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fundamental and closely interdependent issues of training, recruitment, and research support. AHCPR will supplement grants to researchers who will make significant contributions to this critical priority in the Nation's health policy agenda. In order to increase the number and, capabilities of minority scientists in health services research sponsored by AHCPR, support will be provided to principal investigators to recruit, train, and employ minority investigators.


Question. Dr. Clinton, what do you see as the major issues in health over the next decade? What plans is the Agency making

to gear its research to these issues?

Answer. We have identified three major sets of issues to be addressed over the course of the decade.

The first revolves around the interrelated problems of
health insurance, public sector health care expenditures,
and the costs of care to individuals. In particular, the
costs of care and access to care for vulnerable

populations--including minorities, those in rural areas, and
the poor--will be increasingly serious health issues if the
costs of care continue to climb at present rates.

We must

The second relates to the quality of medical practice,
including impediments to effective practice.
identify better ways to ensure the quality of health
services and improve mechanisms to protect the public
against substandard health care.

The third set of issues relates to the need for innovation and improvement in primary care, again, focusing in particular on underserved and vulnerable populations, especially women and children in those populations.

AHCPR has developed a long-term strategy as well as some specific goals for addressing each of these sets of issues. Health Insurance, Health Expenditures. and the Cost of Care

The problems associated with the absence of health insurance coverage or under-insurance are well known. One out of five Americans lacked health insurance at some point during all or part of 1987 and more than one in ten were without insurance for an

entire year.1 1 These issues have been of special concern to the Deputy Secretary of DHHS and others in the administration and may be expected to persist and take on greater importance in future years. Up-to-date, detailed, reliable information on health care utilization, costs, and payment sources, including insurance coverage, will be essential for policy makers and program

1Short, P. (1990, September) Estimates of the Uninsured Population, Calendar Year 1987 (DHHS Publication No. (PHS) 90-3469). National Medical Expenditure Survey Data Summary, Agency for Health Care Policy and Research. Rockville, MD: Public Health Service.


administrators to understand the magnitude and determinants of the problem and consider policy options and their implications. current and projected budget constraints, it will become increasingly important to identify gaps in coverage for health care and to identify methods of paying for health services that promote the most efficient use of available resources.

The AHCPR's primary goal in the area of financing and coverage is to provide the information necessary to shape the debate regarding approaches to ensure that vulnerable populations--including the disadvantaged, minorities, and rural populations--have access to appropriate, quality health care. Both extramural and intramural research will contribute to expanding the knowledge base. A major vehicle for developing the information needed is the proposed National Medical Expenditure Survey (NMES) III. Planning and developmental activities are underway now to field NMES III by 1996, and to begin providing data to policy makers as early as 1997.

Enhancing Medical Practice

The legislation creating AHCPR was driven in large part by concerns about the effectiveness of much of current medical practice--particularly in light of evidence demonstrating dramatic variations in physician practice patterns. Our plan is to expand AHCPR's extensive program of medical effectiveness and outcomes research into the development of methods to use this knowledge, and to reduce barriers to its use. The goal is to improve medical practice. The major components of the Medical Treatment Effectiveness Program (MEDTEP)--effectiveness and outcomes research, the development of clinical practice guidelines, data base development, and information dissemination and liaison--will be continued and expanded. In addition, AHCPR's activities will include a broader program to examine the interrelated issues of quality assurance and medical liability.

Over the next 3 to 5 years medical effectiveness research and guidelines development will focus on a broader array of conditions affecting additional population groups; dissemination and use of this information will be emphasized; and a new research and demonstration effort in the related areas of medical liability and quality assurance will be expanded.

Primary Care

Careful attention to research in primary care is important for several reasons. First, most people receive the majority of their care in the primary care setting. When barriers exist to primary care, access to all care is severely limited. Second, the mechanisms or models for organizing primary care are rapidly changing. It is not clear which approaches are best at providing the acceptable, comprehensive, and coordinated services typically associated with good primary care-particularly as services are "unbundled" and free-standing providers proliferate, each rendering only a single or limited array of services. Third, in any effort at health care reform, the role of primary care providers is critical. The organizational, financial, and training arrangements for primary care in this country are

different from those found in Canada and most European countries and warrant careful analysis. Finally, the body of scientific knowledge upon which to base primary care has never been adequately developed. Wide variations abound among the disciplines that practice primary care and between primary care and specialty practitioners. Therefore, the primary care arena represents fertile ground for medical effectiveness and health systems research.

AHCPR's immediate goal is to begin to build the existing primary care research portfolio into a more comprehensive program focusing on ways to use available resources to efficiently and effectively serve the needs of underserved populations. This wil1 include development of practice-based research laboratories in primary care, expanded research on managed care systems, and on improved integration of effectiveness research and information dissemination.

