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organizations to promote and strengthen the provision of clinical preventive, services by primary health care providers. The development and implementation of a national education initiative entitled "Put Prevention into Practice" is one way in which such services will be promoted. In addition, the Department is currently examining the cost-effectiveness of Medicaid and Medicare reimbursement for preventive services through the conduct of a set of prevention demonstration projects under Medicare, while we continue to consider inclusion of specific preventive interventions through Federally-financed medical services and work to identify those for whom financial barriers preclude access to services.
Question. What can be done through Federal programs, such as Medicare which pays large sums for graduate medical education--to achieve this objective?
Answer. The Medicare program will implement a reform in its physician payment system beginning in January, 1992. The new system is expected to redistribute physician payments from surgeons and specialists to physicians in primary care disciplines such as general and family practice and general internal medicine. Since it is these physicians that are most directly involved in preventive clinical services, the reform should encourage greater access to preventive services for the Medicare population.
While graduate medical education programs do receive some reimbursement through the Medicare program, HCFA does not regulate the curricular content of these programs. However, we are proposing a special incentive for primary care interns in the GME reimbursement formula.
within the Public Health Service, the sums devoted to health professions programs are comparatively small. However, as noted in our response to the previous question, we are trying to tilt these programs toward health promotion and disease prevention by urging all applicants for funding to submit work plans that address specific objectives of Healthy People 2000.
Question. I've been told that less than 2 percent of the training our doctors receive focuses on disease prevention and health promotion. Do you believe that the training received by doctors should include a special emphasis on disease prevention and health promotion?
Answer. I believe that all health professionals should receive training which emphasizes disease prevention and health promotion. We are urging all applicants for current Public Health Service programs of support for health professions education to submit
work plans that address specific objectives of Healthy People 2000.
Question. The report accompanying the FY 1991 appropriation requested that the Department undertake a review of Medicare rules and regulations imposed on beneficiaries and providers in rural and other medically underserved areas to determine which may be unnecessary or could be less administratively burdensome while maintaining or improving the quality of care. What have you done to act on this?
Answer. We share your concerns that providers and beneficiaries are not unduly burdened by Medicare rules and regulations. As part of OBRA 1990 we are required to conduct a review of Medicare hospital regulations to determine which requirements could be made less administratively burdensome for rural hospitals without diminishing the quality of care. We are required to report to Congress by April 1, 1992. Although we will be working on this review, we do not yet have any meaningful data.
Question. Mr. Secretary, as you know, in the tables in our Senate report for each institute we only detail the amount for general program research and research training. Funding spent for prevention activities is buried most often within the research management and support line.
In view of the importance that we both place on prevention activities, should we include a new line item to indicate for each NIH institute how much is being spent on prevention and control activities?
Answer. Creating a specific line item for prevention activities would highlight the NIH prevention activities, but might do so at the expense of NIH's ability to manage its programs to respond quickly to emerging scientific opportunities. In terms of structuring and managing a budget account, prevention activities are not analogous to research training. Research training is a separate mechanism and also has a distinct authority. Prevention activities are funded from several different mechanisms, including research training, and would be difficult to define consistently across each of the Institutes,
CANADIAN HEALTH CARE SYSTEM
Question. Much has been said about the fact that U.s. health care costs are skyrocketing, despite the fact that millions of Americans have no health insurance. By contrast, the Canadian health care system covers all of its citizens, at a per capita cost one-third less than the United States.
How does Canada provide universal health care for less cost than the United States?
Answer. There are substantial differences between the Canadian and u.s. health care systems. In general, Canada has fewer specialists and more general practitioners and provides much less technologyintensive care. Also, each provincial government establishes a fee schedule for medical services. These government established fees constitute payment in full. The Canadian system also has much lower administrative costs than the United States. Also, Canada has regionalized health care and a very tight system of capital controls.
However, there are long waits for elective surgery in Canada, and more limited access to technology. Therefore, although we can learn about the best aspects of the Canadian system, we cannot transport the Canadian system to the United States.
Question. Are there elements of the Canadian health care system that can be of value to the U.S. as we search for a way to expand access to care for all Americans, while controlling costs?
Answer. The Canadian system has some interesting features. One feature that we may want to examine is how Canada handles administrative costs. Their administrative costs are substantially lower than in the United States. Reducing American administrative costs might free dollars for needed patient care. since coverage is universal and all health transactions are paid by the government, the government can profile physician practice patterns and identify problems. We are beginning to use profiling more in the United States. Canada has a very tight system of capital controls. Also, Canada has regionalized health care, linking remote rural areas with the best care in tertiary institutions in major cities.
