[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.
    [The information follows:]

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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]

              [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.
    [The information follows:]

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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.
    [The information follows:]

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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

                              ----------                              
                                                                   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

                                

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