for more biomedical research, or the need to expand our National Health Service Corps because in virtually every State there are many underserved areas where people do not have health professionals, we must make judgments as to where the greatest need is and where the greatest return is. We are forced to make those kinds of judgments since we must live within the budget agreement.

I am strongly committed to the National Institutes of Health. Our NIH budget for research project grants increases by 8.8 percent, and our goal is to award at least 5,000 new and competing grants every year. Our budget will allow about 5,700 new and competing grants. The overall NIH budget during the three budget cycles with which I have been involved has increased by approximately $2 billion.

We look at the NIH not simply 1 year at a time but over a period of several years, and we have had significant increases overall. There are always additional opportunities, but we must weigh these in relation to the discretionary dollars that are available to

us.

BUDGET CHOICES

Senator GORTON. Thank you, Mr. Secretary. I have been a member of this subcommittee for about 4 weeks. This is the first day on which it has had any hearings, but I have heard exactly what you reported. There are many constituencies from home with sincere and hardworking people competing over this money. The lesson to them is that as they ask for more, they are taking it away from someone else, probably in a very closely allied field. This is not a welcome lesson or one easy to learn.

But it seems you are saying at a more cosmic level exactly the same thing. If we do not like your priorities-if we wish to add, for all practical purposes, we are going to have to subtract from somewhere within your own budget. We must find one of the areas of increase that we can reduce in order to make up for any increase. Even as a beginning member of this subcommittee, Mr. Chairman, that does not look like a particularly easy task.

INFANT MORTALITY

Secretary SULLIVAN. Senator Gorton, I would respond with the example of infant mortality funding. This is a very controversial topic which has been widely discussed as it relates to the community and migrant health center programs to which I am strongly committed.

I spoke at the 25th anniversary banquet 1 year ago and know many of the people. I have high regard for those programs. Last week I spoke at the 20th anniversary of one of our centers out in Arizona. What we propose to do is to fund 10 demonstration grants to get data as to how we can more effectively decrease infant mortality.

We spend more dollars per capita for health care than any other Nation in the world, but in spite of that, when it comes to infant mortality we rank 24th. What that says to me is that we are not

investing our money correctly. There are 23 nations that are doing better while spending less.

We are proposing to target the infant mortality dollars. We have $105 million of new money, but we also propose to use money from the Community Health Centers Program and from the Maternal and Child Health Program. These dollars are currently being spent on infant mortality within those programs. We are trying to concentrate enough dollars in 10 locations to look at the problem very carefully and gain some knowledge that we can use 5 years from now to find better ways to lower infant mortality nationwide.

There will be 10 projects, and every one of those other community health centers is objecting to the prospect of level funding. We are not decreasing their dollars, but what we propose to do is to take the planned increases in funds and concentrate them. Some of these centers will be winners this year-those who compete successfully for this-but, to look at the larger picture, we all will be winners in the long term if we can get this information.

It will take around 5 years, hopefully less. All of the 550-odd centers and other programs will then have the benefit of this information on how to better address infant mortality. Japan is No. 1 in this area with a per capita expenditure of $1,000 on health care, while we spend $2,500 per capita. We hear about automobile workers, and other companies complaining about the high cost of labor, listing health care as a major cause. We need to find ways to lower that cost. Every time we try to focus the problem, to get information that is helpful to the whole country, people say that it is a great idea, that we need to do it, but please do not do it here.

We are forced to make hard decisions. We are trying to carry on the program and get information as well as to deliver services, but do it within the budget agreement. This forces us to make decisions which should not be interpreted to mean that we are not committed to maternal and child health or the community health centers.

I look at the larger picture, at what is good for the Nation. It may mean that a center in a particular State or particular city may not get the $40,000 increase that they want out of a budget of $3.5 or $4 million, which is the order of the magnitude that we are talking about. We have to make some tough choices. I look at it from the standpoint of what is going to be the best approach for the Nation as a whole.

Senator GORTON. Thank you, Mr. Secretary. Thank you, Mr. Chairman.

