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How does Canada provide universal health care for less cost than the United States?

Answer. There are substantial differences between the Canadian and U.S. health care systems. In general, Canada has fewer specialists and more general practitioners and provides much less technologyintensive care. Also, each provincial government establishes a fee schedule for medical services. These government established fees constitute payment in full. The Canadian system also has much lower administrative costs than the United States. Also, Canada has regionalized health care and a very tight system of capital controls.

However, there are long waits for elective surgery in Canada, and more limited access to technology. Therefore, although we can learn about the best aspects of the Canadian system, we cannot transport the Canadian system to the United States.

Question. Are there elements of the Canadian health care system that can be of value to the U.S. as we search for a way to expand access to care for all Americans, while controlling costs?

Answer. The Canadian system has some interesting features. One feature that we may want to examine is how Canada handles administrative costs. Their administrative costs are substantially lower than in the United States. Reducing American administrative costs might free dollars for needed patient care. Since coverage is universal and all health transactions are paid by the government, the government can profile physician practice patterns and identify problems. are beginning to use profiling more in the United States. Canada has a very tight system of capital controls. Also, Canada has regionalized health care, linking remote rural areas with the best care in tertiary institutions in major cities.



Question. Mr. Secretary, as you know, I have introduced the Older Americans Health Promotion and Disease Prevention Act. This bill expands Part F of the Older Americans Act to establish a state grants program that would provide disease prevention and health promotion services and information at senior centers, congregate meal sites, home-delivered meal programs or at other appropriate sites. Prevention and health promotion is important at any age however, to the elderly, disease prevention and health promotion could well meant the difference between independence or nursing home care. I just think that prevention makes good sense and will save money in the out years.



With this as background, it is of concern to me that the Administration has never requested funding for

Part F of the Older Americans Act

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Health Prevention for Older Americans. Is it felt that these services are unimportant for older Americans, and if you feel that these services are important, why have you not requested funding for Part F?

Answer. I could not agree more that preventive health measures are extremely important for all members of our society, especially for the elderly population. However, we have not established a separate funding stream to support these activities. 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.

In addition to Title III-B activities, health promotion and disease prevention has been a priority under the Title IV Aging Research, Training and Disrectionary Projects program for the past several years. Grants have been made to Universities and local Aging organizations to improve knowledge about and effectiveness of health education and promotion programs for the elderly.


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Each day, about 6,000 people turn 65 years of age. By the year 2,000 just nine short years away 13 percent of the population will be 65 or over. Iowa's 65 and over population is already at 15.1 percent, and we have one of the largest 85 years of age and over populations in the country. In spite of the fact that the "AGING OF AMERICA" is a very real, no increases not even cost-of-living increases have been requested that will put programs into place to deal with this population growth. What steps is/are the Administration taking to put into place long-term strategies and programs to deal with this population growth?

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Answer. While we are not seeking funding increases for Administration on Aging programs, we do expect service levels to increase. Aging service agencies have selected management and program improvements, combined with the long tradition of increasing contributions from program participants, to allow service levels to increase with level funding. For example, supportive services like home health aide, transportation, outreach and legal services to the elderly will increase by 6% on average, and 3.4 million more meals will be served to the elderly in 1992 than were served in 1991. In addition, to ensure that available funds provide assistance to those most in

need, the Administration's legislative proposal to reauthorize and reform the Older Americans Act for 1992 will place greater emphasis on targeting funds and services to the most needy and vulnerable--the lowincome minority elderly.

In addition to implementing service programs, State and Area Agencies on Aging, under the leadership of the Administration on Aging, are working with thousands of community organizations to develop coordinated systems of service to respond to the needs of the growing elderly population within the community.


Question. We have several concerns relating to the implementation of the 1990 reauthorization of Head Start. In creating the quality set-aside, the reauthorization bill was careful to protect the program's ability to maintain current service levels. Section 105 of PL 101-501 specifically states that before the Secretary can use funding increases to expand the number of children served by the program, he must ensure that allocations to existing programs are sufficient to maintain the precious years service level, account for inflation. Please explain why the Administration's FY 1992 budget proposal outlines its intention to use increase to serve additional children and not to provide an inflation adjustment so that existing programs can meet rising costs such as rent, heat and supplies?

