DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED AGENCIES APPROPRIATIONS FOR 2004 HEARINGS BEFORE A SUBCOMMITTEE OF THE COMMITTEE ON APPROPRIATIONS HOUSE OF REPRESENTATIVES ONE HUNDRED EIGHTH CONGRESS FIRST SESSION SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED AGENCIES RALPH REGULA, Ohio, Chairman C. W. BILL YOUNG, Florida DAVID R. OBEY, Wisconsin ERNEST J. ISTOOK, Jr., Oklahoma STENY H. HOYER, Maryland ROGER F. WICKER, Mississippi NITA M. LOWEY, New York ANNE M. NORTHUP, Kentucky ROSA L. DeLAURO, Connecticut RANDY "DUKE" CUNNINGHAM, California JESSE L. JACKSON, Jr., Illinois KAY GRANGER, Texas PATRICK J. KENNEDY, Rhode Island JOHN E. PETERSON, Pennsylvania LUCILLE ROYBAL-ALLARD, California DON SHERWOOD, Pennsylvania DAVE WELDON, Florida MICHAEL K SIMPSON, Idaho NOTE: Under Committee Rules, Mr. Young, as Chairman of the Full Committee, and Mr. Obey, as Ranking Minority Member of the Full Committee, are authorized to sit as Members of all Subcommittees. Craig Higgins, Susan Ross Firth, Meg Thompson, Sue Quantius, Francine Mack-Salvador, and Nicole Kunko, Subcommittee Staff PART 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES Page Secretary of Health and Human Services 1 Bioterrorism and Other Public Health Emergencies 531 Centers for Medicare and Medicaid Services 703 Administration for Children and Families 1203 Administration on Aging 1867 Special Tables 2043 Printed for the use of the Committee on Appropriations DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED AGENCIES APPROPRIATIONS FOR 2004 bAl HEARINGS 2t003 M BEFORE A P*-^ SUBCOMMITTEE OF THE COMMITTEE ON APPROPRIATIONS HOUSE OF REPRESENTATIVES ONE HUNDRED EIGHTH CONGRESS FIRST SESSION SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED AGENCIES RALPH REGULA, Ohio, Chairman C. W. BILL YOUNG, Florida DAVID R. OBEY, Wisconsin ERNEST J. ISTOOK, Jr., Oklahoma STENY H. HOYER, Maryland ROGER F. WICKER, Mississippi NITA M. LOWEY, New York ANNE M. NORTHUP, Kentucky ROSA L. DeLAURO, Connecticut RANDY "DUKE" CUNNINGHAM, California JESSE L. JACKSON, Jr., Illinois KAY GRANGER, Texas PATRICK J. KENNEDY, Rhode Island JOHN E. PETERSON, Pennsylvania LUCILLE ROYBAL-ALLARD, California DON SHERWOOD, Pennsylvania DAVE WELDON, Florida MICHAEL K. SIMPSON, Idaho NOTE: Under Committee Rules, Mr. Young, as Chairman of the Full Committee, and Mr. Obey, as Ranking Minority Member of the Full Committee, are authorized to sit as Members of all Subcommittees. Craig Higgins, Susan Ross Firth, Meg Thompson, Sue Quantius, Francine Mack-Salvador, and Nicole Kunko, Subcommittee Staff PART 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES Page Secretary of Health and Human Services 1 Bioterrorism and Other Public Health Emergencies 531 Centers for Medicare and Medicaid Services 703 Administration for Children and Families 1203 Administration on Aging 1867 Special Tables 2043 Printed for the use of the Committee on Appropriations U.S. GOVERNMENT PRINTING OFFICE 87-818 WASHINGTON : 2003 COMMITTEE ON APPROPRIATIONS C. W. BILL YOUNG, Florida, Chairman RALPH REGULA, Ohio DAVID R. OBEY, Wisconsin JERRY LEWIS, California JOHN P. MURTHA, Pennsylvania HAROLD ROGERS, Kentucky NORMAN D. DICKS, Washington FRANK R. WOLF, Virginia MARTIN OLAV SABO, Minnesota JIM KOLBE, Arizona STENY H. HOYER, Maryland JAMES T. WALSH, New York ALAN B. MOLLOHAN, West Virginia CHARLES H. TAYLOR, North Carolina MARCY KAPTUR, Ohio DAVID L. HOBSON, Ohio PETER J. VISCLOSKY, Indiana ERNEST J. ISTOOK, Jr., Oklahoma NITA M. LOWEY, New York HENRY BONILLA, Texas JOSE E. SERRANO, New York JOE KNOLLENBERG, Michigan ROSA L. DeLAURO, Connecticut JACK KINGSTON, Georgia JAMES P. MORAN, Virginia RODNEY P. FRELINGHUYSEN, New Jersey JOHN W. OLVER, Massachusetts ROGER F. WICKER, Mississippi ED PASTOR, Arizona GEORGE R. NETHERCUTT, Jr., Washington DAVID E. PRICE, North Carolina CHET EDWARDS, Texas RANDY "DUKE" CUNNINGHAM, California TODD TIAHRT, Kansas ROBERT E. "BUD" CRAMER, Jr., Alabama ZACH WAMP, Tennessee PATRICK J. KENNEDY, Rhode Island TOM LATHAM, Iowa JAMES E. CLYBURN, South Carolina ANNE M. NORTHUP, Kentucky MAURICE D. HINCHEY, New York ROBERT B. ADERHOLT, Alabama LUCILLE ROYBAL-ALLARD, California JO ANN EMERSON, Missouri SAM FARR, California KAY GRANGER, Texas JESSE L JACKSON, Jr., Illinois JOHN E. PETERSON, Pennsylvania CAROLYN C. KILPATRICK, Michigan VIRGIL H. GOODE, Jr., Virginia ALLEN BOYD, Florida JOHN T. DOOLITTLE, California CHAKA FATTAH, Pennsylvania RAY LaHOOD, Illinois STEVEN R. ROTHMAN, New Jersey JOHN E. SWEENEY, New York SANFORD D. BISHOP, Jr., Georgia DAVID VITTER, Louisiana MARION BERRY, Arkansas DON SHERWOOD, Pennsylvania DAVE WELDON, Florida MICHAEL K. SIMPSON, Idaho JOHN ABNEY CULBERSON, Texas MARK STEVEN KIRK, Illinois ANDER CRENSHAW, Florida James W. Dyer, Clerk and Staff Director DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RE- LATED AGENCIES APPROPRIATIONS FOR 2004 Thursday, March 20, 2003. DEPARTMENT OF HEALTH AND HUMAN SERVICES WITNESS HON. TOMMY THOMPSON, SECRETARY Mr. Regula. Good morning, Mr. Secretary. We are delighted to have you here. We have