791, 1850
Community Health Centers.............1728, 1731, 1732, 1733, 1738, 1823,
1826, 1854, 1858
Community Health Centers Maps................................1734, 1735
Continuation Costs............................................... 1792
Data Bank........................................................ 1796
Denali........................................................... 1801
Dental Services........................................1799, 1807, 1823
Distance Learning................................................ 1783
Drug Discount Pricing............................................ 1787
Emergency/Hospital Preparedness.................................. 1716
Faculty Loan Repayment........................................... 1792
Geriatrics...................................................1744, 1750
Graduate Medical Education..................1783, 1793, 1794, 1859-1893
Hansen's Disease................................................. 1762
HCOP............................................................. 1793
Health Care for the Homeless..................................... 1754
Health Center Grants..........................................1840-1845
Health Center Loan Guarantee Program............................. 1786
Health Centers.......................1712, 1713, 1754, 1791, 1829, 1839
Healthy Communities Innovation Initiative....................1715, 1798
Healthy Schools/Healthy Communities.............................. 1854
Health Professional Shortage Area................................ 1786
Health Professions............................................... 1817
Health Professions Program Reductions............................ 1748
Health Professions Training..................................1749, 1825
Heritable Disorders.............................................. 1830
HIV Home Services................................................ 1760
Homeland Security................................................ 1716
Information Technology........................................... 1790
Introduction of Witnesses........................................ 1719
Kids Into Health Careers......................................... 1738
Living Donor..................................................... 1720
Long Distance Learning........................................... 1712
MCH Block Grant........................1796, 1808-1817, 1834-1836, 1852
Medical Home..................................................... 1745
Medicare/Medicaid............................................1744, 1763
Migrant Health................................................... 1761
Migrant/Seasonal Workers......................................... 1791
Minority HIV Aids................................................ 1803
National Center for Health Workforce, Information & Analysis..... 1763
National Health Service Corps (NHSC)............1714, 1724, 1732, 1752,
1823, 1845
Newborn Hearing Screening........................1739, 1742, 1797, 1821
Nurse Training Shortage.......................................... 1718
Nursing Awareness................................................ 1738
Nursing Education Loan Repayment.......................1718, 1795, 1857
Nursing Shortage...........................1717, 1723, 1737, 1788, 1857
Nursing Workforce............................................1727, 1792
Office of Legislation............................................ 1803
One Department................................................... 1716
Opening Statement.............................................1686-1697
Oral Health...................................................... 1806
Organ Donation, Procurement and Transplantation..............1716, 1719,
1732, 1756, 1799
Poison Control...............................................1756, 1828
Pediatric Graduate Medical Education............................. 1732
Primary Care Training............................................ 1853
Primary Health Care.............................................. 1736
Program Evaluations.............................................. 1818
Program Management............................................... 1802
Program Reductions............................................... 1831
Public Communication............................................. 1710
Ricky Ray........................................................ 1802
Rural Health.....................................1726, 1753, 1800, 1847
Ryan White.................................1724, 1741, 1758, 1759, 1850
Scholarships for Disadvantaged Students.......................... 1793
School Programs.................................................. 1712
Security and Preparedness........................................ 1715
Standard Level Users Charge...................................... 1758
State Children's Health Insurance Program (SCHIP)................ 1805
State Planning Grants............................................ 1838
Taps............................................................. 1763
Telehealth..................................1711, 1786, 1804, 1836-1838
Title VII........................................................ 1739
Title VII and Title VIII Effectiveness........................... 1856
TORT............................................................. 1761
Transplantation.................................................. 1720
Trauma EMS...................................................1786, 1797
Traumatic Brian Injury........................................... 1796
Underserved Areas............................................1753, 1760
Unobligated Balances...................................1760, 1784, 1785
Vision Screening................................................. 1782
Witnesses....................................................1683, 1685
Workforce Analysis............................................... 1794
Workforce Task Force............................................. 1820