Senator HARKIN. Senator Burdick.

COMMUNITY SERVICE PROGRAMS

Senator BURDICK. Mr. Secretary, I was disappointed to see the administration proposes to delete most of the funding for the community service programs. According to your budget justification book, only $10.8 million would be allocated, and all of that would go to one of the discretionary programs.

Your stated rationale for deleting virtually all of the community service programs is that the community action agencies have been successful in obtaining funds from other sources. What other funding sources would you recommend for a State such as mine, where the economy is still very poor, the main industry of agriculture has

undergone a terrible decline, and a number of poor people that need community action agency services has grown not decreased. Where should we look for money?

Secretary SULLIVAN. Senator Burdick, we would be happy to have our staff review this with yours. We have a number of categorical programs in my Department for which organizations in North Dakota would be eligible to apply.

For example, the National Health Service Corps program has a number of corps physicians and other health professionals who work in your State. We are emphasizing greater health promotion and disease prevention to address a number of these issues.

The profile of each State will be very different. I can provide a complete answer to that question and will be pleased to have my people work with yours.

Senator BURDICK. Can you provide a list of specific funding sources available to North Dakota community action agencies? We do not have the programs.

Secretary SULLIVAN. I would be happy to see that you get a list of all of the categorical programs in my Department. There are people in the various organizations in North Dakota who are familiar with private sources of support that can help.

[The information follows:]

COMMUNITY ACTION AGENCIES

Community Action Agencies [CAA's] will be able to access funding from other Federal, State, and local sources, e.g., the Job Opportunities and Basic Skills [JOBS] program, Head Start, Child Care and Development Block Grants, the Social Services Block Grant, nutrition programs operated by the Administration on Aging, certain programs administered by HUD, the Emergency Food and Shelter Program in FEMA, food programs administered by the Department of Agriculture such as Food Stamps and Women, Infants, and Children [WIC], as well as from private sources.

INFANT MORTALITY

Senator BURDICK. I just want to say that my State and areas around it have undergone a terrible drought in the last 3 years, and are going on the fourth one. These services that have been provided in the past have been invaluable to those people, and to cut them back as suggested here is going to create a great deal of hardship, and I hope we can find some other sources to replace them. You provide some information for me, tell me where to go. Will you do that?

Secretary SULLIVAN. We will be happy to have our staff get with yours, Senator.

Senator BURDICK. All right. Thank you.

Senator HARKIN. Thank you, Senator Burdick.

Mr. Secretary, let us get back to reducing infant mortality again. You said in your statement you wanted to increase women's access to prenatal and perinatal care, looking at the budget document here, and yet your request totally eliminates all of the health professions programs that train family doctors, pediatricians, nurse midwives, nurse practitioners, and physician's assistants-totally eliminates them. So my question to you is, who is going to provide the care?

Secretary SULLIVAN. Well, Senator, we do not totally eliminate them. The National Health Service Corps program is one that we

have increased. It was at the level of $8 million when I came in 2 years ago, it is now up to $49 million, and we have included a $5 million increase over that in the budget.

These dollars are primarily for training more disadvantaged students for the health professions to address the disparate health status of our minority and disadvantaged populations.

Another thing is our support for graduate medical education through the Medicare program. We are giving greater support for residency programs in primary care, family medicine, general internal medicine, and pediatrics.

Senator HARKIN. Under what program?

Secretary SULLIVAN. Support for graduate medical education is through the Health Care Financing Administration. What we are doing is restraining the support for residency programs in specialties such as ophthalmology, anesthesiology, or radiology, and providing support for residents in family medicine, pediatrics, or general internal medicine, because of the need for more primary care physicians in urban inner cities and rural areas.

PUBLIC HEALTH AND HEALTH ADMINISTRATION

Senator HARKIN. Mr. Secretary, would you on your budget proposal-would you look under the heading of "Public Health and Health Administration" and the following items: public health training internships, family medicine, general internal medicine and pediatrics, physician's assistants, family medicine—did I mention that?—all of these are zeroed out.

