fense facility transferred to the city in 1985 that I had worked on. There is an additional homeless women's facility which was established in May 1983 as a small, 20-bed facility, and this is really separate from the request which I had discussed with you last year and have been made a part of the Senate report accompanying the Labor, Health and Human Services, and Education appropriation bill on page 182 (S. Rept. 101-127) there is a reference to the committee having provided $9,090,000 for a homeless research demonstration project, and it enumerates a number of factors, including detoxification services and referenced on the same page problems in cities such as Philadelphia. So, I just want to round that out by saying this is different, and I would very much appreciate your attention to this one as soon as we can process the application.

Secretary SULLIVAN. I will give it my personal attention. We want to do everything we can to be sure that the response in our agency is as rapid as possible.

Senator SPECTER. I would appreciate that.

You had commented that there had been a delay on appropriations, and I had questioned that and I was told that it is a general practice to await the appropriations process. I ask you to review that, as to whether it is necessary to await the final appropriation, where you have a project as important as this one.

But, at any rate, we are on track now, so I would appreciate your attention to it.

DRUG REHABILITATION

Dr. Sullivan, last year I had brought up the subject with you which I had raised with your predecessor, Dr. Bowen, the year before, regarding what rehabilitation works on the drug issue. When Dr. Bowen was here in 1988, there had been a comment that they did not really have much to rely upon in the way of experience as to what was successful.

As I had expressed to you last year, this is a concern I have had for more than two decades since the founding of drug rehabilitation centers that I helped with in Pennsylvania in 1968. I am interested to know, and you might want to submit this in writing since time is short, and it is past noon, as to what progress has been made on the identification of treatments which work.

You had submitted a written answer for the record last year, and there had been some preliminary information, but there were more projects to be evaluated, and I would be very much interested to follow this up not only with a written answer now, but with continuing responses so we can evaluate just what we are accomplishing by way of finding out what does work.

Secretary SULLIVAN. We will be pleased to submit that to you. I am pleased that with the increased funding for demand reduction activities will provide significant increased funding for research on new types of therapy.

[The information follows:]

METHODS OF TREATMENT

I share your concern in determining what methods of treatment are effective. Dr. Charles Schuster, Director of the National Institute on Drug Abuse, will provide the committee with a report on treatment method effectiveness. In August, 1989, a tech

nical review was sponsored by NIDA on “Improving Drug Abuse Treatment”. A full report of what was discussed at the technical review will also be included in Dr. Schuster's report to the Committee.

MENTAL HEALTH

Senator SPECTER. Well, there had been that direction in the 1988 legislation giving your Department a new responsibility. If we can document programs which work on rehabilitation, I think that the Congress would be very interested in increasing funding.

Dr. Sullivan, the next point that I want to take up with you briefly is the issue of mental health, and I do not know that there is a whole lot to be said about it except that we really need to search for additional funding. I ask your assistance on that as Senator Harkin and I and others try to find more money for that very important line.

There is a lot of sentiment in Congress for increased funding because there have been so many breakthroughs and it seems so productive to utilize those funds at this time.

Secretary SULLIVAN. Senator Specter, I share your concern. I was pleased that Congress passed the resolution to declare 1990 the decade of the brain. We have proposed in our budget $99 million for research in schizophrenia. We believe that much remains to be done. We look forward to working with you as we expand our research and our understanding of mental disorders such as Alzheimer's disease.

Senator SPECTER. Very good. We will look forward to doing that. The next topic that I want to just touch on is this issue of crack babies. I recently visited St. Francis Hospital in Pittsburgh, where there has been a grant of some $1 million, and there is very important research being undertaken on women who are addicts are giving birth, Thomas Jefferson Hospital, where there is a special pediatric AIDS program and St. Christopher's Hospital in Philadelphia. Again, we are balancing many needs for funding, and we are trying to find answers through limited funds for pilot projects, and I just wanted to mention that we will be following up with you on this matter of expanding on present efforts.