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Answer. Ensuring that the level and quality of Head Start services are maintained during the on-going enrollment expansion program is one of our top priorities. Funds from the FY 1992 requested budget increase will be available for grantees to maintain the current level of service in their programs. The recent amendments to the Head Start Act do not require a costof-living increase for all grantees, but rather that enrollment is not increased without first assuring that grantees have sufficient funds to maintain the previous year's service levels. This will be accomplished by allowing grantees to use funds from their FY 1992 increase to maintain services, before they add new children to their programs. Such decisions will be made on a case-by-case basis, since the amount of funds that will be needed to maintain service levels will vary depending on each program's particular circumstances.


Question. The inventory of unresolved complaints before the Office for Civil Rights has increased from 558 in 1989, to 597 in FY 1990, and up to 637 unresolved cases at the start of FY 1991. The FY 1992 budget projects another increase in unresolved complaints.

How do you account for this steady increase?

Answer. The increase can be attributed to the following: a projected average annual increase of more than eleven percent in complaint receipts between FY 1989 and FY 1992; a relatively constant level of compliance staff; and the Office for Civil Rights' concurrent effort, beginning in FY 1990, to operate a balanced program of complaint investigations, compliance reviews and outreach activities.

Question. What level of FTE and funding, in your view, would be required to decrease the backlog of unresolved cases? Please be specific.

Answer. It is important to note that the year-end inventories are not unattended "backlogs", since they principally include cases that are being processed, as well as cases received during the last half of the previous fiscal year. In FY 1989 and 1990, the inventories were 29.6 and 31.27 percent respectively of total workload. In FY 1992, that percentage is expected to rise to 33.2 percent of total caseload.

By regulation, OCR is required to promptly address complaints of discrimination and carry out other compliance activities such as periodic compliance reviews. The Department has chosen to maintain a balanced enforcement program of complaint investigations, compliance reviews and outreach activities which, because of resource limitations, has resulted in a small increase in the end-of-year inventory. In FY 1992, should the end-of-year inventory become unmanageable, the agency has the flexibility to redistribute resources as needed.


Question. How many Policy Research Studies are planned for FY 1992? How many of these will be conducted within the Department, and how many contracted out?

Answer. Policy Research will generate approximately thirty studies let through various contracts and grants in FY 1992. We do not conduct studies per se. However, we do utilize the research data gathered by these studies to translate the science of policy research to the development of the Departments planning and policy analysis.

Question. What are the priority areas for Policy Research studies in FY 1992?

Answer. The Policy Research program examines broad issues that cut across agency and subject lines, as well as new policy approaches developed outside the context of existing programs. The research will focus on policy issues in these major areas: services

integration; children and youth; family; long-term care; health care infrastructure and financing; and minorities.

Question. Please provide the Subcommittee with copies of recent studies on the family supported through Policy Research funds.

Answer. The following two examples of studies conducted on the family are being provided to the Subcommittee under separate cover: "Identifying Successful Families: An Overview of Constructs and Selected Measures" and a compendium of "Research on Children, Youth, and Families.

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Copies of other studies are available through the Policy Information Center (PIC), a resource center for evaluation, short-term evaluative research, and policyoriented projects for the Department. The PIC is operated by the Office of the Assistant Secretary for Planning and Evaluation. Upon request, PIC staff will conduct searches of its on-line query system and make available copies of final reports and/or executive summaries which focus on the Department's programs and policy issues. The PIC is located in Room 438-F, Hubert H. Humphrey Building, 200 Independence Ave. S.W., Washington D.C. 20201, telephone (202) 245-6445.


Question. The budget requests $5 million for a new clearinghouse on third party liability, which proposes to identify beneficiaries' available health coverage and ensure that secondary payer provisions of law are followed.

As this new clearinghouse is envisioned,

beneficiary participation in the clearinghouse appears to be mandatory, likened to providing information to the IRS. What specific information would beneficiaries be required to provide about themselves and their families?

Answer. Under the proposed new legislation, beneficiaries would not be mandated to provide any information to the IRS. Experience has demonstrated that information obtained from beneficiaries is often incomplete and inaccurate. The clearinghouse avoids this problem by going straight to the employer for the necessary information on health care coverage of their employees. The employer would be required, as part of the annual W-2 Form process, to provide information on employee health coverage for the tax year just completed. Although the details of this process need further development, the information provided by the employer would be limited to one of four categories with respect to the potential beneficiary/employee:

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