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Question. To date, AIDS has claimed more American lives than the Vietnam War. The National Commission on AIDS projects an additional 200,000 deaths over the next four years, increasingly among women and children, IV drug users, and minority populations.

Your FY 1992 budget proposes a modest increase in AIDS funding, all of it directed to research. The budget proposes level funding of Ryan White AIDS care programs in FY 1992 without an increase even for inflation.

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Do you believe the budget reflects the right balance in funding between research and health care services?

Answer. Yes, I believe my budget reflects the right balance in funding between AIDS research and services. However, while we have continued funding of "Ryan White" activities at the same level provided by Congress in FY 1991, we remain concerned about piecemeal, disease-specific approaches to financing health care services. It should also be noted that our projected costs for caring for AIDS patients through the Medicaid and Medicare programs will approach $1.36 billion in FY 1992, an increase of over $300 million from FY 1991.

Question. What was the funding level proposed in the original HRSA budget submission, and what level of funds for Ryan White did your budget submission to OMB propose?

Answer. The HRSA and HHS budgets were originally developed prior to the passage of the Ryan White Comprehensive Care Act. Therefore, neither the HRSA nor the Department budgets included funding specifically for the "Ryan White" activities.

Question. The recent case of the Florida dentist who appears to have infected some of his patients with HIV has renewed concerns about HIV testing of health care workers. What is the Department's position on HIV-=virus testing for doctors, dentists, nurses, and other health workers?

Answer. CDC continues to emphasize adherence to its guidelines for preventing the transmission of HIV and other blood borne pathogens in the health care setting. These guidelines promote following universal precautions, including proper cleaning of instruments and preventing blood contact between patient and health care worker. On February 21 -22, CDC held an open meeting to review current information on the risks of transmission of HIV and other blood borne pathogens during invasive procedures and to assess the implications of these risks. Participants of the

meeting have been provided time to submit written comments about the meeting. Once these comments have been received, CDC will begin a deliberative process of reexamining and updating the prevention guidelines for health care workers performing invasive procedures. Once the Department has approved the draft, guidelines, the Department will provide a 60 day period for submitting public comment before issuing any final guidelines.

Finally, in FY 1992, the Department is requesting $29.2 million to continue information and education projects related to preventing HIV transmission in health care workers.


Question. How much time will Title X providers have to decide whether they will comply with the 1988 regulations?

Answer. If the Supreme Court upholds the regulations, the Department will allow 30 days for each grantee to provide assurance of compliance, and another 30 days to implement compliance. A longer period for compliance may be authorized in the small number of cases where compliance requires a grantee to obtain new facilities or to redesign their accounting systems. While this may seem a short time period, grantees have had three years to consider and plan for the implementation of these regulations.

Question. If any Title X providers refuse to comply, does the Department plan to discontinue funding them and if so, how will you ensure that Title X services will be continued without interruption?

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Answer. We believe that few if any Title X grantees will refuse to participate in the program if the Supreme Court upholds the regulations. Should a grantee decide to drop out of the program, however, there will be little difficulty in transferring the funding to a new grantee in an orderly manner.


Question. Perhaps one of the most important components of our health care system for meeting the Health Objectives for the Year 2000 is a strong public health system. As you know, a number of reports, including a report by the Institute of Medicine, have found that our public health system is in disarray and that there is a lack of federal leadership. What additional steps are needed to build a state and federal public health infrastructure so the Health Objectives for the Year 2000 can be met?

Answer. Our budget request for fiscal year 1992 for the Centers for Disease Control emphasizes the need to strengthen the public health infrastructure. CDC proposes to expand the Preventive Health Services Block Grant by 12 percent, or to a level of $101.5 million. This should begin to enable State health departments to fulfill the Institute of Medicine charges to develop policies to assure the delivery of preventive health services.

A second aspect of building this infrastructure is to strengthen CDC's ability to provide leadership. Progress toward achieving the Year 2000 objectives must be measured, more than one-fourth of 1990 objectives could not be measured. This is the reason CDC is seeking a $15 million increase, or 21 percent, for the National Center for Health Statistics. Added data collection capacity and enhanced automation and analytical approaches will strengthen CDC's excellence in infectious and chronic diseases, and occupational and environmental health, to meet the challenges of the future.


