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Question. Dr. Sullivan, I know that you are an advocate of pristine living, good nutrition and no smoking. What are some the current Departmental activities related to smoking prevention, educations and treatment? How about nutrition?



In my tenure as Secretary, I have repeatedly stressed the role of personal responsibility in improving health and preventing disease. This is especially true as it relates to both the use of tobacco and in what we eat. We are vigorously pursuing our fight against cigarette smoking and tobacco use, the single most preventable cause of premature death and disability in our country. In FY 1992 we seeking a 9% increase throughout the OHS agencies for anti-smoking activities including: a request to double the budget for the Office of Smoking and Health; increased resources for NCI'S ASSIST (Americans Stop Smoking Intervention Study) program a large scale demonstration effort to disseminate information on past success in 20 States and large cities; and through CDC, increasing support for smoking cessation program aimed at pregnant women.

Because of the crosscutting nature of nutrition, nutrition is an element in the programs of all PHS agencies, as well as the office of Human Development Services (Head Start), the Family Support Administration (Office of Community Services) and the Administration on Aging.

Nutrition is an important part of our overall strategy to improve health. In fact, a number of nutrition objectives are included in "Health People 2000: National Health Promotion and Disease Prevention Objectives". In addition, NIH is involved in a wide range of research efforts related to nutrition. NIH spent over $287 million on nutritional research in FY 1989 (the last year for which we have data) and will continue these efforts in FY 1992. One prominent nutrition issue is obesity. In the US, it is estimated that 34 million are affected, with the rates highest among the poor and minorities, particularly women.


Question. Mr. Secretary, I am surprised to see the $5 billion figure you quote in your opening statement as funds focused on infant mortality.

Mr. Secretary, this of course is the broadest possible definition of funds being spent towards the goal of reducing infant mortality. Are you suggesting that the $5 billion is somehow a coordinated program to reduce the infant mortality rate?

Answer. As you know, the problem of infant mortality is the result of many contributing factors inadequate access to health care services, poor nutrition/diet, the use of tobacco, alcohol, or drugs by the pregnant mother, genetic disorders and a variety of diseases. To fully address the problem requires efforts to be made on a number of fronts. With its exceptionally broad mandate, the Department of Health and Human Services has at its disposal a diversity of tools which can be brought to bear on this problem.

The FY 1992 request of $5 billion for Department efforts to combat infant mortality includes funding for a variety of activities representative of this Department's diverse resources (e.g., targeted health care services, disease prevention, biomedical research, and health care financing). All of these programs have an impact on our ability to provide health care to mothers and their infants, and, ultimately, to reducing infant mortality. The Department's efforts are coordinated by ensuring that each objective (e.g., conducting research on SIDS, immunizing infants against hepatitis B, providing prenatal care to poor or disadvantaged women) is assigned to the agency or program best suited to complete the task.

To exclude any of these programs from our efforts would fail to recognize the extent of the problem of infant mortality, which could hinder our progress on infant mortality.


Question. National health care expenses totalled $604.1 billion in 1989. The health care inflation rate is now over 10% a year. If it continues at the same rate as it has since 1980, costs will double every seven years. Today, we spend 35% more per capita on health care than Canada, 91% more than West Germany, 124% more than Japan, and 173% more than Britain.

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Yet the U.S. ranks behind 16 other developed
countries in infant mortality;

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Maternal mortality rates soared 27% between 1987 and 1988;

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Between 5 and 10 million Americans need treatment for drug abuse;

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Mr. Secretary, I want to ask you the question the Ronald Reagan asked the American people: Are we better off today than we were 10 years ago? Is it time to abandon the piecemeal approach of the last decade and pursue true health policy reform, such as national health insurance?

Answer. I have said before, and continue to believe, that this Nation still possesses the best health care available in the world today. I agree that gaps in access persist, and we are working on a number of fronts through programs such Community and Migrant Health Centers, the National Health Service Corps, and Medicaid to address these problems.

As to whether the people of this nation are better off today than a decade ago, I believe the answer is yes. Mortality rates from most diseases and disorders continue to fall while we continue to lower current rates of infant mortality and cancer deaths, our success in these areas is far better now than in 1980. Over the past decade medical technology has leapt forward at an astonishing rate, making some procedures thought experimental in 1980 now seem almost routine. Within the past year advances such as the discovery of the cystic fibrosis gene and the initiation of gene therapy for immune deficiency disorders hold great promise for the future. This progress is a tribute to, and product of, our health care and biomedical research system. We should work to improve what we now possess.


