Head Start: Last year, the Congress and the President agreed that it was unacceptable for Head Start, the cost-effective and proven-to-work early childhood development program, to serve only a little more than a quarter of all eligible youngsters. As a result, the most far-reaching Head Start reauthorization since the program's inception in 1965 was enacted. It authorizes funding necessary to serve all eligible preschoolers by fiscal year 1994 and includes major steps to strengthen the quality of services children receive.

The Head Start bill passed overwhelmingly last year calls for FY 1992 funding of $4.3 billion (an increase of $2.3 billion). We strongly urge the Subcommittee to act accordingly and do what is necessary to keep the program on the road to full participation by 1994.

Childhood Immunizations:

The Childhood Immunization program was

revitalized and renewed. Declining immunization rates in the United States have resulted in the outbreak of wholly preventable disease, like measles, especially among young children. In 1990, more than 25,000 cases of measles were reported in the United States--two-thirds of them could have been prevented if preschoolers had received their vaccinations on time.

In accordance with the recent recommendations of the National Vaccine Advisory Committee, CDF urges the Subcommittee to appropriate $267.7 million (a $50 million increase) for Childhood Immunizations to help stem the current measles outbreak.

Help for Homeless Children: The McKinney Act was reauthorized and included a new $12.5 million demonstration program to help families separated or at-risk of being separated by inadequate housing or homelessness. It also authorized the Education of Homeless Children program at $50 million to better help homeless children stay in and achieve in school. We strongly recommend funding these two critical programs at their fully authorized levels in FY 1992.

Family Support Services:

Reports from across the country of increases in child abuse and neglect, growing homelessness among families, and escalating foster care caseloads dramatize the need for more support to families earlier. That's why Congress created the Family Resource and Support Grant program to help states build statewide networks of local family preservation services to help support families before crises arise. We recommend an appropriation of $30 million for this critical preventive investment program in FY 1992.

Children, of course, have many and varied needs. In addition to these initiatives, CDF urges the Subcommittee to continue and expand upon its traditional support of other critical programs to help assure that children grow up strong, healthy and educated as it marks up the Labor, Health and Human Services and Education Appropriations bill for FY 1992.

Job Training: In order to build upon the proven success of the cost-effective Job Corps program, CDF joins business, political and academic leaders in urging you to begin implementing the Jobs Corps 50-50 Plan. By adding 50 new centers over the next five years and increasing the capacity of the program by 50 percent, Job Corps will be able to reach as many as half of all youths who need its intensive education and vocational training services. We recommend an appropriations of $1.160 billion (a $292.5 million increase) of which $160 million is needed to begin 10 new centers.

Children's Health: We urge your support for several programs that are critical to assuring access to basic health care services to infants, children and women of childbearing age. These programs have played a major role in reducing maternal and infant mortality, improving child health, raising immunization rates and increasing access to care. We recommend: $679.9 million (a $150 million increase) for Community and Migrant Health Centers, of which $80 million is needed to fund the infant

mortality initiative in S. 493; $151.7 million (a $60 million increase) for the National Health Service Corps; $687.3 million (a $100 million increase) for the Maternal and Child Health Block Grant "Title V"; $344.4 million (a $200 million increase) for Title X family planning services; and $25 million (a $17.2 million increase) for the Lead Poisoning Prevention program. Child Welfare: We also hope you will consider increases for a range of programs targeted on the most vulnerable children--those who are victims of abuse or neglect, have runaway or are homeless, or have serious emotional problems. Investment of an additional $102.2 million will expand these much-needed prevention and treatment programs: $325 million (a $51.7 million increase) for the Child Welfare Services program; $55 million (a $15.5 million increase; for the Child Abuse Prevention and Treatment and Challenge Grants; $50 million (a $14.9 million increase) for Runaway and Homeless Youth; $25 million (a $15.1 million increase) for Runaway Youth/Transitional Living; $14.4 million (a $5 million increase) for the Child and Adolescent Service System program.

In addition, we urge you to reject any attempt to impose a cap on administrative costs under the Title IV-E Foster Care program. These administrative costs include not only general overhead but also the costs of implementing critical protections for children who are at risk of placement or already placed in foster care. Imposition of a cap, without distinguishing between general administrative costs and costs associated with child protection activities, will jeopardize children and families suffering from abuse and neglect, homelessness, and substance

abuse.

