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Drug abuse continues to extract too high a toll on our children, on our families and on our society as a whole. We have requested an increase of $ 108 million for drug abuse treatment, research and prevention efforts throughout the Alcohol Drug Abuse and Mental Health Administration. Included in this total is $99 million to expand the overall drug abuse treatment capacity of the Nation. Resources will be focused in areas where the current drug abuse problem far outstrips the capacity to provide treatment services. The total funding for drug abuse research, prevention and treatment activities within HHS is $2 billion, an historically high level of support.

Almost a third of the discretionary expenditures for HHS or nearly $10 billionare devoted to the biomedical and behavioral research efforts carried out by the National Institutes of Health and the Alcohol Drug Abuse and Mental Health Administration. The 6 percent requested increase of $681 million will fund ongoing research in the prevention and treatment of diseases such as cancer, AIDS and other sexually transmitted diseases, heart disease, and stroke. This budget directs funds toward a variety of initiatives, including efforts to map the human genome, developing drugs to treat people suffering from mental health disorders and drug and alcohol addiction, and re-building the research infrastructure on the NIH campus.

As a result of a growing national concern over both the quality and rising costs of health care, the Agency for Health Care Policy and Research was created one year ago to organize and support research studies focused on improving health care delivery methods. The budget for 1992 includes $122 million, an increase of 6 percent over 1991, to undertake a wide variety of projects that will ultimately improve the patient's outcome.

I am committed to ensuring the quality of service provided to the American public through the large entitlement programs administered by this Department Social Security, Medicare, and Medicaid. In recent years, budgets for both the Social Secu. rity Administration (SSA) and the Health Care Financing Administration (HCFA) have grown faster than inflation. As the beneficiary population grows in the future, it will put additional pressure on us to develop more efficient and effective ways to manage within the available administrative resources. This year, we were faced with difficult choices in managing within the constraints of the Budget Enforcement Act. The requested funding, is adequate to meet the basic mandates of these agencies. HCFA contractors will pay Medicare bills within the statutory time frames. SSA will focus its resources on processing claims applications and maintaining service levels. However, in some areas, there may be slow downs.

However, we are examining options for both SSA and HCFA to develop strategies for finding the most cost-efficient ways to provide service to the people who depend on us. SSA is developing a long-range strategic plan which will define service requirements, means to increase productivity and efficiency, and, in general, provide a picture of how $SA will deliver high quality service to the American public. HCFA is actively exploring ways to improve the uniformity, efficiency, and performance of Medicare contractors, including a review of alternatives to current contractor arrangements.

We are requesting a $232 million supplemental appropriation for 1991 for the SSA to provide administrative resources to enable the Agency to carry out the additional work required as a result of the Supreme Court decision in Sullivan vs. Zebley. As funds were not included in the regular appropriation for this purpose, a supplemental appropriation is needed in order to meet the additional work demands.

As you are well aware, the Budget Enforcement Act of 1990 established absolute spending limits for all discretionary programs. In order to stay within the prescribed ceilings, we propose the following spending reductions.

The budget requests $1 billion in funding for the Low Income Home Energy Assistance Program (LIHEAP). This amount is $585 million less than the fiscal year 1991 level. LIHEAP was created as a temporary program in the late 1970's in response to the energy crisis. These reductions reflect the fact that LIHEAP was never intended to meet the entire home energy costs of low-income households, but rather to supplement assistance available through other Federal and state programs.

The Community Services Block Grant and related discretionary grant programs are proposed for elimination in fiscal year 1992. This would represent a savings of $425 million. This program was initiated in fiscal year 1981 to assist in establishing an infrastructure for improving services to low-income individuals and families. Since that time, basic reforms have been institutionalized and increased funding has been provided for activities such as employment services through the JOBS program and child development through Head Start and the Child Care and Development Block Grant.

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The budget also proposes a reduction of $186 million in funding for the Health Professionals Training Program. This represents a common theme throughout the budget of focusing resources toward programs that target minority and disadvantaged populations and away from broad-based categorical health professions programs.

In conclusion, we have endeavored to balance the competing demands of providing for the vast and varied health and income security needs of this Nation while staying within the absolute fiscal constraints defined by the Budget Enforcement Act of 1990. The programs administered by the Department of Health and Human Services touch Americans throughout their lives, providing essential prenatal and child care for low-income families, ensuring that all children start school on equal footing, advancing our scientific knowledge of disease prevention and treatment methods, and providing financial support for our elderly citizens. This budget reflects our strong commitment to ensuring the health and well-being of all our

citizens. I look forward to working with you for its enactment.

