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elder abuse, and promoting coordinated research, training, capacity building and enforcement activities among those involved with elder abuse reporting, investigation and follow-up.


Question. Secretary Sullivan, just yesterday, HCFA in testimony before the Ways and Means Health Subcommittee, criticized Representative Stark's long-term care legislation saying it was a 'fragmented" or piecemeal approach and that "It would be unwise to take a fragmented approach to long-term care reform." I find this criticism intriguing. There is considerable opinion that, in light of our current budgetary circumstances, longterm care improvements will occur incrementally rather than in one fell swoop.

Can we infer from HCFA's testimony that the Administration prefers to move long-term care reform on a comprehensive basis rather than in a series of steps? If so, when might we expect a comprehensive proposal?

Answer. I believe there is a good prospect that over the next several years we will be able to make some significant improvements in long-term care financing and service delivery. However, we are not likely to reach consensus about this complex issue without informed debate. So what I have

consistently said is that I would like to step back a bit from starting with solutions and look at what the need for various kinds of long-term care is, how today's need may differ from tomorrow's, and how well various proposals, both comprehensive and incremental, are likely to stack up in meeting our nation's long-term care needs in ways that are realistic and affordable. This process of inquiry and evaluation is going on now within my Department, the Social Security Advisory Commission, the National Governor's Association and other groups. expect to be discussing some of my conclusions by the summer.


I would add in this regard that I think longterm care reforms must address continuing improvements in the economic status of many elderly persons resulting from increases in women's labor force participation, two-income families, improved pension coverage and vesting, and real economic growth. This means that a growing proportion of the elderly will be able to afford to purchase their own care. Even more people will be able protect themselves in the event they need long-term care if we can increase participation in various private risk pooling arrangements such as long-term care insurance.


Question. Last year, in OBRA 90, Congress created a new Medicaid State option for home and community-based services for frail elders. This truly can be characterized as a small and

incremental step in long-term care. Yet, in light of our budgetary situation, it was the best we could do. What is wrong with this step. that if we take no action until we thing at one time, we may never get there?

Do you not worry can do the whole

Answer. I do not believe that government alone can be responsible for long-term care reform. The private sector must be involved in providing insurance and other options for those who can afford them. Individuals and families must be involved in understanding their risk of needing long-term care and planning for this risk. People cannot wait until they are very old and experiencing chronic disability before they think about how they want their long-term care needs met. And I also think government must be involved to support people who do not have other choices. There are many different steps that can be taken to achieve this type of reform. We do not necessarily need to do it all at


The new Medicaid option for home and communitybased services for frail elders has several positive features. It does focus on people with the greatest needs. It also includes a cost containment mechanism to avoid the very real prospect that open ended funding for home and community based services could become an astronomical public expense, particularly if it replaced the three quarters of all long-term care now provided free of charge by families. However, this new option has been superimposed on many other community care funding streams, further fragmenting the organization and delivery of services. I don't agree with a strategy that does not try to integrate its purposes with existing programs but is simply layered on top of them.


Question. Secretary Sullivan, your track

record as a strong advocate for much greater emphasis on health promotion and disease prevention is well-known, and you are to be lauded for it. In fact, at your speech before AARP last summer you stated, "One of the best investments we can make is to emphasize health promotion and disease prevention."

I absolutely share your view.

In this vein, I was disappointed to see that the President's budget does not include a request for any funding for part F or Title III of the Older

Americans Act, which is the health promotion portion of the Act. I will also add that Congress has not yet provided any funding for this part which was established in 1987 amendments to the Act. I am pleased to say that just last week I joined Chairman Harkin and other Senators in sponsoring legislation to strengthen this important part of the Act.

Will you support efforts to make this part of the Act a reality by arguing within the

Administration to support any Congressional efforts to provide funding for this part of the OAA?

Answer. I could not agree more that preventive health measures are extremely important for all members of our society, especially for the elderly population. You are correct that this separate funding stream for aging health promotion activities has never been funded since initially authorized in 1987. However, 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.

Question. If there is no support for funding this part of the Act, is there any point in keeping the health promotion provisions in the Act?

