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I agree that

Answer. I have said before, and continue to believe, that this Nation still possesses the best health care available in the world today. gaps in access persist, and we are working on a number of fronts through programs such Community and Migrant Health Centers, the National Health Service Corps, and Medicaid to address these problems.


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As to whether the people of this nation are better off today than a decade ago, I believe the answer is yes. Mortality rates from most diseases and disorders continue to fall while we continue to lower current rates of infant mortality and cancer deaths, our success in these areas is far better now than in 1980. Over the past decade medical technology has leapt forward at an astonishing rate, making some procedures thought experimental in 1980 now seem almost routine. Within the past year advances such as the discovery of the cystic fibrosis gene and the initiation of gene therapy for immune deficiency disorders hold great promise for the future. This progress is a tribute to, and product of, our health care and biomedical research system. We should work to improve what we now possess.


Question. Some 37 million Americans don't have health insurance-- and the number of uninsured children jumped 40% between 1977 and 1987. And, unfortunately, we know that lack of insurance translates directly into limited access to health care services.

Last year when you came before this Committee, you said you were awaiting the report of the Pepper Commission and other councils studying the pressing issue of national health insurance and the 37 million Americans who don't have health insurance.

In a recent speech you said that calls for national health insurance are "false prophecy from those preaching easy solutions."

What solutions do you propose for the uninsured?


Answer. Solutions for resolving the problems of uninsurance must emerge from national consensus. Administration is continuing to participate in the broad national dialogue that marks movement toward health financing reform. Additional important contributions to this debate are expected from the National Governors' Association and the Steelman Commission later this year. It would be premature for me to point to any particular approach as being the most appropriate solution.

What is clear is that while our current system has problems that require resolution, it also has many strengths. Solutions must build on those strengths rather than cast them aside for a speculative embrace

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of radical change. Furthermore, solutions must promote restraint of the increase in health care costs, personal and family responsibility in financing health care and maintaining a healthy lifestyle, an orderly private health insurance marketplace, and the targeting of public subsidies on those most in need.


Question. Mr. Secretary, the infant mortality initiative in the budget has opened up a can of worms with its proposal to reprogram funds from the Maternal and Child Health Block Grant and "target" funds from the community health center program.

Yet we haven't heard any specifics from your Department about this initiative which cities are targeted, how funds would be used, how the program would be administered.

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What are your intentions: Do you plan to start this initiative in FY 1991, and if so, will we be receiving a reprogramming request form the Department?

Answer. We cannot continue with business as usual. I believe it is imperative that we begin at once to combat the unacceptably high infant mortality rates many areas in our country face. Therefore, we plan to begin our Healthy Start Initiative in FY 1991 with $57.3 million. On March 12, I sent a letter to the Senate outlining my plans to reprogram $33.7 million from the Maternal and Child Health Block Grant to the initiative and to target $23.7 million within existing programs such as the Community Health Centers, the Perinatal Case Management Initiative, Health Care in Underserved Neighborhoods, and the National Health Service Corps. Let me be clear, I am not proposing to reduce funding for Community Health Centers. proposing limiting most of the FY 1991 increase to Community Health Centers within targeted areas.

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Question. Is it the Administration's position that FY 1991 funding from the MCH Special Projects of Regional and National Significance will be used for this initiative OR as the Committee directed in the FY 1991 Appropriations bill?

Answer. The Administration intends to use the Maternal and Child Health Block Grant set-aside for Special Projects of Regional and National Significance as directed by Congress.


Question. In a recent survey of State executives conducted by your Department, 41 Governors said that rural health care is a "chief concern." Yet a review of your FY 1992 budget shows that

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No funds are requested for the Essential Access
Community Hospital or Rural Primary Care Hospital

No funds are proposed for rural health transition

After almost two years, no one has been appointed
director of ADAMHA's Office of Rural Mental Health

No funds are requested for the health professions
programs targeted to rural areas, such a AHECS;
border health education centers; or
interdisciplinary training grants;

There is a proposal to outreach health services
and link service providers it looks a lot like
my rural health outreach grants
but your
proposal is only for 10 cities, no funds are
requested for rural health outreach grants;

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There is even a cut proposed for the Office of
Rural Health Policy, with just $800,000 proposed
to support State Offices of rural health in 1992.

Yet here you are, for the third year in a row, claiming to be interested in rural health care.