HEAD START Senator HARKIN. Mr. Secretary, thank you for a very forceful statement and a clear declaration of your intent and policy positions of the Department. I would like to have a copy of that statement also as well as the one that was submitted earlier with all of the facts and figures in it, too, because I would like to read some of the things that you were talking about there.

The culture of character that you said money cannot buy reminds me of what my dad once told me. He said, you know, it is pretty hard to pull yourself up by your bootstraps when some rich kid has stolen your boots. Yes; we like people to pull themselves up by their bootstraps, but they have got to have the wherewithal and they have got to have the boots first. And I know that money cannot buy everything.

But it seems to me that despite all of the different conflicts that confront Americans today, we are an open, free society. We believe in individual initiative and effort. There is sort of a cross-current there. The traditional values, the work ethic, saving money, studying, getting ahead, faith, taking care of your family, strong community-these are old, traditional American values which permeated through all sectors of our society and all races in our society. And now there is a cross-current cutting across that, a cross current of do your own thing. Everyone is free to do whatever they want to do, lack of responsibility for one's actions, lack of accountability for what one does. And I think it permeates all of our society.

It seems to me that there are no simply answers. I understand that. It seems to me that we have gotten away from the basics. We are very good in our society in health areas especially, also education, social services, all the areas that we basically cover herethat your Department covers. I say education but also in Head Start and things like that.

We have become so focused on fixing things up, patching, curing once you are ill, remedying, acute care, and

health care. Once you get sick, we can take care of it. If you cannot read, we will have remedial reading. We have got remedial this, remedial that, remedial everything in our society to take care of these problems.

I am proposing that perhaps we focus on not having those problems in the first place. And the place to start is with kids, children, and that means a broad approach at prevention and health promotion. And we know it works. You know it works. You take infant mortality. There is no real secret about reducing infant mortality. You extend maternal and child health care services to a pregnant woman from month one through delivery and postdelivery, and you are not going to have low birth weight babies. We know it works.

Your Department has the data and the documentation on that $600 for maternal and child health care for 9 months versus $ 15,000 maybe to take care of a low birth weight baby. We know those programs work. You say money is not the answer? If we fully fund the Maternal and Child Health Care Program, it will work. We have proved that it works.

Head Start-you, yourself, said this is a success program. We have got 25 years now? Twenty-five years of Head Start? We know it works. We have seen the cohorts as they have gone along. We know what happened to the kids in Head Start compared to their counterparts that did not partake of Head Start.

You have asked for an increase in Head Start-$100 million or something like that. And yet we are only servicing 25 percent of the kids today—25 percent get served by head Start. So we have $2.1 billion that we are putting into Head Start. You can correct me if I am wrong on these figures, but I am pretty close-about $2.1 billion into Head Start. We are getting 25 percent of the eligible kids.

Now there are stated goals. I know that I keep hearing them around here. We have a goal of fully funding Head Start by 1994. Did that come out of the administration?

VOICE. That is the Dodd bill.

Senator HARKIN. There are a number of Senators I know here that supported this concept of fully funding Head Start by 1994. That would require $2 billion next year, $2 billion more in 1983, and $2 billion in 1984. That gets us to 100 percent, about $8 billion a year. A $100 million increase in Head Start. I am sorry. That does not do it. That does not do anything. That just sort of keeps it going along. That is not to say that the $2 billion we are spending is wasted. But let us get to all these kids early on when they are 3 years old and 4 years old, so we do not have to remedy it later on.

I guess that is my response to your statement. I like what you have to say, but let us start focusing these things on early childhood. Let us not rob maternal and child health care programs to pay for something else. Let us recognize programs that work. WIC programs-not in your bailiwick, but WIC programs work. Head Start works. The child care bill will work. And we have just got to put more money into it.

And you say money is not the answer. But if that kid does not have his boots, you can preach to him all day long about pulling himself up by his bootstraps and developing character, but if he does not have the boots, he cannot pull himself up.

And so I kind of agree with you and kind of disagree. I agree that money does not solve everything, because the way we spend it does not work. We are trying to remedy things and patch things up later on, after the damage is done. You take a kid that is born, and his mother-her mother-has not had proper nutrition and that baby does not get proper nutrition when it is born. It does not get stimulation in the early years of its life. I do not care how much

remedying you want to do, that kid is stunted the rest of his or her life.

We have to shift the focus. We have to shift it and put it into prevention and early health care promotion. To that extent I am with you-to the extent that you want to take it out of maternal and child health care programs, I think we are going to part ways on that.