Question. Some 37 million Americans don't have health insurance-- and the number of uninsured children jumped 40% between 1977 and 1987. And, unfortunately, we know that lack of insurance translates directly into limited access to health care services.

Last year when you came before this Committee, you said you were awaiting the report of the Pepper Commission and other councils studying the pressing issue of national health insurance and the 37 million Americans who don't have health insurance.

In a recent speech you said that calls for national health insurance are "false prophecy from those preaching easy solutions."

What solutions do you propose for the uninsured?

Answer. Solutions for resolving the problems of uninsurance must emerge from national consensus. The Administration is continuing to participate in the broad national dialogue that marks movement toward health financing reform. Additional important contributions to this debate are expected from the National Governors' Association and the Steelman Commission later this year. It would be premature for me to point to any particular approach as being the most appropriate solution.

What is clear is that while our current system has problems that require resolution, it also has many strengths. Solutions must build on those strengths rather than cast them aside for a speculative embrace

of radical change. Furthermore, solutions must promote restraint of the increase in health care costs, personal and family responsibility in financing health care and maintaining a healthy lifestyle, an orderly private health insurance marketplace, and the targeting of public subsidies on those most in need.


Question. Mr. Secretary, the infant mortality initiative in the budget has opened up a can of worms with its proposal to reprogram funds from the Maternal and Child Health Block Grant and "target" funds from the community health center program.

Yet we haven't heard any specifics from your Department about this initiative which cities are targeted, how funds would be used, how the program would be administered.

What are your intentions: Do you plan to start this initiative in FY 1991, and if so, will we be receiving a reprogramming request form the Department?

Answer. We cannot continue with business as usual. I believe it is imperative that we begin at once to combat the unacceptably high infant mortality rates many areas in our country face. Therefore, we plan to begin our Healthy Start Initiative in FY 1991 with $57.3 million. On March 12, I sent a letter to the Senate outlining my plans to reprogram $33.7 million from the Maternal and Child Health Block Grant to the initiative and to target $23.7 million within existing programs such as the Community Health Centers, the Perinatal Case Management Initiative, Health Care in Underserved Neighborhoods, and the National Health Service Corps. Let me be clear, I am not proposing to reduce funding for Community Health Centers. I am proposing limiting most of the FY 1991 increase to Community Health Centers within targeted areas.


Is it the Administration's position that FY 1991 funding from the MCH Special Projects of Regional and National Significance will be used for this initiative OR as the Committee directed in the FY 1991 Appropriations bill?

Answer. The Administration intends to use the Maternal and Child Health Block Grant set-aside for Special Projects of Regional and National significance as directed by Congress.


Question. In a recent survey of State executives conducted by your Department, 41 Governors said that rural health care is a "chief concern. Yet a review of your FY 1992 budget shows that

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No funds are requested for the Essential Access Community Hospital or Rural Primary Care Hospital programs;

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No funds are proposed for rural health transition grants;

After almost two years, no one has been appointed director of ADAMHA's Office of Rural Mental Health Research;

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No funds are requested for the health professions programs targeted to rural areas, such a AHECS; border health education centers; or interdisciplinary training grants;


There is a proposal to outreach health services and link service providers it looks a lot like my rural health outreach grants

but your proposal is only for 10 cities, no funds are requested for rural health outreach grants;

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There is even a cut proposed for the Office of Rural Health Policy, with just $800,000 proposed to support State Offices of rural health in 1992.

Yet here you are, for the third year in a row, claiming to be interested in rural health care.

If you don't support funding for these programs, which rural health programs do you support?

Answer. I support programs that work. The General Accounting Office, in a report issued on February 15, indicates that although several of our efforts, including the Essential Access to Community Hospitals and Rural Primary Care Hospitals programs, provide some financial relief to certain subgroups of rural hospitals, they are not well-targeted mechanisms for maintaining access to hospital care. The study indicated that providing financial assistance to broadly defined groups of rural hospitals is neither an effective nor an efficient method for preserving such


The report also reveals that there is no evidence that Medicare-dependent hospitals are at higher risk of closure, and that paying full Medicare costs would not solve the financial problems of these hospitals.

While the Transition Grant program was found to have potential for helping communities address their specific access problems, it was determined that a more targeted effort which would also assist providers other than hospitals may be preferable to the current program. The GAO has determined that where access to essential hospital services may be threatened, Federal support through the Transition Grant program might best

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