If you don't support funding for these programs,
which rural health programs do you support?


I support programs that work. The General Accounting Office, in a report issued on February 15, indicates that although several of our efforts, including the Essential Access to Community Hospitals and Rural Primary Care Hospitals programs, provide some financial relief to certain subgroups of rural hospitals, they are not well-targeted mechanisms for maintaining access to hospital care. The study indicated that providing financial assistance to broadly defined groups of rural hospitals is neither an effective nor an efficient method for preserving such


The report also reveals that there is no evidence that Medicare-dependent hospitals are at higher risk of closure, and that paying full Medicare costs would not solve the financial problems of these hospitals.

While the Transition Grant program was found to have potential for helping communities address their specific access problems, it was determined that a more targeted effort which would also assist providers other than hospitals may be preferable to the current program. The GAO has determined that where access to essential hospital services may be threatened, Federal support through the Transition Grant program might best

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be used to support innovative State or local projects. This would require legislation.

The 1992 budget does include an estimated $404 million to improve access to health care for rural Americans. Of this amount, $336 million will provide health services to rural communities and $68 million will support research which will evaluate the unique circumstances facing providers and consumers of rural health care. In addition to these specifically targeted programs, rural communities are eligible to apply for funds through most other HHS programs. include the infant mortality initiative you mention which is proposed for 10 areas, as well as receiving their fair share of Federal block grants to States.


Finally, although the 1992 request does not include significant funding increases for rural health programs, I am absolutely committed to the President's Rural Economic Development effort. Rural America is facing a number of social and economic problems of which health care is a symptom. I plan to continue to work very closely with the Secretary of the Department of Agriculture on issues of health and social services policy and believe this White House effort will contribute to solving the health care problems of rural communities.


Question. Has the Department developed a comprehensive plan laying out each objective, which changes in federal programs or increases in federal funding should be made so that we can achieve in the Year 2000 what we did not achieve in 1990?

Answer. The success of Healthy People 2000 will depend upon changes in both individual behaviors and on the ability of the health care profession to prevent as well as to treat disease. The President's Budget shows a commitment to those aspects of Healthy People 2000 which can be supported at the national level, e.g. a six percent increase for biomedical & behavioral research and better access for minorities and the disadvantaged. The budget also contains increases to address specific 1990 Healthy People goals which were not fully achieved, e.g., $171 million in targeted assistance to reduce infant mortality rates. in meeting the goals of Healthy People 2000 requires that local communities throughout this country translate national objectives into state and local action. A new edition of model standards, Health Communities 2000: Model Standards, Guidelines for Attainment of Year 2000 Objectives for the Nation, provides a flexible planning tool to enable communities to share in the various efforts necessary to obtain these objectives.



Question. Mr. Secretary, your budget for the Social Security Administration calls for more than doubling the backlog of disability claims, and seems to accept high busy signal rates on the toll-free "800" telephone service. In the Medicare program, your budget would produce huge backlogs in hearings over disputed claims, and allow millions of public inquiries about Medicare to go unanswered.

Mr. Secretary, I can tell you, if these proposals actually occur, you'll be getting a lot more mail and phone calls from members of Congress asking you to expedite services on behalf of disgruntled constituents. How did these service cutbacks get into your budget?

Answer. The limited growth for domestic discretionary programs envisioned in the Budget Enforcement Act will make it difficult to process growing workloads. The FY 1992 budget forced us to make difficult choices in these accounts. The administrative budgets for both SSA and HCFA are workload-driven budgets budgetary requirements are partially determined by the growth in the beneficiary population and the number of Social Security and Medicare claims received each year. Key workloads, which are rising faster than the domestic discretionary caps, put considerable pressure on these budgets. budget will allow us to meet our obligations by processing mandatory workloads, but the quality of service may diminish in some areas such as you've mentioned.



Question. Do you have a long-range solution to deal with the enormous growth in Medicare claims and social security workloads?

Answer. We are moving forward in both programs to meet this challenge in future years. SSA is developing a strategic plan which will define service requirements, means to increase productivity and efficiency, projected investments in new technology, and, in general, provide a picture of how SSA will deliver high quality service to the American public. Future budget requests will reflect the strategies developed in the Strategic Plan, targeting resources so that the quality of service will be maintained or improved in the face of rapidly rising workloads. is considering options for the long-term reform of Medicare Administration which should further economize on resources used to process Medicare bills over the next decade.


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