Answer. Since State and Area Agencies on Aging can and do conduct these activities under the Title III-B Supportive Services program, and since Part F duplicates authorities already existing under other parts of the Older Americans Act, we are

recommending that Part F be repealed from the Older Americans Act.

Question. If that is not your view, what recommendations can you offer us_to_strengthen efforts under the Older Americans Act to engage in health promotion and disease prevention related efforts?

Answer. There are no legislative changes necessary to strengthen on-going health promotion and disease prevention efforts. State and Area Agencies on Aging, under the leadership of the Administration on Aging, are providing health promotion and disease prevention services to the elderly. The Administration on Aging has been working with States to improve the planning and delivery of services in the area of health


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.

Question. Along these lines, what role do you believe that the National Institute of Aging should play in this area? Are there initiatives you intend to pursue with NIA in this regard?

Answer. Although the National Institute on

Aging focuses more on biomedical research to discover effective prevention and treatment methods for diseases afflicting the elderly, there is much room for cooperation between NIA and the Administration on Aging, which is expert in educating older Americans on healthy lifestyles through its aging network. NIA and AoA have an ongoing Memorandum of Understanding (MOU) that promotes collaboration efforts in health promotion and disease prevention for the elderly. Past projects conducted under this MOU include: a workshop to develop a research agenda on minority aging, a workshop on in-home health and supportive services, and a planning workshop on the

consequences of harmful dietary habits. In addition to the MOU, NIA and AoA have already completed two workshops conducted under an FY 1991 Interagency Agreement to identify and address the health needs of the elderly Hispanic population.


Question. Can you share with the Committee what you are doing to ensure that women in this country receive the highest quality mammogram currently possible and whether you have plans to strengthen the interim rule?

Answer. The Department published an interim final rule on December 31, 1990, in the Federal Register, to implement provisions of OBRA 1990 which provide Medicare coverage of screening mammography. This rule contains very strict standards mandated by the law which we consider very important for ensuring safety and quality. Once we have comments on the interim final rule, we will determine whether there needs to be further clarification of the standards.


Question. I'd like to know what you see as FDA's role in mammography. Do you have plans to broaden the authority of the FDA to collect data on the type and model of equipment; to ensure that the

mammography machines in use are of sufficiently high
quality to detect even the smallest tumors; or to
provide states assistance in inspecting facilities
to ensure that quality assurance programs are in

Answer. The FDA has a long and successful history in working with the States and professional organizations to assure that medical devices, including machines used for mammography, are both properly made and properly used. As a result of this cooperation, the practice of mammography has improved significantly without FDA infringing on the States' control of medical practice. Specifically, FDA worked extensively with the American College of Radiology to develop an accreditation program for mammography facilities. Since this program has been implemented, the number of facilities successfully meeting accreditation requirements has increased from 65% to 87%. FDA has also added a mammography section to the Radiological Health Science File, a teaching aid whose films form the basis of the American Board of Radiology's certification examination. FDA is also working closely with CDC and NIH to develop the National Strategic Plan for the Early Detection and Control of Breast and Cervical Cancer. Components of this plan include surveillance, quality assurance, and public & professional education.


Question. Can you please explain this apparent inconsistency and tell the Committee when you plan to direct the NIH to proceed with this effort?

Answer. Congress has provided the Department mixed signals concerning the conduct of this study. While the Senate has encouraged us to proceed, the House has prohibited us from moving forward without specific approval. At this juncture, you are correct in noting that NICHD has reserved $3 million in its budget request for work on this project. The FY 1992 funding request will allow us to more fully develop the survey vehicle, train interviewers, and begin the preliminary recruitment and sampling of subjects. The total cost of full implementation is estimated to be $15 to $18 million.


Senator HARKIN. Thank you, Mr. Secretary. The subcommittee will stand in recess until 10 a.m., Thursday, March 7, when we will meet in SD-192 to hear from the Family Support Administration, Human Development Services, and the inspector general.

[Whereupon, at 4:02 p.m., Tuesday, March 5, the subcommittee was recessed, to reconvene at 10 a.m., Thursday, March 7.]

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