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have increased. It was at the level of $8 million when I came in 2 years ago, it is now up to $49 million, and we have included a $5 million increase over that in the budget.
These dollars are primarily for training more disadvantaged students for the health professions to address the disparate health status of our minority and disadvantaged populations.
Another thing is our support for graduate medical education through the Medicare program. We are giving greater support for residency programs in primary care, family medicine, general internal medicine, and pediatrics.
Senator HARKIN. Under what program?
Secretary SULLIVAN. Support for graduate medical education is through the Health Care Financing Administration. What we are doing is restraining the support for residency programs in specialties such as ophthalmology, anesthesiology, or radiology, and providing support for residents in family medicine, pediatrics, or general internal medicine, because of the need for more primary care physicians in urban inner cities and rural areas.
PUBLIC HEALTH AND HEALTH ADMINISTRATION
Senator HARKIN. Mr. Secretary, would you on your budget proposal-would you look under the heading of "Public Health and Health Administration" and the following items: public health training internships, family medicine, general internal medicine and pediatrics, physician's assistants, family medicine-did I mention that?-all of these are zeroed out.
I will have my staff give you a list of the ones that are zeroed out here. What I would like your staff to do is to tell me where these are being picked up. If we are duplicating these things, I would like to know about it, and I think what you were saying to me is that this is being picked up some place else. I would like to know about that, because you asked to zero them out. If they are being done some place else, I would like to know about it. So I will submit to you a list of the ones I am talking about here, where the budget request is for zero-for example, family medicine was $36 million last year and it is a zero request this year. I would like to know where that is being picked up.
Secretary SULLIVAN. We will be happy to get a response back to you, Senator.
Senator HARKIN. I would appreciate that. [The information follows:]
In fiscal year 1991, public health traineeships, family medicine, general internal medicine and pediatrics, family medicine departments, and physicians assistants were supported at $68 million. While we are not proposing support for these specific programs in fiscal year 1992, we are supporting training in these disciplines through a number of other mechanisms. Our request for the National Health Service Corps recruitment programs will grow to $54 million, compared to $11 million in fiscal year 1990. Through our minority and disadvantaged efforts, we are seeking $73 million to support a number of programs including Exceptional Financial Need Scholarships and the Health Careers Opportunity Program. Additionally, we are requesting $15 million to recapitalize the Health Professions Student Loan Program which already has approximately $65 million available in the revolving loan fund for fiscal year 1992. These minority and disadvantaged training programs support a variety of health professions disciplines including: medicine, nursing, osteopathic
medicine, dentistry, pharmacy, podiatric medicine, optometry, veterinary medicine, allied health, public health and clinical psychology.
Through the Medicare program, we will spend more than $5 billion in fiscal year 1992, on the direct and indirect Medicare costs associated with training interns and residents. In fiscal year 1991, we spent approximately $4.7 billion on these training costs. Our fiscal year 1992 legislative package contains a proposal which adjusts our graduate medical education payment to encourage the training of primary care residents.
INFANT MORTALITY INITIATIVE
Senator HARKIN. One more thing on the infant mortality initiative. Are you going to declare what cities they are? Is there going to be some kind of a long process of cities applying for this? How is this going to run?
Secretary SULLIVAN. It will be competitive, Senator. We will invite applications from areas that have high infant mortality. Consideration will be given to the quality of the proposed approaches for reducing infant mortality over a 5-year period by at least 50 percent, and the evaluation process proposed for measuring the impact of their efforts.
It will not be the top 10 areas-cities and rural-that will be competing. It will be a discrete geographic or governmental unit, and will include the level of infant mortality, and the quality of the program. We want to know at the end of this what works and why. We can then take the best data and use that to develop a national approach.
Senator HARKIN. So, it sounds like you are going to have a competition out there and you are going to, first of all, publish the criteria they have to meet and how they would compete for the funds. So, you are talking about a period of time here.
When would you expect that the final date would be for the cities-you mention rural areas, but I understand it is just cities, 10 cities. That is the way it has been told to us. When would be the final date that you anticipate that you would have for their application?