Question. Has the Department developed a

comprehensive plan laying out for each objective which changes in Federal programs or increases in Federal funding should be made so that we can achieve in the Year 2000 what we did not achieve in 1990?

Answer. The Public Health Service is engaged now in developing such an "implementation plan" that will show for each priority area of Healthy People 2000_what allocations of resources are being focused to achieve the Year 2000 objectives and what issues need special attention. This plan is slated to be completed in late 1991 and will be updated periodically throughout the decade.

Question. Goal 21.4 of the Year 2000 Objective states: financing and delivery of clinical preventive services so that virtually no American has a financial barrier to receiving, at a minimum, the screening, counseling, and immunization services recommended by the U.S Preventive Services Task Force. What steps is the Department taking or will it recommend be taken to meet that objective?

Answer. Recent statutory changes have expanded Medicare and Medicaid preventive services for specific screening and immunization services, such as Pap smears and mammography. States, however, have broad discretion to limit the amount, duration, and scope of services.

The Department is looking for opportunities within its own service delivery programs as well as working with State and community agencies and professional

organizations to promote and strengthen the provision of clinical preventive, services by primary health care providers. The development and implementation of a national education initiative entitled "Put Prevention into Practice" is one way in which such services will be promoted. In addition, the Department is currently examining the cost-effectiveness of Medicaid and Medicare reimbursement for preventive services through the conduct of a set of prevention demonstration projects under Medicare, while we continue to consider inclusion of specific preventive interventions through Federally-financed medical services and work to

identify those for whom financial barriers preclude access to services.


Question. What can be done through Federal

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programs, such as Medicare which pays large sums for graduate medical education--to achieve this objective?

Answer. The Medicare program will implement a reform in its physician payment system beginning in January, 1992. The new system is expected to redistribute physician payments from surgeons and specialists to physicians in primary care disciplines such as general and family practice and general internal medicine. Since it is these physicians that are most directly involved in preventive clinical services, the reform should encourage greater access to preventive services for the Medicare population.

While graduate medical education programs do receive some reimbursement through the Medicare program, HCFA does not regulate the curricular content of these programs. However, we are proposing a special incentive for primary care interns in the GME reimbursement formula.

Within the Public Health Service, the sums devoted to health professions programs are comparatively small. However, as noted in our response to the previous question, we are trying to tilt these programs toward health promotion and disease prevention by urging all applicants for funding to submit work plans that address specific objectives of Healthy People 2000.

Question. I've been told that less than 2 percent of the training our doctors receive focuses on disease prevention and health promotion. Do you believe that the training received by doctors should include a special emphasis on disease prevention and health promotion?

Answer. I believe that all health professionals should receive training which emphasizes disease prevention and health promotion. We are urging all applicants for current Public Health Service programs of support for health professions education to submit

work plans that address specific objectives of Healthy People 2000.


Question. The report accompanying the FY 1991 appropriation requested that the Department undertake a review of Medicare rules and regulations imposed on beneficiaries and providers in rural and other medically underserved areas to determine which may be unnecessary or could be less administratively burdensome while maintaining or improving the quality of care. What have you done to act on this?

Answer. We share your concerns that providers and beneficiaries are not unduly burdened by Medicare rules and regulations. As part of OBRA 1990 we are required to conduct a review of Medicare hospital regulations to determine which requirements could be made less administratively burdensome for rural hospitals without diminishing the quality of care. We are required to report to Congress by April 1, 1992. Although we will be working on this review, we do not yet have any meaningful data.

Question. Mr. Secretary, as you know, in the tables in our Senate report for each institute we only detail the amount for general program research and research training. Funding spent for prevention activities is buried most often within the research management and support line.

In view of the importance that we both place on prevention activities, should we include a new line item to indicate for each NIH institute how much is being spent on prevention and control activities?

Answer. Creating a specific line item for prevention activities would highlight the NIH prevention activities, but might do so at the expense of NIH's ability to manage its programs to respond quickly to emerging scientific opportunities. In terms of structuring and managing a budget account, prevention activities are not analogous to research training. Research training is a separate mechanism and also has a distinct authority. Prevention activities are funded from several different

mechanisms, including research training, and would be difficult to define consistently across each of the Institutes.


Question. Much has been said about the fact that U.S. health care costs are skyrocketing, despite the fact that millions of Americans have no health insurance. By contrast, the Canadian health care system covers all of its citizens, at a per capita cost one-third less than the United States.

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