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investing our money correctly. There are 23 nations that are doing better while spending less.
We are proposing to target the infant mortality dollars. We have $105 million of new money, but we also propose to use money from the Community Health Centers Program and from the Maternal and Child Health Program. These dollars are currently being spent on infant mortality within those programs. We are trying to concentrate enough dollars in 10 locations to look at the problem very carefully and gain some knowledge that we can use 5 years from now to find better ways to lower infant mortality nationwide.
There will be 10 projects, and every one of those other community health centers is objecting to the prospect of level funding. We are not decreasing their dollars, but what we propose to do is to take the planned increases in funds and concentrate them. Some of these centers will be winners this year—those who compete successfully for this—but, to look at the larger picture, we all will be winners in the long term if we can get this information.
It will take around 5 years, hopefully less. All of the 550-odd centers and other programs will then have the benefit of this information on how to better address infant mortality. Japan is No. 1 in this area with a per capita expenditure of $1,000 on health care, while we spend $2,500 per capita. We hear about automobile workers, and other companies complaining about the high cost of labor, listing health care as a major cause. We need to find ways to lower that cost. Every time we try to focus the problem, to get information that is helpful to the whole country, people say that it is a great idea, that we need to do it, but please do not do it here.
We are forced to make hard decisions. We are trying to carry on the program and get information as
well as to deliver services, but do it within the budget agreement. This forces us to make decisions which should not be interpreted to mean that we are not committed to maternal and child health or the community health centers.
I look at the larger picture, at what is good for the Nation. It may mean that a center in a particular State or particular city may not get the $40,000 increase that they want out of a budget of $3.5 or $4 million, which is the order of the magnitude that we are talking about. We have to make some tough choices. I look at it from the standpoint of what is going to be the best approach for the Nation as a whole.
Senator GORTON. Thank you, Mr. Secretary. Thank you, Mr. Chairman.
Senator HARKIN. Senator Burdick.
COMMUNITY SERVICE PROGRAMS Senator BURDICK. Mr. Secretary, I was disappointed to see the administration proposes to delete most of the funding for the community service programs. According to your budget justification book, only $10.8 million would be allocated, and all of that would go to one of the discretionary programs.
Your stated rationale for deleting virtually all of the community service programs is that the community action agencies have been successful in obtaining funds from other sources. What other funding sources would you recommend for a State such as mine, where the economy is still very poor, the main industry of agriculture has
undergone a terrible decline, and a number of poor people that need community action agency services has grown not decreased. Where should we look for money?
Secretary SULLIVAN. Senator Burdick, we would be happy to have our staff review this with yours. We have a number of categorical programs in my Department for which organizations in North Dakota would be eligible to apply.
For example, the National Health Service Corps program has a number of corps physicians and other health professionals who work in your State. We are emphasizing greater health promotion and disease prevention to address a number of these issues.
The profile of each State will be very different. I can provide a complete answer to that question and will be pleased to have my people work with yours.
Senator BURDICK. Can you provide a list of specific funding sources available to North Dakota community action agencies? We do not have the programs.
Secretary SULLIVAN. I would be happy to see that you get a list of all of the categorical programs in my Department. There are people in the various organizations in North Dakota who are familiar with private sources of support that can help. The information follows:)
COMMUNITY ACTION AGENCIES Community Action Agencies (CAA's) will be able to access funding from other Fed. eral, State, and local sources, e.g., the Job Opportunities and Basic Skills (JOBS] program, Head Start, Child Care and Development Block Grants, the Social Services Block Grant, nutrition programs operated by the Administration on Aging, cer
programs administered by HUD, the Emergency Food and Shelter Program in FEMA, food programs administered by the Department of Agriculture
such as Food Stamps and Women, Infants, and Children (WIC), as well as from private sources.
INFANT MORTALITY Senator BURDICK. I just want to say that my State and areas around it have undergone a terrible drought in the last 3 years, and are going on the fourth one. These services that have been provided in the past have been invaluable to those people, and to cut them back as suggested here is going to create a great deal of hardship, and I hope we can find some other sources to replace them. You provide some information for me, tell me where to go. Will you do that?
Secretary SULLIVAN. We will be happy to have our staff get with yours, Senator.
Senator BURDICK. All right. Thank you.
Mr. Secretary, let us get back to reducing infant mortality again. You said in your statement you wanted increase women's access to prenatal and perinatal care, looking at the budget document here, and yet your request totally eliminates all of the health professions programs that train family doctors, pediatricians, nurse midwives, nurse practitioners, and physician's assistants—totally eliminates them. So my question to you is, who is going to provide the care?
Secretary SULLIVAN. Well, Senator, we do not totally eliminate them. The National Health Service Corps program is one that we 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:)
BUDGET PROPOSAL 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 supp 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 Serv. ice 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.
REPROGRAMMING Senator HARKIN. Then we will not be asked for reprogramming for 1991, then.
Secretary SULLIVAN. No; for 1991 or 1992?
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.
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 num. ber. 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.