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access to care for high-risk women and to develop treatment programs.

After birth, children need access to essential programs. So I am pleased to announce that we are requesting $6 billion in fiscal year 1992 for programs designed to improve access to care for children and youth. This represents an increase of $659 million or 12 percent over fiscal year 1991 levels for activities such as child care, Head Start, child welfare services, and child protective services to abused and neglected children.

As part of this request we are asking for approximately $4 billion for child care and development programs. This represents a $366 million increase, or 11 percent, over fiscal year 1991 and a $2 billion increase, or more than 100 percent, over the 2-year period.

Now Head Start is one of our most important and one of our most successful governmental programs to help our children. Therefore, we are asking for a total of $2.1 billion for Head Start in 1992 which represents an increase of $100 million over fiscal year 1991, and an $817 million, or 66 percent, increase since President Bush took office. This will allow us to reach over 633,000 eligible children, an increase of almost 180,000 during this 3-year period.

State child welfare services agencies cope with family disruption and breakup. The 1992 budget provides $364 million for child welfare services, an increase of $90 million or 33 percent over 1991 funding levels.

We also need to open up our hearts and create homes for many of our children. We believe that the number of children now in foster care exceeds 360,000, so our proposed budget includes $2 billion for 1992 payments to States for foster care and adoption assistance, $203 million more than 1991.

We will also continue our commitment to children in other programs, for example, aid to families with dependent children grows in 1992 to $11.7 billion, an increase of $839 million or 7.4 percent over prior year levels. This increase is the result of ongoing growth in case loads, of increases in States' payment standards, and a full implementation of benefits for unemployed-parent families.

But we need much more than money. The President is doing his part. But all of us have a role to play. We need political as well as moral leadership. We need to revitalize our sense of community and recognize our mutual need and dependence on each other, and develop steadfast resolve to end the suffering, the disease, and the death that we inflict on our own children.

Obviously, one of the most threatening and most subtle evils facing our society is the erosion of basic values and the breakdown of the institutions which teach them, namely family and community. We must work to keep our families together. We must increase our efforts to strengthen our communities. In short, we must all accept our personal responsibility to create a better, a safer, and a healthier environment in which to raise our children. In other words, we must work together individually and as a community on behalf of our children, fostering a culture of character, a climate of personal and societal responsibility.

As we saw so dramatically in Africa in January, Government programs are important, but many of our children and many of the

problems that they have are symptoms of a culture of despair, of indifference, and unconcern. And this requires us to change attitudes, as well as to cure illness, to make better decisions to reduce morbidity and mortality and to increase vitality and fulfillment in all stages of the lives of our citizens.

A culture of character is something that money cannot buy but that our individual decisions can create. It must be a necessary, decisive element in our efforts to help our children survive and to grow into healthy and responsible adults.


So Mr. Chairman and members of the committee, the President and I need your help and we need your support. Surely, our partnership can be a formative first step.

Thank you.

[The statement follows:]


Mr. Chairman and members of the committee, thank you for inviting me here today to discuss the President's fiscal year 1992 budget proposal for the Department of Health and Human Services. Our budget totals $525 billion, an increase of $39 billion, or 8 percent over current year spending.

Our appropriation request for HHS programs considered by this Committee totals $161 billion. This is $13 billion over 1991, or an increase of 9 percent.

This budget reflects the President's and my own priorities for the programs and services delivered by this Department and I look forward to working with the Congress for the enactment of this budget.

We find ourselves at a unique time in our ability to address the health care needs of this Nation. We are faced with grave public health challenges such as unacceptably high rates of infant mortality—particularly in our minority communities, the devastating impacts of drug abuse, and far too many deaths from preventable diseases. These problems and others extract an enormous toll from our society in terms of personal suffering as well as spiralling socioeconomic costs. Certainly these problems cannot be solved overnight. However, we can have a tremendous impact by using our resources to improve both the scope and delivery of our health care services, by expanding our understanding of life processes and disease through research, and by calling on every citizen to take personal responsibility for making positive, healthy choices for their lives.

During 1992, we will continue our work to improve the health and well-being of this Nation by helping children and strengthening families; by improving the health status of minority and low-income Americans; by intensifying disease prevention and health promotion activities; by advancing our scientific understanding of the basic biomedical and behavioral research opportunities before us; and by continuing to improve the delivery of programs and services for which we are responsible.

I would now like to share with you, in greater detail, how our 1992 budget will help us to be responsive to the enormous challenges before us:

During 1992, HHS will provide over $6 billion for child care, child development and child welfare programs for America's families in need. This amount represents an increase of $659 million, or 11 percent over 1991 levels. Let me briefly highlight these programs for you.

The 1992 budget proposes spending $4 billion on child care and development, a $366 million or 11 percent increase over 1991. These programs recognize the critical role that child care plays in assisting low-income families achieve and maintain economic self-sufficiency. Included is $732 million for the new Child Care and Development Block Grant enacted by Congress last Fall; $300 million for At-Risk Child Care grants which will provide child care to families at risk of becoming dependent on welfare if it were not for child care assistance; $350 million for child care that will support Aid to Families with Dependent Children (AFDC) recipients' efforts to leave welfare; and $83 million for Transitional Child Care to help prevent families from returning to welfare.