Secretary SULLIVAN. Thank you.

GAUCHER'S DISEASE

Senator SPECTER. Now, the final subject I want to talk to you about-and there are many, many like these, but I had a contact on a special problem relating to a disease known as Gaucher's disease. And the President of the Gaucher's Foundation, Mr. Michael Epstein met with Dr. Mray Goldstein, Director of the National Institute on Neurological Disorders and Stroke and Dr. Ross Brady, head of the Gaucher's disease intramural research program at NINDS.

What this boils down to is that they need additional enzyme for clinical treatment to determine the appropriate dosage, as I understand it, for a treatment of Gaucher's disease, which affects some 15,000 to 20,000 children nationwide.

It comes down to a need to find $2.5 million to buy the enzyme, and among the many, many requests which have crossed my desk,

I thought this one was worth a few moments of our time here today.

They talk about a supplemental appropriation, but I do not know where or when, and the question arose as to whether this might be important enough for an effort by you personally. In your Department with your budget, I am aware, even as big as your budget is, you do not have much loose money lying around. But what I would ask you to do is to review this personally and see if you might find the funding, $2.5 million, to make this enzyme purchase which would enable this testing program to go forward.

Secretary SULLIVAN. I will be happy to review that and see if indeed there are any funds that we could give. Gaucher's disease is one of the lipid storage disorders that causes all kinds of problems, and if a way has been found that suggests a therapeutic approach, we certainly would be interested.

I am not familiar with the details, but I will review that and see if we can be of help.

Senator SPECTER. Well, thank you very much, Dr. Sullivan. As usual, you are very responsive and helpful.

We talk about so many problems and when they come to our attention we all try to do the best we can with so very many demands and such limited resources, and we thank you for your high level of professionalism. It is a pleasure to work with you, and we will keep plunging ahead. Thank you.

Secretary SULLIVAN. Thank you, Mr. Chairman.

AIDS

Senator HARKIN [presiding]. I have a couple of last things I want to go over. One has to do with AIDS and AZT. We included $29.6 million last year for AZT, $19.7 million for home health care, $1.5 million for subacute care. None of these have been funded in your request.

Particularly with regard to AZT in view of what I said in my opening statement about the new findings with regard to AZT, and last year your own department estimated that 248,000 HIV positive individuals would come down with AIDS between 1989 and 1992.

What is your strategy-if you do not request money for AZT or for home health care or subacute care, what is your strategy to deal with the need for AZT and other drugs for people who are HIV positive but cannot afford any treatment or do not have insurance to cover it?

Secretary SULLIVAN. Senator Harkin, I actually have difficulties with the concept of designated drugs for treatment. We don't fully understand the dimensions of the problem. I want to assure you we are committed to doing everything we can to address it.

We feel that it is more appropriate to have those funds in our general care dollars, that is, Medicaid and Medicare. Individuals, who are eligible for support are provided that drug through those programs.

We want the greatest possible flexibility with the dollars that we have because, while today we may have a problem, say, with AZT or AIDS, 5 years from now it may be some other problem. Once we

start having categories of dollars for specific drugs, it really gives administrative problems.

Senator HARKIN. OK, I understand that, but how about people who are HIV positive and-their assets may be a little bit more than what qualifies them for Medicaid, yet they may not have health insurance? And I know you have to spend down to be eligible for Medicaid. I mean, you have to spend everything down to get there.

Do you have any plans to deal with this? As I understand it, some of this AZT money was for filling in that kind of a gap. You said Medicaid would take care of it. That is true, once you get down to that spend down to that level that qualifies you for Medicaid. Is that what you are saying, that these individuals should do that?

Secretary SULLIVAN. I think this really falls under the category of how we organize our health care system. Our programs are designed to provide funds for those who are most vulnerable in our population. However, we do have problems such as what you have alluded to.

That is one of the kinds of issues that we are reviewing as we examine options for potential reforms in our health care system. A similar question applies to the whole issue of long-term care: To what degree does the individual have a responsibility for providing their resources either through insurance or their other resources versus societal responsibility.