Secretary SULLIVAN. I can get that information back to you, Senator. It would be during fiscal year 1992. I will get you the schedule for the application cycle.
[The information follows:]
HEALTHY START INITIATIVE
The Healthy Start Initiative will provide communities with funding to create_a comprehensive prenatal care program for low-income women and their infants. To accomplish this goal, medical and social services providers within the targeted communities will work collaboratively to develop new and innovative means of delivering services to meet the needs of pregnant women and infants. We believe it is imperative to begin this initiative immediately. Therefore, Federal Register notices will be published in April announcing the availability of fiscal year 1991 funds. The Health Resources and Services Administration will provide pre-application technical assistance, including several bidders conferences beginning in late April. The deadline for Healthy Start applications will be July 1, 1991. We hope to award grants to approximately 10 communities in August. As you are aware, I had initially planned on $57 million to launch Healthy Start in fiscal year 1991, however, based on Congressional action only $25 million will be available.
Senator HARKIN. Then we will not be asked for reprogramming for 1991, then.
Secretary SULLIVAN. No; for 1991 or 1992?
Senator HARKIN. 1991.
Secretary SULLIVAN. We are asking for reprogramming for 1991 to get started on this initiative as soon as possible. We want to begin during the current year.
Senator HARKIN. I do not understand.
Secretary SULLIVAN. The total program will be $171 million.
Senator HARKIN. Why would you want it reprogrammed this year if, in fact, you will not even be disbursing any of the moneys for at least another year, into fiscal year 1992?
Secretary SULLIVAN. We plan to have up to 10 areas that we would have funded. We want to get started this year. We do not want to wait and make all of the awards simultaneously. If we did that, we would have to wait until we had a total of $171 million.
We have asked for $105 million in new money in 1992, but want to start in 1991 with reprogramming from the community health center, maternal and child health, and some other programs.
Senator HARKIN. Of about $57 million, but it does not take $57 million between now and October to get the criteria set and get the information out to the cities. I mean, I cannot believe it would cost $57 million to do that.
INFANT MORTALITY INITIATIVE
Secretary SULLIVAN. That would include some of the awards that would be made in 1991.
Senator HARKIN. But I just asked you about the awards. You said this would be into 1992 before you would have the closing date for all the cities. You are going to have the criteria, they are going to have to apply, they are going to have to meet certain standards, you are going to have to review all these things, and you say it is not going to be until well into fiscal year 1992, so why do you need $57 million this year? I just do not understand that.
Secretary SULLIVAN. It would be 1992 before the program is up to full steam. We want to get started now because this is an urgent problem. The reprogramming of 1991 dollars would help us get started early.
We will have many applications and limited dollars. Out of 10 successful applications we might fund 3 now, or some other number. Then when additional dollars are available, we would fund additional successful applicants.
Senator HARKIN. So there could be applicants that would qualify prior to the end of this fiscal year?
Secretary SULLIVAN. Yes.
Senator HARKIN. Will you be sending up a formal request for reprogramming?
Secretary SULLIVAN. Yes.
Senator HARKIN. When will we receive that? I have been reading about it and we have talked about it on the phone, of course.
Secretary SULLIVAN. I will get a response back to you on that shortly.
[The information follows:]
The Healthy Start reprogramming letter was sent to the Senate on March 12, 1991.
Senator HARKIN. Thank you. OK, that clears that up pretty well.
I did want to cover one other thing on rural health care with you, Dr. Sullivan. In a recent survey of State executives conducted by your Department, 41 Governors said that rural health care is a chief concern, yet a review of your 1992 budget shows:
One, no funds requested for the essential access community hospital or rural primary care hospital programs;
Two, no funds proposed for rural health transition grants-I mentioned that in my opening statement earlier;
Three, after almost 2 years, no one has been appointed director of ADAMHA's Office of Rural Mental Health Research;
Four, no funds are requested for the health professions programs targeted to rural areas, AHECS, board of health education centers; and
Five, there is a proposal to outreach health services that links service providers, but your proposal is only for 10 cities and no funds are requested for rural health outreach grants.