As you know, educating our youth is a top priority of this Administration. The Head Start program has been one of the most important and successful governmental efforts to help children enter school ready to learn. This budget includes $2

billion for Head Start, an increase of $100 million over 1991; the amount of our increase was dictated by our management concerns for the program. These funds will be used not only to expand enrollment in the Head Start program but also, most importantly, to assure the proper management of the huge infusion of funds Head Start has received over the past two years. We are very pleased to report that by the end of fiscal year 1992, the Head Start program will enroll 180,000 more children than we did before President Bush and I came into office.

State Child Welfare Services agencies and Foster Care and Adoption Assistance programs cope with large numbers of troubled children and families and create homes for many of our Nation's children. The 1992 budget includes $2 billion for payments to States for Foster Care and Adoption Assistance, $203 million above the 1991 level, for children currently in foster and adoptive homes. The 1992 budget also provides $364 million for Child Welfare Services, a $90 million or 33 percent increase over 1991, to strengthen efforts to prevent children from entering foster


The Department will also enhance efforts to protect children from abuse and neglect. Funds are requested to increase coordination of child abuse and neglect prevention efforts, evaluate treatment innovations, and implement a new National Child Abuse and Neglect Reporting System to further our understanding of the causes and extent of child abuse and neglect.

As Secretary of HHS, one of my top priorities is to lessen the burden of disease, disability and premature death which disproportionately affects many of our poor and minority citizens. Key factors contributing to the continuing disparity in the health status between minority and non-minority Americans are the lack of access to adequate health care and an insufficient number of adequately trained health professionals serving minorities and economically disadvantaged populations.

I, along with many others, am disturbed that the U.S. infant mortality rate continues to be worse than that of nearly every other industrialized country in the world. The rate within our black community is more than twice that within our white community. The 1992 budget requests $5 billion to continue our efforts to reverse this tragic statistic. Included within this total is $171 million for an initiative that targets funds to communities suffering from the highest rates of infant mortality in order to remove the barriers that prevent pregnant women and teenagers from receiving prenatal and perinatal care for themselves and their infants. There is still much work that needs to be done in this area; the additional funds requested are critical in enabling us to save more lives.

Additionally, the 1992 budget request of $170 million represents more than a 28 percent increase in our efforts to train health professionals who are interested in serving minority and low-income populations. Prominent elements of this initiative include significant expansion of the National Health Service Corps recruitment program, recapitalizing the Health Professional Student Loan program, and the establishment of a new Federal construction program to enable historically black colleges, universities, and similar institutions to improve their research infrastructure and increase their competitiveness for Federal research funds.

Of equal importance as providing access to health care is preventing disease. Throughout HHS, we are seeking more than $7 billion for prevention activities, a 9-percent increase over 1991.

Breast cancer remains one of the leading causes of death for women aged 35 to 54. Early detection and diagnosis are key elements to combating these preventable deaths. The 1992 request includes $50 million to assist States and local health departments in offering breast and cervical cancer screening programs for low-income and disadvantaged women, an increase of 71 percent compared to fiscal year 1991. Additionally, for women over 65, mammography screenings are now available as a covered service under Medicare.

Our prevention effort also seeks $258 million for child immunizations, an increase of $40 million or 19 percent over 1991. Under the leadership of the Centers for Disease Control, many childhood diseases, such as tetanus, diphtheria, and polio have been brought almost entirely under control. However, outbreaks of other childhood diseases, such as measles, mumps, rubella, and pertussis still exist, particularly among pre-school, inner-city children. These resources will focus efforts to remove barriers currently hindering delivery of immunization services to poor and disadvantaged children.

Recently, the Centers for Disease Control announced that over 100,000 Americans have died from AIDS. We must continue both our research and education efforts to reach all Americans with understandable and accurate prevention information. In 1992, AIDS research, prevention, and education efforts throughout the Public Health Service will receive almost $2 billion, a 50-percent increase since I took of fice.

Drug abuse continues to extract too high a toll on our children, on our families and on our society as a whole. We have requested an increase of $108 million for drug abuse treatment, research and prevention efforts throughout the Alcohol Drug Abuse and Mental Health Administration. Included in this total is $99 million to expand the overall drug abuse treatment capacity of the Nation. Resources will be focused in areas where the current drug abuse problem far outstrips the capacity to provide treatment services. The total funding for drug abuse research, prevention and treatment activities within HHS is $2 billion, an historically high level of support.

Almost a third of the discretionary expenditures for HHS or nearly $10 billionare devoted to the biomedical and behavioral research efforts carried out by the National Institutes of Health and the Alcohol Drug Abuse and Mental Health Administration. The 6 percent requested increase of $581 million will fund ongoing research in the prevention and treatment of diseases such as cancer, AIDS and other sexually transmitted diseases, heart disease, and stroke. This budget directs funds toward a variety of initiatives, including efforts to map the human genome, developing drugs to treat people suffering from mental health disorders and drug and alcohol addiction, and re-building the research infrastructure on the NIH campus.

