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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 os 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 negotiated 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 policy 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 a 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 federal, 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 HRSA'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 & 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 transferred?
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
cocaine in the past month; increase the proportion of high school seniors who perceive social disapproval associated with the heavy use of alcohol, occasional use of marijuana, and experimentation with cocaine; and increase the proportion of high school seniors who associate risk of physical or psychological harm with heavy use of alcohol, regular use of marijuana, and experimentation with cocaine.
The perception of social disapproval or risk of personal harm can be powerful in determining behavior. So I think promoting these perceptions about alcohol and drugs is very worthwhile. But something's missing: tobacco is responsible for one out of every six deaths in America every year.
Why isn't tobacco included in these goals? (As background, the report has two tobacco goals: reduce from 30 percent to 15 percent the proportion of those who smoke regularly by age 20; and reduce smokeless tobacco use. However, there is no mention of educating kids about tobacco's risks or trying to reduce smoking by encouraging disapproval of it.)
Answer. The priority area that addresses reduction of tobacco use includes, as objective 3.10, an objective to establish tobaccofree environments and include tobacco use prevention in the curricula of all elementary, middle, and secondary schools. Although the work group developing the tobacco use objectives did not include levels of adolescent social disapproval as a measure of effectiveness in efforts to reduce smoking and use of smokeless tobacco (as was done for alcohol and drugs in the priority area on those forms of substance abuse), the survey that tracks perceptions of social disapproval for alcohol and drugs also asks high school seniors about perceptions regarding tobacco use as well. We will use the measure to evaluate the effectiveness of school-based and other anti-smoking health education directed at youth. You can be assured that prevention of the initiation of tobacco use will be a priority of the coming decade. In fact, one of Secretary Sullivan's nine major program directions specifically addresses this significant health promotion issue.
Question. The National Academy of Sciences stated in a recent report on health promotion and disease prevention that "Federal subsidies to tobacco growers should be eliminated," and that "cigarette advertising should be prohibited." Do you agree or disagree, and why?
Answer. We agree. Clearly, the Public Health Service is not the only voice with perspectives on the issues posed by tobacco use, and we do not have principal responsibility for agriculture or trade (advertising) policies. Our position on tobacco, however, is clear and uncompromising. Tobacco kills people--over 400,000 each year. From a health perspective, it has no redeeming qualities. While we understand that there are no longer any direct subsidies to tobacco growers, we advocate agriculture policy that shifts farming away from economic dependence on tobacco production and advertising policy that prohibits the glamorizing of a product that causes an immense amount of suffering and death.
PHYSICAL FITNESS AND SPORTS
Question. The budget request for the Office of Physical Fitness and Sports indicates that the Office supports "publication of research information". Please provide the Committee with details on this activity, including copies of such publications.
Answer. The President's Council on Physical Fitness and Sports publishes the Physical Fitness and Sports Medicine Bibliography on a quarterly basis in cooperation with the National Library of Medicine. This publication encompasses such areas as exercise and physiology, sports injuries, physical conditions and the medical aspects of exercise. It serves as a scientific resource for physicians,
physical educators, coaches, athletic trainers, physical therapists and others interested in the medical aspects of exercise and sport. A copy of this publication is being forwarded to the Committee under separate cover.
INDIVIDUAL RESPONSIBILITY FOR PERSONAL HEALTH
Question. Secretary Sullivan's speeches and much of the published material contained in your budget justifications seem to place ma jor emphasis on individual responsibility for personal health. In your view, what is the appropriate federal role in promoting and protecting Americans' health?
Answer. First, let me point out that Secretary Sullivan and I have emphasized individual responsibility for personal health to redress the balance of emphasis in health and medicine. We believe that it is crucial that Americans understand that the medical care system is, in fact, not the most important determinant of their health status. The science backs up this point. The leading causes of death in this country today are largely outcomes of diseases that occur because of behaviors, such as smoking, alcohol and drug use, poor diet, sedentary lifestyles, unsafe sexual practices, and inattention to safety precautions like the use of seat belts in automobiles. We strongly endorse an emphasis on health promotion and disease prevention to prevent unnecessary disease, disability, and death.
That is not to say that health or even prevention is only a matter of behavior. AS I pointed out in my opening statement, prevention involves personal behavior, environmental protection, and services. Each is crucial; none can be ignored if we are to take full advantage of opportunities available to improve the health of Americans. The Federal role must--and does--address all three of these elements of prevention. Our emphasis on individual responsibility is clearly not the only Federal response to America's health needs; but we believe that it is one that needs special emphasis because Americans have become tro dependent on the health care system to take care of problems that could have been prevented.
Second, we should be reminded that, under the Constitution, States have the principal responsibility and authority for public health. The Federal government, through the Public Health Service, provides leadership (as in the Secretary's speeches that gain appropriate national attention), agenda - setting (as with Healthy People 2000), support for basic and applied research and development, protective regulation to ensure the safety of medications and the food supply, direct services to special population groups and support for services to underserved populations, national surveillance and monitoring, collaboration with the States to initiate and improve services (e.g., through block grant programs and special initiatives such as the breast and cervical cancer screening programs), and dissemination of health information.
Question. What education activities are your office undertaking, and how are these coordinated with the various clearinghouses of PHS agencies and the information dissemination activities of the Agency for Health Care Policy and Research?
Answer. Most of the health education initiatives of the Public Health Service are carried out as part of the ongoing programs of PHS agencies. Examples include high blood pressure and cholesterol education programs of the National Heart, Lung, and Blood Institute (NIH); cancer prevention and control initiatives of the National Cancer Institute (NIH); alcohol and drug abuse prevention initiatives of the Office of Substance Abuse Prevention (ADAMHA); anti-smoking initiatives of the Center for Chronic Disease Prevention and Health Promotion (CDC); and the Depression Awareness, Recognition, and Treatment Program (ADAMHA). From the Office of the Assistant