Education: A crisis continues in the nation's education system and is greatest in resource-short schools and classes serving poor and minority children. We encourage you to reinforce improvement efforts being made in schools across the country and recommend: $7.214 billion (a $1 billion increase) in the Chapter 1 compensatory education program to expand the number of students served; $4.85 billion (a $2.4 billion increase) for the Individuals with Disabilities Education Act with special attention to the early intervention programs now up for reauthorization; and $267.7 million (a $100 million increase) for Title VII bilingual education programs to help respond to the influx of immigrant children.

As Congress weighs the shape and direction of the federal government's commitment to higher education, we also urge you to reverse the trend toward ever more debt burden on low- and middle-income students and instead provide them with more generous grants and scholarships.

POVERTY RATE

Senator BUMPERS. It goes without saying, because it is said so often in this city, Ms. Haycock, that as we have indeed reduced the poverty rate among the elderly, we have at the same time, obviously, increased the poverty rate dramatically among children, the most vulnerable, defenseless of all. It is a strange thing, isn't it, in our society that we have allowed that to happen? And I do not know of any really major thrust to reverse it.

You heard me mention earlier my concerns about the Delta. There are all kinds of poverty, but you just don't find it any more pervasive and agonizing than you do in the Delta area. And one of the things I did last year, a small thing, was to get $1 million to be administered by the Arkansas Children's Hospital to pick out three rather poor communities in that area and pay for their medical insurance over a period of 3 or 4 years to prove what I already know, and that is that good health care for children improves their

learning skills dramatically. That is the kind of thing—that is just such a drop in the bucket.

Well, I guess I could sit here and you and I would be preaching to the saved. We both agree on all of these things.

Mrs. Bumpers is not going to give up her peace efforts, but she is going to get back deeply involved in the immunization program. She has been so disturbed about how the national effort which she led back in the late 1970's was so successful, and she warned at the time that this has to have steady, constant attention every year, and it didn't get it. So, now you see what is happening; 60 children died last year of measles. By the scheme of things, 1,000 Kurds are dying a day, that does not sound like very much, but for a great, powerful, rich nation like this, it is unforgivable. Ms. HAYCOCK. We will be glad to have her back.

Senator BUMPERS. I want to thank you very much for your testimony and your concern and for the Children's Defense Fund.

On Medicare contractors, I was curious as to why the number of claims filed will go up 11.6 percent. Do you have a reason for that? Mr. COHODES. I wish I understood as well, but for the last 3 years we have been in double digits, this year about 13 percent. Part of that growth is explainable to actions taken by Congress last year which required physicians to file claims on behalf of beneficiaries who previously had had claims that were unassigned. As a result of that, a number of claims that were perhaps lost in shoe boxes are now finding their way into the system.

But by and large, the elderly use health care services far more intensely than any other segment of the population, and they file a significant number of claims. In the aggregate, we expect to handle nearly 670 million claims next year.

Senator BUMPERS. Well, considering the kind of increased workload you are going to be having and what the budget proposes for you, we are going to have a breakdown.

Mr. COHODES. We are going to have a serious problem, sir.

Senator BUMPERS. Dr. Satcher, let me ask you a couple of questions. During the mid-1980's we had a decline in minority students in undergraduate schools in the country. I think that that has begun to turn around in the last 24 months. I hope those statistics that I have seen are correct. Is that true of minorities in medical schools?

Dr. SATCHER. Well, I think so. Our applicant pool increased last year from 2,160 the year before to 2,540. This year our medical school applicant pool is 3,220. Now, we have applicants other than minority students, but we get a larger percentage of minority students I think probably than any other medical school.

Senator BUMPERS. What is the breakdown at Meharry?

Dr. SATCHER. Seventy-five percent of our students are black, 15 percent are white, 5 percent are Asian, and about 5 percent Hispanic approximately. But we graduated 75 to 80 percent black students a year.

Senator BUMPERS. How much overall Federal funding does Meharry get?

Dr. SATCHER. Overall?

Senator BUMPERS. Yes; what percentage of your budget would you say is Federal funding?

Dr. SATCHER. I think probably about 18 percent overall.
Senator BUMPERS. Eighteen?

Dr. SATCHER. Right. Now, if you say the whole budget, that includes research and special programs. The average medical school in this country I believe has 20 to 25 percent Federal research as its budget, but when we say 18 to 20 percent, that includes research, and the Centers of Excellence Program. We have a small AHEC program, as you know, and some other categorical programs.

Senator BUMPERS. Maybe you ought to move Meharry to Washington. I think we do much better by Howard than that.

Dr. SATCHER. No question about it. [Laughter.]