As a result of a growing national concern over both the quality and rising costs of health care, the Agency for Health Care Policy and Research was created one year ago to organize and support research studies focused on improving health care delivery methods. The budget for 1992 includes $122 million, an increase of 6 percent over 1991, to undertake a wide variety of projects that will ultimately improve the patient's outcome.

I am committed to ensuring the quality of service provided to the American public through the large entitlement programs administered by this Department Social Security, Medicare, and Medicaid. In recent years, budgets for both the Social Security Administration (SSA) and the Health Care Financing Administration (HCFA) have grown faster than inflation. As the beneficiary population grows in the future, it will put additional pressure on us to develop more efficient and effective ways to manage within the available administrative resources. This year, we were faced with difficult choices in managing within the constraints of the Budget Enforcement Act. The requested funding is adequate to meet the basic mandates of these agencies. HCFA contractors will pay Medicare bills within the statutory time frames. SSA will focus its resources on processing claims applications and maintaining service levels. However, in some areas, there may be slow downs.

However, we are examining options for both SSA and HCFA to develop strategies for finding the most cost-efficient ways to provide service to the people who depend on us. SSA is developing a long-range strategic plan which will define service requirements, means to increase productivity and efficiency, and, in general, provide a picture of how SSA will deliver high quality service to the American public. HCFA is actively exploring ways to improve the uniformity, efficiency, and performance of Medicare contractors, including a review of alternatives to current contractor arrangements.

We are requesting a $232 million supplemental appropriation for 1991 for the SSA to provide administrative resources to enable the Agency to carry out the additional work required as a result of the Supreme Court decision in Sullivan vs. Zebley. As funds were not included in the regular appropriation for this purpose, a supplemental appropriation is needed in order to meet the additional work demands.

As you 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.

The budget requests $1 billion in funding for the Low Income Home Energy Assistance Program (LIHEAP). This amount is $585 million less than the fiscal year 1991 level. LIHEAP was created as a temporary program in the late 1970's in response to the energy crisis. These reductions reflect the fact that LIHEAP was never intended to meet the entire home energy costs of low-income households, but rather to supplement assistance available through other Federal and state programs.

The Community Services Block Grant and related discretionary grant programs are proposed for elimination in fiscal year 1992. This would represent a savings of $425 million. This program was initiated in fiscal year 1981 to assist in establishing an infrastructure for improving services to low-income individuals and families. Since that time, basic reforms have been institutionalized and increased funding has been provided for activities such as employment services through the JOBS program and child development through Head Start and the Child Care and Development Block Grant.

The budget also proposes a reduction of $186 million in funding for the Health Professionals Training Program. This represents a common theme throughout the budget of focusing resources toward programs that target minority and disadvantaged populations and away from broad-based categorical health professions programs.

In conclusion, we have endeavored to balance the competing demands of providing for the vast and varied health and income security needs of this Nation while staying within the absolute fiscal constraints defined by the Budget Enforcement Act of 1990. The programs administered by the Department of Health and Human Services touch Americans throughout their lives, providing essential prenatal and child care for low-income families, ensuring that all children start school on equal footing, advancing our scientific knowledge of disease prevention and treatment methods, and providing financial support for our elderly citizens. This budget reflects our strong commitment to ensuring the health and well-being of all our citizens. I look forward to working with you for its enactment.


Senator HARKIN. Mr. Secretary, thank you for a very forceful statement and a clear declaration of your intent and policy positions of the Department. I would like to have a copy of that statement also as well as the one that was submitted earlier with all of the facts and figures in it, too, because I would like to read some of the things that you were talking about there.

The culture of character that you said money cannot buy reminds me of what my dad once told me. He said, you know, it is pretty hard to pull yourself up by your bootstraps when some rich kid has stolen your boots. Yes; we like people to pull themselves up by their bootstraps, but they have got to have the wherewithal and they have got to have the boots first. And I know that money cannot buy everything.

But it seems to me that despite all of the different conflicts that confront Americans today, we are an open, free society. We believe in individual initiative and effort. There is sort of a cross-current there. The traditional values, the work ethic, saving money, studying, getting ahead, faith, taking care of your family, strong community-these are old, traditional American values which permeated through all sectors of our society and all races in our society. And now there is a cross-current cutting across that, a cross current of do your own thing. Everyone is free to do whatever they want to do, lack of responsibility for one's actions, lack of accountability for what one does. And I think it permeates all of our society.

It seems to me that there are no simply answers. I understand that. It seems to me that we have gotten away from the basics. We are very good in our society in health areas especially, also education, social services, all the areas that we basically cover herethat your Department covers. I say education but also in Head Start and things like that.

We have become so focused on fixing things up, patching, curing once you are ill, remedying, acute care, and health care. Once you get sick, we can take care of it. If you cannot read, we will have remedial reading. We have got remedial this, remedial that, remedial everything in our society to take care of these problems.

I am proposing that perhaps we focus on not having those problems in the first place. And the place to start is with kids, children, and that means a broad approach at prevention and health promotion. And we know it works. You know it works. You take infant mortality. There is no real secret about reducing infant mortality.

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