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and hope that teens will use both oral contraceptives as preventers of pregnancy and condoms as protection against sexually transmitted diseases. The other is to support the AFL approach of trying to develop models to encourage abstinence, and supporting familles and communlties to adopt postponement of teen sexual activity as a realistic, necessary and achievable goal. Contraception should be available for teens who decide to become sexually active, but emphasizing that teens have the choice not to become sexually active is still the intervention of choice.
GOALS OF SEX EDUCATION
Question. A study of the impact sex education has on sexual activity, contraceptive use, and teen pregnancy found that teens who are exposed to sex education aren't any more lékely to be sexually active than other adolescents. But they are significantly more likely to use contraceptives, and less likely to become pregnant than those who have not taken a sex education course. What is the appropriate goal for these programs: should the goal be teaching responsible sex education and family planning?
Answer. There have been many studies on the impact of school based sex education programs and, overall, no consistent effects on adolescent sexual activity, contraceptive use and pregnancy have been found. The most recent--Kirby, Waszak and Ziegler, Six SchoolBased clinics: Their Reproductive Health Services and Impact on Sexual Behavior', Family Planning Perspectives, Vol. 23, No. 1, January/February 1991--found no effect on the onset of adolescent sexual activity, varying effects on contraceptive use, and no effect on pregnancy rates.
The factors that influence early adolescent sexual activity, contraceptive use and pregnancy are complex and not well understood. However, we do know that contraceptive based sex education programs have not had any significant impact on the problems of adolescent sexual activity and pregnancy. In addition, people in many communities feel that these programs, especially when school based, create an environment in which adults and authority figures appear to condone early sexual activity as long as contraception is used.
Given the research on this subject and the fact that adolescent sexual activity, the incidence of STDs and AIDS in the adolescent population, and out-of-wedlock births to adolescents continue to increase from already alarming levels, it seems unlikely that increased provision of contraceptive based sex education programs is the answer to these problems.
DUPLICATION IN OASH PROGRAM OFFICES
Question. Several program offices within the Office of Assistant Secretary appear to be duplicative of other programs in PHS. For example, the National Vaccine Program Office works on improving our vaccine capability, as does NIH, CDC, and FDA. The Office of Minority Health aims to improve the health status of minorities, the same goal as several HRSA and CDC programs. The Office of Minority Health even has a special AIDS unit, separate from your National AIDS Program Office -- which itself is separate from the AIDS research and care programs. You can probably see where I'm heading -- Are these offices truly necessary within the Office of the Assistant Secretary, or should we be targeting funds to the programs themselves?
Answer. The Assistant Secretary for Health (DASH) believes that these offices are essential in assisting him to manage the PHS effectively as they:
(1) coordinate complex and high visibility activities occurring in
several PHS agencies, encouraging interagency communication and
helping to avoid interagency duplication and (2) provide visibility for an important issue at the highest level
within PHS to assure that the ASH is kept aware of developments
In some cases, there are legislative requirements for the program office (or its head) to be located in OASH. For example, P.L. 94-317 established the Office of Disease Prevention and Health Promotion in OASH in 1984. The position of the Deputy Assistant Secretary for Population Affairs is legislatively located in DASH (P.L. 91-572). In 1990, the position of Deputy Assistant Secretary for Minority Health (who directs the OASH Office of Minority Health) was established within OASH by the Disadvantaged Minority Health Improvement Act of 1990, P.L. 101-527.
Proposals to establish new program offices in OASH are always reviewed carefully within PHS to ensure that duplication does not occur; these proposals are also submitted to the office of the Secretary for approval. In addition, we periodically examine the organizational structure of the Office of the Assistant Secretary for Health to verify that each OASH program component should remain át this organizational level.
Funds certainly should be targeted to the programs themselves, but to ensure that these programs are efficiently administered by the PHS agencies, it is essential to have these small coordinating offices at the OASH level.
Question. If an Assistant Secretary-level office is important for coordination in the Department, would moving the Office of Rural Health Policy to the Assistant Secretary's level help with efforts to improve rural health care?
Answer. At the present time, there is no reason to move the Office of Rural Health Policy (ORHP) to the Assistant Secretary's level since ORHP's current location in the Health Resources and Services Administration (HRSA) is practical and is working well. The Director, ORHP reports directly to the HRSA Administrator and, from that position within the Office of the Administrator, has the advantage of being able to coordinate and have an impact on rural health programs.
