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National Institute of Mental Health's overall research budget, which increased by 43 percent during this same time period.

QUESTIONS SUBMITTED BY SENATOR BROCK ADAMS

ELDER ABUSE

Question. Secretary Sullivan, last summer, in you speech at the AARP convention, you said that we must "do everything possible to strengthen our ability to protect older Americans from abuse, wherever they are." You rightfully expressed your outrage at this terrible social blight an announced your departmental task force to develop a comprehensive elder abuse strategy, including "new legislative initiatives to deal with the problem." You also called upon Commissioner on Aging Berry to "expand and strengthen efforts" of the older Americans Act long-term care ombudsman program to investigate and resolve complaints of abuse against our older Americans.

In light of this, I hope that you were pleased that Congress appropriated for FY 1991 the first funding for the elder abuse provisions of the OAA (Title III, part G). The amount is only $2.9 million for the nation, but it is a good start. Also, we provided $2.4 million specifically for the ombudsman program.

I must say that I am disappointed that the President's budget calls for no increase in these small amounts for these critical programs. I have a couple of questions for you about this:

1) Does the OMB passback reflect your recommendations or views concerning funding for elder abuse and ombudsman activities under the older Americans Act?

Answer. The FY 1992 President's Budget reflects our recommendations for funding for elder abuse and ombudsman activities under the older Americans Act.

Question. Do you believe we should increase funding for these activities? If so, what do you believe would be a legitimate level of funding for these efforts?

Answer. We are recommending a total of $5.4 million in FY 1992 to continue programs that provide grants to States to respond to and prevent instances of elder abuse and neglect in both the community and long-term care facilities. A total of $5.4 million is included in for: Long-Term Care Ombudsman

Services to provide States resources to investigate and resolve complaints on behalf of older individuals residing in nursing homes and board and care homes, funded at $2.4 million; and Grants to States to conduct abuse, neglect and exploitation prevention activities including outreach, education, reporting, and referral of complaints to law enforcement agencies, funded at $3.0 million.

Question. As you know, this year we will reauthorize the older Americans Act. This provides an opportunity to strengthen these efforts in the older Americans Act?

Answer. State and Area Agencies on Aging, as well as the Administration on Aging, have broad authorities to conduct elder abuse and ombudsman activities under the existing provisions of the older Americans Act. There are no legislative changes necessary to continue to carry out these activities.

Further, I want to be clear that states have a major responsibility in efforts to eliminate elder abuse. The Administration on Aging recognizes its obligation to support these state-directed efforts. The older Americans Act, as currently enacted, provides sufficient authority for AoA to assist States in addressing elder abuse.

Question. What recommendations would you make regarding legislative initiatives aimed at combatting elder abuse in all its forms?

Answer. I believe legislation already exists to address the problem of elder abuse. What we need is enhanced awareness, coordination and responsiveness to the problem of elder abuse at all levels of government and society.

Question. Finally, please update us on the activities of your task force and what is your current expectation as to what the outcome of this effort will be?

Answer. The purpose of the Task Force is to develop a departmental strategy to promote the prevention and improved reporting, investigation and follow-up of elder abuse. Task Force members consist of the heads of the Administration on Aging, the Health Care Financing Administration, the National Institute on Aging, and the Assistant Secretary for Planning and Evaluation.

The task force is currently developing a set of recommendations aimed at increasing the awareness of professionals and practitioners who deal with elder abuse, improving the coordination of federal, state and local entities that respond to complaints of

elder abuse, and promoting coordinated research, training, capacity building and enforcement activities among those involved with elder abuse reporting, investigation and follow-up.

LONG-TERM CARE

Question. Secretary Sullivan, just yesterday, HCFA in testimony before the ways and Means Health Subcommittee, criticized Representative Stark's long-term care legislation saying it was a "fragmented" or piecemeal approach and that "It would be unwise to take a fragmented approach to long-term care reform." I find this criticism intriguing There is considerable opinion that, in light of our current budgetary circumstances, longterm care improvements will occur incrementally rather than in one fell swoop.

Can we infer from HCFA's testimony that the Administration prefers to move long-term care reform on a comprehensive basis rather than in a series of steps? If so, when might we expect a comprehensive proposal?