OLDER AMERICANS HEALTH PROMOTION AND DISEASE PREVENTION
Question. Mr. Secretary, as you know, I have introduced the older Americans Health Promotion and Disease Prevention Act. This bill expands Part F of the older Americans Act to establish a state grants program that would provide disease prevention and health promotion services and information at senior centers, congregate meal sites, home-delivered meal programs or at other appropriate sites. Prevention and health promotion is important at any age -- however, to the elderly, disease prevention and health promotion could well meant the difference between independence or nursing home care. I just think that prevention makes good sense and will save money in the out years.
with this as background, it is of concern to me that the Administration has never requested funding for Part F of the older Americans Act Health Prevention for older Americans. Is it felt that these services are unimportant for older Americans, and if you feel that these services are important, why have you not requested funding for Part F?
Answer. I could not agree more that preventive health measures are extremely important for all members of our society, especially for the elderly population. However, we have not established a separate funding stream to support these activities. States can, and already do, use older Americans Act funds to carry out the health promotion and disease prevention activities authorized by Part F of the Act. Title III-B of the Act allows for a wide range of supportive and social services for the elderly, such as community health, home health aid, outreach and information and referral services. Title III-B programs are funded at $291 million in the FY 1992 President's Budget, $19 million above the FY 1990 appropriation.
In addition to Title III-B activities, health promotion and disease prevention has been a priority under the title IV Aging Research, Training and Disrectionary Projects program for the past several years. Grants have been made to Universities and local Aging organizations to improve knowledge about and effectiveness of health education and promotion programs for the elderly.
Question. Each day, about 6,000 people turn 65 years of age. By the year 2,000 just nine short years away 13 percent of the population will be 65 or over. Iowa's 65 and over population is already at 15.1 percent, and we have one of the largest 85 years of age and over populations in the country. In spite of the fact that the "AGING OF AMERICA" is a very real, no increases not even cost-of-living increases have been requested that will put programs into place to deal with this population growth. What steps is/are the Administration taking to put into place long-term strategies and programs to deal with this population growth?
Answer. While we are not seeking funding increases for Administration on Aging programs, we do expect service levels to increase. Aging service agencies have selected management and program improvements, combined with the long tradition of increasing contributions from program participants, to allow service levels to increase with level funding. For example, supportive services like home health aide, transportation, outreach and legal services to the elderly will increase by 6% on average, and 3.4 million more meals will be served to the elderly in 1992 than were served in 1991. In addition, to ensure that available funds provide assistance to those most in
need, the Administration's legislative proposal to reauthorize and reform the older Americans Act for 1992 will place greater emphasis on targeting funds and services to the most needy and vulnerable--the lowincome minority elderly.
In addition to implementing service programs, State and Area Agencies on Aging, under the leadership of the Administration on Aging, are working with thousands of community organizations to develop coordinated systems of service to respond to the needs of the growing elderly population within the community.
Question. We have several concerns relating to the implementation of the 1990 reauthorization of Head Start. In creating the quality set-aside, the reauthorization bill was careful to protect the program's ability to maintain current service levels. Section 105 of PL 101-501 specifically states that before the Secretary can use funding increases to expand the number of children served by the program, he must ensure that allocations to existing programs are sufficient to maintain the precious years service level, account for inflation. Please explain why the Administration's FY 1992 budget proposal outlines its intention to use increase to serve additional children and not to provide an inflation adjustment so that existing programs can meet rising costs -- such as rent, heat and supplies?
Answer. Ensuring that the level and quality of Head Start services are maintained during the on-going enrollment expansion program is one of our top priorities. Funds from the FY 1992 requested budget increase will be available for grantees to maintain the current level of service in their programs. The recent amendments to the Head Start Act do not require a costof-living increase for all grantees, but rather that enrollment is not increased without first assuring that grantees have sufficient funds to maintain the previous year's service levels. This will be accomplished by allowing grantees to use funds from their FY 1992 increase to maintain services, before they add new children to their programs. Such decisions will be made on a case-by-case basis, since the amount of funds that will be needed to maintain service levels will vary depending on each program's particular circumstances.
OFFICE FOR CIVIL RIGHTS
Question. The inventory of unresolved complaints before the office for civil Rights has increased from 558 in 1989, to 597 in FY 1990, and up to 637 unresolved cases at the start of FY 1991. The FY 1992 budget projects another increase in unresolved complaints.