HRSA provides a supportive environment for ORHP activities which include managing a departmental telecommunications demonstration project, administering several grant programs, and sponsoring workshops and conferences to focus on rural health issues. ORHP coordinates departmental rural health research as well as the PHS responsibilities pertaining to the rural economic development activities of the Secretary's Policy Council. In addition, ORHP is involved in several collaborative efforts with other Federal agencies.
ORHP has established good working relationships with the Health Care Financing Administration (HCFA) regarding the coordination and review of HCFA policies which impact on rural health care. ORHP provides technical assistance to HCFA in the design and Implementation of HCFA grant programs aimed at assisting rural hospitals.
At the discretion of the Assistant Secretary for Health, additional coordinative efforts can be carried out by ORHP without changing its organizational location. Since ORHP is effectively carrying out its responsibilities, I believe that the HRSA location offers the most advantages. It allows ORHP to carry out policy and
program activities which focus on improvements to rural health care and, through these activities, gives ORHP the ability to present a 'real world rural health perspective to PHS, HCFA, and oš management when policy issues are being considered.
Question. Dr. Mason, as you know, both the House and the Senate last year asked NIH to develop a cost management plan in an effort to bring some stability and predictability to NIH funding patterns. This draft plan was submitted to us on January 15 and has a number of key features including: 1) establishing 4 years as the average length of research grants, 2) requiring that the average cost increases for research grants be held to the biomedical price index, 3) funding the number of training slots recommended by the National Academy of Sciences, .4) abolishing the use of the concept of approving grant applications, and 5) increasing funding for other mechanisms to reflect inflationary costs.
Dr. Mason we have yet to receive the final cost management plan from the department. Do you support the draft cost management plan that has been prepared by NIH?
Answer. The draft is still under review. Dr. Healy, the new NIH Director, has been asked to review the current draft before it is forwarded to the Secretary for his approval.
Question. Dr. Mason, as you may know, we had discussions this year with the Secretary and the Inspector General about the issue of indirect costs associated with biomedical research, which as you know range from 6.3 percent for the Foundation at the New Jersey Institute of Technology to 155 percent for the Michigan Cancer Foundation. The IG suggested we might consider several ideas for controlling indirect costs including, 1) a cap; 2) cost sharing with the institution, or 3) providing just one lump sum payment to the researcher who then would negotiate with his or her institution as to the required overhead payment. Do you have any views on this issue? How can we create an incentive for the institutions to limit their indirect cost requirements?
Answer. Consideration is currently being given to reexamining the indirect cost component of research grants as part of the forthcoming PHS plan for managing the costs of biomedical research. This plan is still in its formative stages but it is PHS's intention to recommend that a panel be established to review issues relative to indirect costs and to determine if such costs can be reasonably contained without jeopardizing the ability of grantee institutions to conduct research. in particular, the PHS wants assurance that the indirect-cost pool is free of non-research costs and that PHS awards are not bearing a disproportionate share of the total overhead associated with research.
In the short term, it is PHS's intention to seek approval from the Secretary to establish the indirect cost rate negotlated for the initial year as the rate for all years of the recommended period of support, normally from one to five years. This will be a small but important contribution to making future funding levels as nearly predictable as possible.
HEALTHY PEOPLE 2000
Question. Your office recently issued the Healthy People 2000 plan for improving America's health over the next decade. Healthy Youth 2000 is excerpted from the larger plan, and focuses on Improving adolescent health. Healthy Youth 2000 notes that over 25 percent of people aged 12-17 have used alcohol in the past month,
and some 58 percent of those aged 18-20 have been drinking in the past month. A stunning 33 percent of high school seniors have been *binge' drinking five or more drinks at a time -- in the past two weeks. The plan also notes that the average first use of cigarettes is before age 12.
Healthy People 2000 sets as goals to: reduce deaths caused by alcohol-related traffic accidents; and increase by at least one year the age of first use of alcohol, as well as cigarettes and marijuana.
The plan also notes the clear connection between higher excise taxes and reduced consumption of alcohol, especially among people aged 16 to 21. Do you believe that higher excise taxes on cigarettes and alcohol is a means to reduce consumption, as the report notes? And if so, do you support higher excise taxes?
Answer. As noted in Healthy People 2000 and excerpted in Healthy Youth 2000, the level of excise taxes on alcohol has been demonstrated to effect consumption of alcohol, particularly among youth. We agree that tax policy is one effective intervention among many in addressing the kinds of use reduction envisioned in the year 2000 objectives. Objective 4.16 calls for an increase in the number of States that have adopted policies, beyond those in existence in 1989, to reduce access to alcoholic beverages by minors; and the note for this objective specifically mentioned product pricing as a recommended policy. At the Federal level, tax pollcy is not within the purview of the Phs or the Department to determine. We applaud the increases effected by Congress and the President in 1990 and will certainly advocate within the Administration for future attention to this, as one of many potential avenues to bring about reduced use of alcohol by young people.
