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(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?


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 allocated to the so-called demand side rehabilitation education contrasted with the supply side interdiction, strike forces, et cetera.

There were quite a few of us on the Judiciary Committee who urged a 50–50 split, and I would be interested in your view as to what an appropriate division would be, and I might say that I ask that question with the hope that we can increase the division to 50_50 and can look to some advocacy from your Department in that regard.

Secretary SULLIVAN. Thank you, Senator Specter.

As Governor Martinez may have mentioned to you, we look at the dollars devoted to demand reduction. My Department has a major responsibility in that area which includes treatment, prevention, education, and research. We compare the dollars for law enforcement, and the dollars for preventing drugs from coming into the country involving our State Department, military, Coast Guard, and others. It breaks down into roughly thirds. Of the $11 billion now in the drug program we are spending approximately one-third, or around 30 percent, for demand reduction activities.

My budget has an increase of $128 million for treatment which would add some 9,000 drug treatment slots. If the States match our dollars on the ratio that they have in the past, we would increase the number of people who can be treated by 200,000. I can get those specific figures back to you.

Senator SPECTER. Are you satisfied with a 70–30 split-70 for law enforcement? I understand that is what it is. It is not too far from two-thirds/one-third, with an even slightly more, as I understand it, balance for supply side. Are you satisfied with—we will take your figure-one-third for demand, two-thirds for supply?

Secretary SULLIVAN. We have had significant increases in funding for demand reduction. We have doubled our research budget and increased dollars for treatment.

The problems we are running into are not related to a shortage of funding. The major problem is getting drug treatment facilities established in communities. What we have seen all over the country is the objection of people to having such facilities in their communities.

Senator SPECTER. Are you saying you cannot utilize any more funding on the demand side?

Secretary SULLIVAN. We think that with the dollars that we have now, we will be reaching virtually everyone who is on drugs who is ready for treatment. I will be happy to get these figures back to you with the methodology used to derive them. With the funds we have requested, we would be able to reach the majority of addicts who are ready for treatment.

[The information follows:)

ANTIDRUG ABUSE ACTIVITIES The $1.8 billion requested in my fiscal year 1992 budget for antidrug abuse activi. ties represents a five-fold increase in HH$ antidrug abuse activities since 1986. This is significant. Recent data such as the High School Senior Survey and the National Household Survey show that we are making progress in the War on Drugs, but we still need more treatment services than are currently available. However, it is important to ensure that additional treatment dollars go to those areas most in need. That is why my budget proposes a new $99 million treatment program that will provide grants to States based on community needs assessment and the State's plan for providing drug treatment services. Expanding drug treatment capacity through this mechanism is preferable to the Alcohol, Drug Abuse and Mental Health Serv. ices Block Grant because it allows us to target our resources to communities which need them the most.

ALLOCATION OF DRUG FUNDING Senator SPECTER. Senator Biden has asked for an additional $3 billion, with a significant part of that to go to the demand side. Are you of the opinion that-well, I am asking you the same question, and I am not quite sure what your answer was—are you getting all of the money that you can effectively utilize on the demand side?

Secretary SULLIVAN. Senator Specter, given the budget agreement we would have to take $3 billion from something else in our Department. I would

say that that would be totally inappropriate. Senator SPECTER. That is a different question about priorities, and I understand that you are a Cabinet officer of an administration which has a policy, and maybe you are bound by the policy, so that is that.

But we have to make an evaluation from a congressional point of view in the Senate as to what the priorities ought to be, and it is not an easy matter to evaluate how well we are doing in Peru, how well we are doing in Columbia, what the effect of strike forces is, the overall balance and I know the administration has come up with two-thirds, one-third, or a 70–30 split, and I have a judgment which is contrary to that.

I think there is a growing body of sentiment in the Congress that the educational aspect is probably the most cost effective, even more so than rehabilitation, and we are putting a tremendous sum of money into drugs. We added $1.8 billion in the 1986 legislation, $2.7 billion in 1988, and the funding now is $1 billion over last year. We are up to $11.7 billion.

Let me ask you to do this. Let me ask you to take a look at the allocation and you and I will be around to discuss this next year, but I would urge you to take a look at a greater proportion on demand, and perhaps it might be possible to have some sort of an evaluation somewhere.

Maybe we might request this, Senator Harkin, from one of the agencies, telling us what we are getting for the extra dollar on interdiction or law enforcement. Maybe one of the agencies could give us some evaluation, because it is very hard to make a call on it. But I think there is more to be said for that kind of a balance.

Let me take up one other question, because the hour is growing late, Dr. Sullivan, and this has just come to my attention, and it is an unusual problem which has arisen in Pittsburgh, where the Urban League of Pittsburgh, Inc., received a letter from you dated December 31 congratulating them on being selected as a grantee for the community coalition to support health and human service needs of the minority male grant program.

They took this letter to mean approval of a demonstration program for black males. Then they received another letter from Dr. Harold L. Kelly, Chief of Special Initiatives of your Department, on February 4, advising them that the issue of the demonstration project for black males was under consideration and that the prior letter had been a grant for a conference on black males.

Acting on the conclusion that the first letter was the grant for the demonstration project on black males, they made a number of commitments and announcements and acquisition of an operative van for health purposes, and I am told some other commitments.

I would appreciate it if you would take a look at this and see if the unique circumstances might not weigh heavily on an award for the demonstration program for the black males, so that they will have the resources to support the commitments which have allocated in that direction.

I know you have not had any notice of this, and as I say, I just found out about it today. It seems like every time a Secretary appears we get an emergency call from some locale where some critical problem has just arisen.


Secretary SULLIVAN. Sometimes we are rain makers, Senator. I will be happy to get a response back to you. I learned about this problem earlier today, and I will be happy to look into it. There are really two applications from the Urban League.

The first was for the conference grant and the second for the program grant. The second is still in process. The review process is still underway. We expect to be making some decisions this spring, but I will be happy to get this back to you in writing.

(The information follows:)

GRANT AWARD I regret that there has been some confusion relating to the award of a grant to the Pittsburgh Urban League. In the fall of 1990, the Pittsburgh Urban League received a grant award for a conference grant in connection with our Minority Male Initiative. Tre Urban League received notification of its receipt of the award at that time. However, because of my keen interest in the Minority Male Initiative, that announcement was followed by a personal letter from me. Unfortunately, because my letter arrived after the official notification of grant award, it was interpreted that I was referring to a different application which the Urban League had submitted for a 3-year coalition demonstration grant, another component of the Minority Male Initiative. That application is now under review and we expect to make our final selection later this Spring.

HEALTH OBJECTIVES 2000 Senator SPECTER. Well, Mr. Secretary, my final comment is, I compliment you on your extraordinary staff, because my extraordinary staff of Earthamae Isaac, Craig Higgins, and Bettilou Taylor just told me about it, and with your staff operating as fast, you have got a very good staff. [Laughter.]

Secretary SULLIVAN. We are the kinder, gentler Department, Senator.

Senator SPECTER. Thank you, Mr. Chairman.

Senator HARKIN. I just have a couple, I am cognizant of the time here.

One is on prevention. You mentioned the Health Objectives 2000 Act, passed last year here in Congress to incorporate your health objectives 2000. As you pointed out, we are spending over $600 billion a year.

Let us look at the past. How about the health objectives for 1990? Instead of eliminating tuberculosis, which is one of the goals,



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