There is a cut proposed for the Office of Rural Health Policy, with just $800,000 proposed to support State offices of rural health in 1992.
Maybe this represents my own bias, because as you know I come from a town of 150 people-you cannot get much more rural than that and so I take a very close look at what is in here for rural America, and I was surprised to hear about Pennsylvania-you are right, Senator Specter. If you have 2 million people in rural Pennsylvania, that is as much as we have got—well, not quite. What did you say, 2 million or 2.5 million?
Senator SPECTER. 2.5 million people in rural Pennsylvania.
Senator HARKIN. That is almost-well, we have about 2.9 million in the entire State of Iowa. When I see all these cuts coming in rural areas, I get quite concerned, and I would just like to hear any thoughts you have on these proposed cuts and I am sure you see rural America and rural health care as part of your domain also, not just the cities out there.
Secretary SULLIVAN. On the issue of health personnel-our National Health Service Corps program is one program that helps rural areas significantly in obtaining the personnel who are needed. That program has increased from $8 million when I came in as Secretary to $49 million. We propose an additional increase of $5 million for next year.
This program provides not only scholarship support but also loan repayment moneys for individuals who commit themselves to serving in medically underserved areas.
The Office of Rural Health Care goes from $4.7 million down to $4.1 million. This does represent a decrease, but there is still a significant budget for that office.
We are working with our regional directors and with the State rural health councils where our regional directors sit on these councils to work with them on their plans.
The rural access centers was established as a demonstration program and is in its second year. We have felt the need to wait for additional information on how effective these access centers are before asking for more money. That is why we have not asked for additional dollars for this year. We need to see how the centers that we have funded are working before coming back to ask for additional dollars.
Senator HARKIN. Thank you very much, Dr. Sullivan. Senator Specter?
EVALUATING DRUG PROGRAMS
Senator SPECTER. Thank you, Mr. Chairman.
Mr. Secretary, when you have appeared here in the past, I have asked you about the process of evaluating drug programs on therapy rehabilitation to make a determination as to what, if anything, is being successful. Can you shed any additional light at this time on what programs on rehabilitation are working where your Department has been making grants?
Secretary SULLIVAN. Yes, Senator Specter. I will send back a full statement for the record from my staff with details. I have been told by Dr. Mason, my Assistant Secretary for Health, and Dr. Goodwin, our Administrator of the Alcohol, Drug Abuse, and Mental Health Administration, that the programs are effective. They are working, and the longer we keep people in treatment the higher the success rate is. We have to look upon drug addiction as a chronic relapsing disorder and accept the fact that we will have failures. It is similar to diabetes or osteoarthritis in that they are chronic disorders, but they are helped by treatment.
I want to get back to you on the specifics of the various treatment programs.
Senator SPECTER. I would appreciate that, Mr. Secretary. I would like to know which programs are working, and would like to know the statistical basis for that determination. For example, how many people have been in the program, what kind of tracking there is after they leave the program, how many are involved in recidivism, how many are involved in additional drug use.
This is a question which has been of concern to me for a long time, since I had a hand in bringing Gandenzia House Rehabilitation Center to Pennsylvania-Westchester-back in 1968, and I have not yet seen enough by way of follow-up on addiction to be satisfied as to the efficacy of the rehabilitation program, so I would like to have that in detail.
[The information follows:]
I have asked Dr. Fred Goodwin, the Administrator of the Alcohol, Drug Abuse and Mental Health Administration to prepare a report which provides information on which drug abuse treatment programs work. We will provide this report to the Congress by June 1, 1991.
ALLOCATION OF DRUG FUNDING
Senator SPECTER. Mr. Secretary, let me ask you about the allocation of drug funding. We had the confirmation hearing of Governor Martinez a few days ago in the Judiciary Committee, and we went through the continuing debate about how much ought to be allo