Answer. I believe there is a good prospect that over the next several years we will be able to make some significant improvements in long-term care financing and service delivery. However, we are not likely to reach consensus about this complex issue without informed debate. So what I have consistently said is that I would like to step back a bit from starting with solutions and look at what the need for various kinds of long-term care is, how today's need may differ from tomorrow's, and how well various proposals, both comprehensive and incremental, are likely to stack up in meeting our nation's long-term care needs in ways that are realistic and affordable. This process of inquiry and evaluation is going on now within my Department, the Social Security Advisory Commission, the National Governor's Association and other groups. I expect to be discussing some of my conclusions by the summer.

I would add in this regard that I think longterm care reforms must address continuing improvements in the economic status of many elderly persons resulting from increases in women's labor force participation, two-income families, improved pension coverage and vesting, and real economic growth. This means that a growing proportion of the elderly will be able to afford to purchase their own care. Even more people will be able protect themselves in the event they need long-term care if we can increase participation in various private risk pooling arrangements such as long-term care insurance.

LONG-TERM CARE

Question. Last year, in OBRA 90, Congress created a new Medicaid state option for home and community-based services for frail elders. This truly can be characterized as a small and incremental step in long-term care. Yet, in light of our budgetary situation, it was the best we could do. What is wrong with this step. Do you not worry that if we take no action until we can do the whole thing at one time, we may never get there?

Answer. I do not believe that government alone can be responsible for long-term care reform. The private sector must be involved in providing insurance and other options for those who can afford them. Individuals and families must be involved in understanding their risk of needing long-term care and planning for this risk. People cannot wait until they are very old and experiencing chronic disability before they think about how they want their long-term care needs met. And I also think government must be involved to support people who do not have other choices. There are many different steps that can be taken to achieve this type of reform. We do not necessarily need to do it all at once.

The new Medicaid option for home and communitybased services for frail elders has several positive features. It does focus on people with the greatest needs. It also includes a cost containment mechanism to avoid the very real prospect that open ended funding for home and community based services could become an astronomical public expense, particularly if it replaced the three quarters of all long-term care now provided free of charge by families. However, this new option has been superimposed on many other community care funding streams, further fragmenting the organization and delivery of services. I don't agree with a strategy that does not try to integrate its purposes with existing programs but is simply layered on top of them.

HEALTH PROMOTION AND DISEASE PREVENTION

Question. Secretary Sullivan, your track record as a strong advocate for much greater emphasis on health promotion and disease prevention is well-known, and you are to be lauded for it. In fact, at your speech before AARP last summer you stated, "One of the best investments we can make is to emphasize health promotion and disease prevention." I absolutely share your view.

In this vein, I was disappointed to see that the President's budget does not include a request for any funding for part for Title III of the older Americans Act, which is the health promotion portion of the Act. I will also add that Congress has not yet provided any funding for this part which was established in 1987 amendments to the Act. I am pleased to say that just last week I joined Chairman Harkin and other Senators in sponsoring legislation to strengthen this important part of the Act.

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will you support efforts to make this part of the Act a reality by arguing within the Administration to support any Congressional efforts to provide funding for this part of the OAA?

Answer. I could not agree more that preventive health measures are extremely important for all members of our society, especially for the elderly population. You are correct that this separate funding stream for aging health promotion activities has never been funded since initially authorized in 1987. However, 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.

Question. If there is no support for funding this part of the Act, is there any point in keeping the health promotion provisions in the Act?

Answer. Since state and Area Agencies on Aging can and do conduct these activities under the Title III-B Supportive Services program, and since Part F duplicates authorities already existing under other parts of the older Americans Act, we are recommending that Part F be repealed from the older Americans Act.

Question. If that is not your view, what recommendations can you offer us to strengthen efforts under the older Americans Act to engage in health promotion and disease prevention related efforts?

Answer. There are no legislative changes necessary to strengthen on-going health promotion and disease prevention efforts. State and Area Agencies on Aging, under the leadership of the Administration on Aging, are providing health promotion and disease prevention services to the elderly. The Administration on Aging has been working with States to improve the planning and delivery of services in the area of health promotion. In addition to Title III-B activities, health promotion and disease prevention

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