I will have my staff give you a list of the ones that are zeroed out here. What I would like your staff to do is to tell me where these are being picked up. If we are duplicating these things, I would like to know about it, and I think what you were saying to me is that this is being picked up some place else. I would like to know about that, because you asked to zero them out. If they are being done some place else, I would like to know about it. So I will submit to you a list of the ones I am talking about here, where the budget request is for zero-for example, family medicine was $36 million last year and it is a zero request this year. I would like to know where that is being picked up.

Secretary SULLIVAN. We will be happy to get a response back to you, Senator.

Senator HARKIN. I would appreciate that. [The information follows:]

BUDGET PROPOSAL

In fiscal year 1991, public health traineeships, family medicine, general internal medicine and pediatrics, family medicine departments, and physicians assistants were supported at $68 million. While we are not proposing support for these specific programs in fiscal year 1992, we are supporting training in these disciplines through a number of other mechanisms. Our request for the National Health Service Corps recruitment programs will grow to $54 million, compared to $11 million in fiscal year 1990. Through our minority and disadvantaged efforts, we are seeking $73 million to support a number of programs including Exceptional Financial Need Scholarships and the Health Careers Opportunity Program. Additionally, we are requesting $15 million to recapitalize the Health Professions Student Loan Program which already has approximately $65 million available in the revolving loan fund for fiscal year 1992. These minority and disadvantaged training programs support a variety of health professions disciplines including: medicine, nursing, osteopathic

medicine, dentistry, pharmacy, podiatric medicine, optometry, veterinary medicine, allied health, public health and clinical psychology.

Through the Medicare program, we will spend more than $5 billion in fiscal year 1992, on the direct and indirect Medicare costs associated with training interns and residents. In fiscal year 1991, we spent approximately $4.7 billion on these training costs. Our fiscal year 1992 legislative package contains a proposal which adjusts our graduate medical education payment to encourage the training of primary care residents.

INFANT MORTALITY INITIATIVE

Senator HARKIN. One more thing on the infant mortality initiative. Are you going to declare what cities they are? Is there going to be some kind of a long process of cities applying for this? How is this going to run?

Secretary SULLIVAN. It will be competitive, Senator. We will invite applications from areas that have high infant mortality. Consideration will be given to the quality of the proposed approaches for reducing infant mortality over a 5-year period by at least 50 percent, and the evaluation process proposed for measuring the impact of their efforts.

It will not be the top 10 areas-cities and rural-that will be competing. It will be a discrete geographic or governmental unit, and will include the level of infant mortality, and the quality of the program. We want to know at the end of this what works and why. We can then take the best data and use that to develop a national approach.

Senator HARKIN. So, it sounds like you are going to have a competition out there and you are going to, first of all, publish the criteria they have to meet and how they would compete for the funds. So, you are talking about a period of time here.

When would you expect that the final date would be for the cities you mention rural areas, but I understand it is just cities, 10 cities. That is the way it has been told to us. When would be the final date that you anticipate that you would have for their application?

Secretary SULLIVAN. I can get that information back to you, Senator. It would be during fiscal year 1992. I will get you the schedule for the application cycle.

[The information follows:]

HEALTHY START INITIATIVE

The Healthy Start Initiative will provide communities with funding to create_a comprehensive prenatal care program for low-income women and their infants. To accomplish this goal, medical and social services providers within the targeted communities will work collaboratively to develop new and innovative means of delivering services to meet the needs of pregnant women and infants. We believe it is imperative to begin this initiative immediately. Therefore, Federal Register notices will be published in April announcing the availability of fiscal year 1991 funds. The Health Resources and Services Administration will provide pre-application technical assistance, including several bidders conferences beginning in late April. The deadline for Healthy Start applications will be July 1, 1991. We hope to award grants to approximately 10 communities in August. As you are aware, I had initially planned on $57 million to launch Healthy Start in fiscal year 1991, however, based on Congressional action only $25 million will be available.