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ies will also seek to develop better means of diagnosis and treatment for these problems.


Senator HATFIELD. Mr. Chairman, I will only make one observation in closing my portion of time. Dr. Sullivan, you know, we are locked into a budgetary process that sometimes fails to give us the full and complete picture. I really hate to look at these programs with the same dollar measurement that I use to look at accounts and costs and appropriations in other budgets, because Mr. Chairman, let us remind ourselves that it is not the total number of dollars we spend, but it is the multiplier, and the character of the dollar and how we invest it.

Of all the people that will appear before our Appropriations Committee representing political policymakers as well as programs, Dr. Sullivan represents the highest cost-benefit ratio multiplier of any Federal dollar that we will appropriate.

For every $1 allocated to health, research, prevention, and care programs, we will get $13 back into the economy. We have heard this figure many times, to the point it becomes redundant, but I just think that when we are looking at dollars here and the impact it has on our general economy we ought to have a different measure than the measure applied to appropriated dollars made to other programs.

In my view, and I believe backed by the statistics, there are no dollars that will bring more back into our economy than the dollars that you represent in the programs of health.

I wish somehow we could get OMB and all the bean counters in the CBO and every other place that they make these adjustments and evaluations to begin to look at the health dollar in a little different light. I will not identify any one of the other programs to make a comparison, but I can tell you that there are zero for zero multipliers, and there is a 1 for 13 multiplier,

I thank the chairman.

Secretary SULLIVAN. Senator Hatfield, I agree with you on the return on the dollars invested. But, in addition to the financial return, the fact is the quality of the lives of our citizens are much improved.

Mr. Chairman, your comments about prevention in terms of birth injury from good prenatal care, is a good example of how we could spend thousands of dollars and still have an impaired individual who is not going to be a productive citizen. I agree fully that the productivity and the quality of the lives of our citizens is another important part of the equation.

Senator HATFIELD. Thank you, Mr. Chairman.
Senator HARKIN. Senator Gorton.


Senator GORTON. Thank you, Mr. Chairman.

Mr. Secretary, you are almost as candid in your written statement as you were in that forceful and eloquent opening statement, and you list a number of fields in which there are changed priorities upward-that is to say, increases which are greater than your 9 percent overall increase. I think those are properly highlighted.

As you get to the end of your written statement, however, on page 10, you tell us, "As you"-that is, we-"are well aware, the Budget Enforcement Act of 1990 established absolute spending limits for all discretionary programs. In order to stay within the prescribed ceilings, we propose the following spending reductions." You list three: low-income energy assistance, community services block grant, and health professionals training program.

I note as I go through the rest of the statement that in addition to those absolute decreases, you highlight a number of areas in which the increase is considerably less than the 9 percent average for your entire Department. Among those are expenditures for biomedical and behavioral research through the National Institutes of Health, and some other research programs. While it is not specifically in your statement, I think AIDS falls into that category.

Now, I believe that it is totally correct and proper to constantly set new priorities and to reexamine old programs; I believe that to a considerable extent you have done that. This is a different mix, and perhaps even a different philosophy, than a budget of even 1 year ago.

I would like you to explain what kind of value judgments or philosophic judgments led you to these changes-not just the three in which there are actual decreases, but some of the others. Perhaps I am most sensitive to the National Institutes of Health and basic research. Why are they either cut or increased at a slower rate than your average?

Secretary SULLIVAN. Yes; Senator Gorton, you are quite correct in saying that it is a different environment this year. One of the most important differences is the budget agreement under which we are operating. That has caused us to make some painful decisions.

We have a target that we cannot exceed and we are no longer competing with the Defense Department or with foreign aid, et cetera. We are competing with other domestic programs. When it comes to programs, most of my Department falls within the domestic discretionary area, so a lot of competition is within my Department. This excludes several large areas that are mandatory.

We are trying to make judgments on the best use of the dollars available to us in terms of the comparative need for the program and the return on our investment. For example, we proposed to reduce the low-income energy assistance program. I have learned in the last 2 years that every dollar has a constituency attached to it that can be very vocal. We have to try to make rational judgments. The low-income energy assistance program was started during the oil embargo back in the late 1970's as a temporary measure because of the high cost of fuel. There are other programs in my Department that provide funds that can be used for energy assistance such as the AFDC program, emergency assistance, and others.

In many of these low-income energy assistance grants made to the States as part of our block grants, not all of these dollars are used. The States can, and do, transfer funds from this program into other programs. They also have the option of transferring funds from other programs into this.

That is not happening. There is no question that the program has value. Yet, when we look at high infant mortality, or the need

for more biomedical research, or the need to expand our National Health Service Corps because in virtually every State there are many underserved areas where people do not have health professionals, we must make judgments as to where the greatest need is and where the greatest return is. We are forced to make those kinds of judgments since we must live within the budget agree


I am strongly committed to the National Institutes of Health. Our NIH budget for research project grants increases by 8.8 percent, and our goal is to award at least 5,000 new and competing grants every year. Our budget will allow about 5,700 new and competing grants. The overall NIH budget during the three budget cycles with which I have been involved has increased by approximately $2 billion.

We look at the NIH not simply 1 year at a time but over a period of several years, and we have had significant increases overall. There are always additional opportunities, but we must weigh these in relation to the discretionary dollars that are available to



Senator GORTON. Thank you, Mr. Secretary. I have been a member of this subcommittee for about 4 weeks. This is the first day on which it has had any hearings, but I have heard exactly what you reported. There are many constituencies from home with sincere and hardworking people competing over this money. The lesson to them is that as they ask for more, they are taking it away from someone else, probably in a very closely allied field. This is not a welcome lesson or one easy to learn.

But it seems you are saying at a more cosmic level exactly the same thing. If we do not like your priorities-if we wish to add, for all practical purposes, we are going to have to subtract from somewhere within your own budget. We must find one of the areas of increase that we can reduce in order to make up for any increase. Even as a beginning member of this subcommittee, Mr. Chairman, that does not look like a particularly easy task.


Secretary SULLIVAN. Senator Gorton, I would respond with the example of infant mortality funding. This is a very controversial topic which has been widely discussed as it relates to the community and migrant health center programs to which I am strongly committed.

I spoke at the 25th anniversary banquet 1 year ago and know many of the people. I have high regard for those programs. Last week I spoke at the 20th anniversary of one of our centers out in Arizona. What we propose to do is to fund 10 demonstration grants to get data as to how we can more effectively decrease infant mortality.

We spend more dollars per capita for health care than any other Nation in the world, but in spite of that, when it comes to infant mortality we rank 24th. What that says to me is that we are not

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.


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 [CAA's] will be able to access funding from other Federal, 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, certain 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.


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.

Senator HARKIN. Thank you, Senator Burdick.

Mr. Secretary, let us get back to reducing infant mortality again. You said in your statement you wanted to 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

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