The AHCPR's long-term goal in this area is to a) increase the capacity for research in primary care and b) expand the knowledge base that supports the organization, practice, and evaluation of primary care programs and practices. While considerably broadening the scope of primary care research issues is encouraged, AHCPR will continue to stress health care services for underserved populations (including rural, minority and disadvantaged populations), infant mortality, HIV/AIDS, and delivery system issues (including comprehensive care and managed care).





Senator HARKIN. Next is the Centers for Disease Control.
Dr. ROPER. Good morning, sir.

Senator HARKIN. Good morning, Dr. Roper.

The fiscal year 1992 budget request for the Centers for Disease Control is $1.39 billion, an increase of $85.3 million over 1991. I am pleased to note that the fiscal year 1992 budget does include some increases in funding for programs that have not only had strong support from Congress but are programs that the Congress has initiated such as lead poisoning, breast and cervical cancer prevention programs, immunization, et cetera.

Again, I know that we owe these increases to your leadership, Dr. Roper, and I am pleased that we are moving forward in these important areas. However, considering the billions of dollars we spend each year on medical care and research, the budget before us today I am concerned may not go far enough. When I consider that only about 1 percent of our health care dollars is spent on prevention and intervention programs, that is what raises my question as to whether or not we are doing enough.

I do not need to go through again my feelings on disease prevention and health promotion, but, again, as you probably heard me say, I think that is really our best bet to improving the quality of life for all Americans, reaching down at the earliest possible stages of life and getting that health promotion attitude.

Inasmuch as the primary mission of the Centers for Disease Control is prevention and intervention, I would like to discuss with you today what more needs to be done. I look forward to your professional judgment in this regard. We have had a long association together, Dr. Roper. You have been a great leader in this area for a long time. I am glad you are where you are, and I look forward to working with you in this area.

I will leave the record open at this point for any statements by ranking member Senator Specter.

Welcome to the subcommittee, and please proceed as you so desire.


Dr. ROPER. Thank you, sir. It is a delight to be with you again. I have enjoyed my association with you in HCFA and in the White House, and I am appreciative of the opportunity to visit with you now and in the future.

I guess I would begin by saying that prevention is an issue whose time has come, and it seems as though everybody, or at least almost everybody, is anxious to move ahead in prevention. I agree with your conclusion that we are not investing nearly enough in prevention activities, but we have sure come a long way fast.

I would just begin by pointing out to you that this is the President's budget for fiscal year 1992; the subject we are talking about today has a chapter entitled "Focusing on Prevention and the Next Generation." This is the first President's budget in the history of the United States that has a chapter on prevention. I would just read from the highlight section in this chapter. It talks about issues such as childhood immunizations, infant mortality reduction, breast and cervical cancer prevention, smoking cessation, physical fitness and nutrition, injury prevention, access to health care, family planning, lead poisoning prevention, substance abuse prevention, and evaluation of prevention programs.

CDC has activities in all of those areas, and in most of them we are the lead agency. As you have just said in your introduction, CDC is the Nation's prevention agency. We are pleased that you recognize that and we are anxious to pursue with you an even more vigorous prevention agenda for the Nation.

With that enthusiasm goes a sense of responsibility. We have to deliver tangible results with the resources you give us. What I am here to talk with you about today, sir, is not pie in the sky dreams but practical programs that are proven in their effectiveness. We want to expand them more broadly to make prevention a practical reality for all of our Nation.

Part of what CDC does is to be ready for unknown and unpredicted problems that come along, new organisms in the infectious disease area, new problems in other parts of our health system. I would just draw a quick analogy to what we have just witnessed in the Persian Gulf war, Desert Storm. Because of building the capability to fight that kind of a war, it went very well. We would like to fight that kind of war on prevention, and it requires investments not only on specific activities that may be popular this year and not popular next year, but it requires investment in a public health system, as you said in your earlier questions to Dr. Mason, that will deliver time and time again.

Let me just draw your attention quickly to three priorities that we have set for ourselves at CDC. I have already mentioned the first, making prevention a practical reality. It is not enough simply to give nice speeches about prevention. It is important that we deliver services not only to people like my wife and myself who have a car with seat belts and know to use them. We need to make prevention a practical reality for people who cannot afford a car and who are in many ways not plugged in to doing things for themselves and preventing health problems.

The second priority is improving the health of children. We have touched on immunization programs, and I want to come back to those later. It is an overarching priority. As I said, the President's budget focuses on investing for the future and the health of our children. Then finally the third area of building a public health system, strengthening the Nation's public health system is a major priority.

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