So your comments got me thinking about that. It was a very provocative statement. I do not mean provocative in a confrontational way—but provoking thinking, and so I appreciate that.

HEAD START

Secretary SULLIVAN. Mr. Chairman, if I might respond. Senator HARKIN. Yes. Secretary SULLIVAN. First, on the issue of Head Start, which is a program we all agree works. It is a very important program and we support it. The President's goal was to provide a Head Start or Head Start-like experience for all eligible 4-year-old children. With our proposal we will be able to reach some 60 percent of all of the eligible 4-year-old children. The difference between our position and others is that they propose the Head Start experience for 3 year olds and 5 year olds. That certainly is worth discussing.

We have chosen the goal of all eligible 4 year olds, because we think it is clear that youngsters exposed to a year in Head Start at age 4 make significant gains. It is not clear that expenditure of dollars beyond that year will result in incremental gains.

Senator HARKIN. Excuse me, sir. Beyond that year or 5 years? Is that what you are talking about or are you talking about 3 year olds and 2 year olds?

Secretary SULLIVAN. I am speaking about 3 year olds and 5 year olds. We believe the optimal year for the Head Start program is the year prior to kindergarten. We want to concentrate on the 4 year olds, because the results are very good.

Given limited resources and the many other demands that we have, we are diligently trying to address many issues. We are not disputing that additional dollars to provide Head Start experience for 3- and 5-year-olds would not have some effect. The judgment we have to make is whether the incremental gain would be sufficient if we put the money there as opposed to other programs.

Our position is that even though Federal dollars are important, it takes more than money. We need a real commitment from the leaders in our communities, including political leaders, clergy, vol. unteer organizations, et cetera. My Department is a department where the programs for which we are responsible are largely designed to support the family, substitute for the family, buttress the family in times of stress or weakness, et cetera-whether it is health or social services.

To the degree that we can strengthen the family, we can help to avoid some of these problems and minimize them. I fully agree with you on the importance of prevention. We recognize that and are fully supportive of it. Last August we released our health goals for the Nation for the year 2000 as part of our overall prevention efforts, and a number of follow-on activities resulting therefrom are underway.

Senator HARKIN. Thank you, Mr. Secretary. I have some more specific questions on a couple of areas, but before I get into those, I would recognize my colleagues.

Senator Hatfield.

INFANT MORTALITY INITIATIVE Senator HATFIELD. Thank you, Mr. Chairman.

Mr. Secretary, I would like to associate myself with the chairman's remarks as to the justification of transferring from the Maternal and Child Health Block Grant Program and community health centers some of the money that would go to this new initiative.

I would like to know a little more, and this you may do for the record rather than today, how you arrived at some of the judgments, because it seems to me that all of those agencies are dealing in some part with infant mortality. And I am troubled just from the standpoint of the valuation on the importance of these two existing programs.

I also wondered, Mr. Secretary, and you are going to be just one of many agencies that I ask this question. Could I have my staff work with you on making some random selection? You say you have 250 programs in this category. Maybe picking 10 of those programs. And I would like to know the amount of dollars of overhead to administer the programs in ratio to the dollars that get to the recipient. Now, I am not raising this with any prejudgments.

I happen to sit on an independent board of Trustees that has an educational program under its jurisdiction. It is a very small one, but the other day we got the budget for the coming year-$480,000 for administrative costs and $300,000 for the program recipients. Now, that to me is a little disproportionate, especially when this was situated in the context of a university.

Now, I agree that dollars in and of themselves do not often constitute the solution or getting to the problem. But I also am constantly aware of the fact that we have perhaps not maximized the dollars we spend. And, as again I am not suggesting this be predetermined before we look at the statistics, but I do think they can be instructive. They will not tell us everything, but certainly it will help us.

Now, I would like to jump to the other end of the life health problems. Mr. Secretary, are you aware of that, the wandering of victims of Alzheimer's is becoming an increasing problem. Last year in New York State, the Harry Helmsley Foundation granted $300,000 for a trial program aimed at reducing the risk for those victims and their wandering. The project is underway in the Northeast corridor. I think there are about 16 chapters now of Alzheimer's advocate organizations that have implemented this little idea of a bracelet and on the back of this bracelet is the in this case—is the name of L.M. Sullivan. [Laughter.]

L.W. Sullivan-excuse me. HHS Secretary, memory impaired. (Laughter.)

Secretary SULLIVAN. I do not know where I lost it, Senator. (Laughter.)

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