Clearly, while I do not have an answer, that is one of the kinds of questions that we are wrestling with as we look at options that are going to be coming forward for our national discussion and debate.

Senator HARKIN. Your 1991 budget estimated there were 600,000 to 1.4 million HIV infected persons in the United States. Last year we were told the estimate was 1 million was to a 1.5 million. Do you have any knowledge of why you lowered your estimates?

Secretary SULLIVAN. We are not really sure yet what all of the factors are. We have had tremendous success, particularly in our homosexual population, with our educational efforts to try and change high-risk behavior. Experts in the department feel this may be the result of progress that we are making.

I am sure you read, as I did, a couple of days ago that we are not seeing that kind of improvement with the IV drug abuse problem, resulting in AIDS in that segment of the population. We have not had that kind of success with behavior change in that population. Whether there are other factors, we do not yet know. Our figures have been revised toward a lower amount.

RURAL HEALTH CARE

Senator HARKIN. Let me turn briefly to rural health care. Last August the National Advisory Committee on Rural Health forwarded to you its recommendations to improve health care. They had a number of recommendations that I will not go over here. But none of the initiatives that they proposed is in your budget. And I am wondering why.

I will just read some of them: implementing Federal grant programs to promote integration and coordination of services in rural areas, increasing Medicare payments for rural primary care physicians, revitalizing and expanding the National Health Service Corps scholarship and loan repayment programs, which is what Senator Bumpers, I think, brought up.

But none of those is in your budget, and I would like to have you, if you could, you or your staff, sort of flesh out for us more of the different rural health care initiatives that you feel are sort of subsumed into this budget that you have sent up to us. I would like to take a look at that.

Secretary SULLIVAN. I will be happy to respond in writing. First of all, Senator Harkin, I have met with Governor Ray, the chairman of that committee, last November, and that was very helpful. We do have in our budget submission some beginning responses. [The information follows:]

RURAL HEALTH CARE INITIATIVES

We have begun specific initiatives within the Department in response to the National Advisory Committee on Rural Health. Already in 1990, the National Institute of Mental Health has created the Office of Rural Mental Health Research and a search committee has been formed to recruit a director. HRSA will fund two new rural health research centers this year which will collect, analyze, and disseminate information on rural health issues of national significance, with one of these centers focusing specifically on the health problems of rural minorities. HCFA also has a new wage survey underway which will help refine Medicare hospital wage index adjustments under the prospective payment system. We expect this information to be available for use in 1991. In addition, I plan to submit a legislative proposal this Fall which will establish a single standardized Medicare payment rate to all hospitals by 1995, effectively eliminating the urban and rural hospital payment differential.

In 1991, the budget also includes funding for a number of activities which address committee concerns. The Medicare hospital capital payments reduction of 15 percent for rural hospitals is more lenient than the 25 percent proposed for urban hospitals and we expect our 1991 proposal to restructure physician payments to benefit rural physicians. As part of the Minority Health Initiative, we also expect the proposed increase of $55 million for the National Health Service Corps Scholarship and Loan program to provide health professionals to underserved rural communities. We have also proposed an increase of $9 million more than in 1990 to increase access to health services through Community and Migrant Health Centers and an increase of $1 million to the Office of Rural Health Policy to provide technical assistance to rural hospitals.

NATIONAL HEALTH SERVICE CORPS

Secretary SULLIVAN. For example, we have expanded National Health Service Corps dollars in our budget. We proposed, of course, as you know you and the other members of the Congress did pass physician payment reform this past year. In that is a provision that gives a greater reimbursement rate for rural-based physicians in primary care.

The problem is that that program does not really come online until 1992. It is not reflected in this year's budget, but the response to those recommendations is underway.

FAMILY PLANNING

Senator HARKIN. Let us turn to family planning services. I can give you a number of statistics about Iowa. In 1984 one out of every