But you need us in the South. You finished talking about the Delta. We are very close to the Delta.

Senator BUMPERS. You are indeed.
Dr. SATCHER. And you need us there.

Senator BUMPERS. We have a number of Meharry graduates in my State.

Dr. SATCHER. That is right.

You remember the story of Ms. Wilson who died and left $100,000 to Meharry. A very poor lady because she had no air-conditioning, and yet every physician she had ever met in Arkansas was a Meharry graduate. So, she left $100,000 to Meharry.

Senator BUMPERS. I remember that story. It is a very poignant story.

The schools of public health. I must confess of all the people who have testified this morning, that is probably the program I know least about.

Mr. GEMMELL. That is our problem, Mr. Chairman.
Senator BUMPERS. How many are there in the country?

Mr. GEMMELL. There are 24. Mr. Chairman, unfortunately, there is not one in Arkansas. The closest one to you I imagine would be the University of Texas at Houston. There is one at Tulane, and there is the University of Alabama at Birmingham, schools of public health. They are in 18 States in this country. That is why they are essentially national schools, Mr. Chairman.

And for your information, the first Federal support to higher education after the Morrell Act, the Land Grant College Act in 1865, was the 1958 Hill-Rhodes Act that was passed for the schools of public health in the recognition that the schools of public health were training physicians to enter Federal service. And since there were only 11 at the time, the Congress thought it appropriate for the U.S. Government to help share in the cost of training these folks that would eventually turn out to administer and run federally mandated programs. So, that tradition has continued since 1958, and that is why we are before you today.

Mr. Chairman, unfortunately, your comment about Senator Pryor reminds me of the problem we have in public health and prevention. When we testify before you, if we are doing our job well, nothing very exciting happens. We cannot prove nonevents. We cannot prove to you that if you provide us with support to train people in preventive medicine and public health and nutrition-we really cannot show results down the line that our efforts paid off successfully because all our successes are not documentable.

Sir, you are not the only person that has a problem with understanding what schools of public health are, but I appreciate your concern and your support.

Senator BUMPERS. Well, let me say to you, Mr. Gemmell, that again I am a very strong advocate of preventive medicine. That is one of the reasons I have been so deeply involved in immunizations during all my public life.

Mr. GEMMELL. Yes, sir; we appreciate that.

Senator BUMPERS. It probably has the best cost-benefit ratio of any health program we fund. Like the preacher preaching against sin, we say it, but we do not really do much about it. Preventive medicine can save this country billions every year. Hubert Humphrey used to say there is no such thing as health insurance. You have to be sick before you can use it. We have sick insurance. Mr. GEMMELL. That is correct.

Senator BUMPERS. And the Ford Motor Co. did a pilot study one time requiring all their employees to take annual physicals and so on, and that was back before we had very sophisticated diagnostic equipment. You can do a cholesterol level every year and find out what kind of dietary habits you need to develop to correct it if it is too high. There is just any number of things we could do in preventive health care that we just simply do not do.

Of course, it is just like all these 20 percent of the children in this country who are in poverty. What a disaster we are setting up for ourselves in the future that could be prevented with leadership. Well, I thank all of you very much for being here this morning. You all made very powerful points.

STATEMENT OF PAUL GREEN, EMERGENCY NURSES ASSOCIATION

Senator BUMPERS. Our next four witnesses are Paul Green, Parvez Shah, Robert Mather, and Dr. Frank B. Ashley. Mr. Green is with Emergency Nurses Association; Mr. Shah, International Association of American Physicians; Mr. Mather, president of the National Association of Rehab Facilities; and Dr. Ashley from Texas A&M of the National Collegiate Athletic Association.

The first witness is Mr. Green.

Mr. GREEN. Mr. Chairman, I am glad to see you here today. I received my undergraduate degree from the University of Central Arkansas in Conway, and lived there in the years when you were Governor and first elected Senator. So, I am glad to see you here. Senator BUMPERS. Thank you.

Mr. GREEN. I am a registered nurse, and I currently serve as the chairperson of the National Government Affairs Committee for the Emergency Nurses Association which represents approximately 21,000 emergency nurses and trauma nurses.

Í am here today to testify in support of the funding for the implementation of the Trauma Care Systems Planning and Development Act of 1990. It is our understanding that the Department of Health and Human Services has taken the position that nothing would be done to implement the act until funding has been received for this program. The new law authorizes $60 million for fiscal year 1991. However, it is our feeling that to begin the program, we need $30 million.