STATE OFFICES OF MINORITY HEALTH
Question. The budget requests an increase within the Office of Minority Health to assist state offices of minority health. Why is it important to support these state offices?
Answer. The 1992 budget for OMH contains $2.0 million for assistance to States and private sector groups. This is an increase of $1.03 million from 1991. We estimate that $1.0 million, an increase of $.5 million, will be used to assist state efforts to establish and maintain offices of minority health. One of the recommendations of the Report of the Secretary's Task Force Report on Black and Minority Health calls for the Department to "build the capacity of the non-federal sector to address minority health problems." The OMH has fostered working relationships with various states, local and community agencies and organizations, as well as private sector entities which have included health related issues on their national agendas.
A number of states have established state offices or commissions of minority health which have similar mission and functions as the Federal office of Minority Health. OMH views these state offices as & valuable integral component of the minority health network of public and private entities involved in efforts to improve the health status of minority populations.
The infrastructure of public health is in need of improvement as documented in the Institute of Medicine's report on The Future of Public Health (1988). It requested a better working relationship between federai, state and local health departments, the academic community and public health practitioners. Several states, as previously indicated, have established infrastructures to address minority health problems within their states. The rationale, structure, and resource commitment in these state offices are evolving. OMH therefore is committed to providing technical assistance to these various offices to ensure better coordination and utilization of resources to address minority health issues and needs. Question. At the same time, the budget also proposes to cut funds (within HRSA) that would support state offices of rural health. Can you explain this inconsistency?
Answer. OMH's relationship with state offices of minority health is quite different from ÅRSA's relationship with state offices of rural health. The OMH has not provided direct operational support to state offices of minority health, and we do not intend to do so in the future. HRSA has directly funded the development of state offices of rural health, with a decreasing ratio of Federal support over a four year period. The OMH does intend to continue to provide technical assistance and consultation to state offices of minority health, and in some cases will support specific projects (such as conferences, analyses of a health problem affecting minorities in a state, etc.).
NATIONAL VACCINE PROGRAM OFFICE
Question. The FY 91 budget requested a 17% increase in funding and a 25% increase in FTES over FY 90 for the National Vaccine Program Office, in order to boost funding of vaccine trials. We provided the increase.
Now the FY 92 budget requests a major funding cut -- minus 76% for this office, noting that funds are being requested in the PHS agencies that conduct the actual research and clinical trials of vaccines.
As a rule, would you say it is more effective to provide direct support of research and service programs in order to achieve health objectives, or to provide funds such as this one?
Answer. As Congressionally mandated, the National Vaccine Program (NVP) was created to coordinate the activities of FDA, CDC and NIH and provide a PHS focal point for immunization activities. The resources provided directly to the National Vaccine Program in FY 1991 funded new and emerging scientific research projects in the areas of pertussis, measles, and the Children's Vaccine Initiative. These resources were used as "seed money' (or start-up costs) and enabled support of high priority immunization projects when rapid funding for critical projects or initiatives would ordinarily be hampered by the time lag in the budget cycle. In FY 1992 the resources for these projects are included in the agencies' budget.
Question. When funds provided to this and other offices within OASH are used for program activities, how much is spent for administration and how much is actually transferredi
Answer. In Fiscal Year 1990, Congress appropriated a total of $5,895,000 to the National Vaccine Program (NVP). A total of $5,111,000 was provided to FDA, CDC, and NIH through Memorandums of Agreement which supported a collaborative effort in support of research and development for a new acellular pertussis vaccine. Of the $9,631,000 available to the NVP in Fiscal Year 1991, approximately $7,300,000 will be given to the Phs agencies supporting immunization research and development. The remaining funds will support the National Vaccine Program Office (NVPO) and the National Vaccine Advisory Committee. The NVPO operated with only 5 FTEs until August, 1990 when recruitment began for a full complement of staff. It is estimated that by early FY 1992, all NVPO staff will be on board. It is this difference in staffing that causes the difference in the ratio of program dollar allocations for FY 1990 and FY 1991.
Question. The Healthy Youth 2000 plan aims to reduce the proportion of young people who have used alcohol, marijuana, and