about five minutes. Mr. Secretary, why don't you make your opening statement and then we will have to recess for votes. We will be a total of about 25 minutes because we have three votes but we have a little time before we need to leave. How much time do you need? Secretary Thompson. I was going to take ten minutes but if you want me to just summarize some things. Mr. Regula. Why don't you summarize and that way we will come back and start the question period. [The justification follows:] (l) 2 STATEMENT BEFORE THE U.S. HOUSE OF REPRESENTATIVES LABOR/ HHS/ ED APPROPRIATIONS SUBCOMMITTEE TOMMY G. THOMPSON SECRETARY DEPARTMENT OF HEALTH AND HUMAN SERVICES March 20, 2003 3 Good morning Mr. Chairman, Congressman Obey and members of the committee. I a m honored to be here today to present to you the President's FY 2004 budget for the Department of Health and Human Services (HHS). I a m certain you will find that, viewed in its entirety, our budget will help improve the health and safety of our Nation. Before I d iscuss the FY 2004 budget, I would like to thank the committee for its hard work and dedication to the programs at HHS. Our FY 2004 request totals S539 billion in outlays, approximately 7.3 percent over the FY 2003 budget. The discretionary budget authority portion of the HHS budget, before this committee, totals $60.7 billion, which is an increase of approximately $1.5 billion, or 2.6 percent over the FY 2003 President's Budget and an increase of approximately $514 million, or 0.9 percent over the FY 2003 enacted appropriation. Mandatory outlays for HHS total $475.9 billion in this budget proposal, an increase in excess of 7 percent. The budget proposed by the President for HHS will enable the Department to continue its important work with our partners at the State and local levels and the newly created Department of Homeland Security. Working together, we will hold fast to our commitment to protecting our Nation and ensuring the health and well-being of all Americans. Many of our programs at HHS provide necessary services that contribute to fighting the war on terrorism and provide us with a more secure future. And, I a m particularly focused on preparedness at the State and local level, HHS's ability to respond rapidly to a bioterrorist attack, research on and development of vaccines and other therapies to counter potential bioterrorist attacks, and ensuring the safety of our food supply. The President's FY 2004 budget request also continues to support the needs of the American people by strengthening and improving Medicare and Medicaid; enhancing Temporary Assistance for Needy Families (TANF) and Foster Care; strengthening the Child Support Enforcement Program; and furthering the reach of the President's New Freedom Initiative. The support of your committee is vital to achieving many of the Administration's most important priorities. I a m grateful for the close partnership we have enjoyed in the past, and I look forward to working with you again on an aggressive appropriations agenda to advance the health and well being of millions of Americans. Today, I w ould like to highlight for you the key issues in the President's budget. Supporting the President's Disease Prevention Initiative One of the most important issues on which we can work together is chronic disease prevention. We all have heard the disturbing news about the prevalence of diabetes, obesity, and asthma that could be prevented through simple lifestyle changes. The statistics, I a m sure, are as alarming to you as they are to me. For example, the incidence of diabetes and obesity among Americans is up sharply in the past decade, putting millions more Americans at higher risk for heart disease, stroke and other related medical conditions. Diabetes alone costs the Nation nearly $132 billion each year in direct medical costs and in indirect economic costs, including disability, missed work, and premature death. Medical studies have shown that modest lifestyle changes - such as getting more exercise and losing weight ~ can reduce an individual's risks for developing this serious health conditions. 2 4 The HHS budget, consistent with the President's HealthierUS effort, proposes a c oordinated, Department-wide endeavor - Steps to a HealthierUS - to promote healthier lifestyles emphasizing prevention of obesity, diabetes, asthma, heart disease, stroke, and cancer. The FY2004 budget includes an investment of $125 million for targeted disease prevention. Improving the Nation's Health Of all the issues confronting this Department, none has a more direct impact on the well being of our citizens than the health of our Nation. Our budget makes a c oncerted effort to improve the health of the American people by taking significant steps that include: reducing prescription drug-related medical costs, financing vaccines, investing in hospital information technology, and continuing the effort to increase and expand the number of Health Centers. The budget includes initiatives that will carry out the Best Pharmaceuticals for Children Act (BPCA) and alleviate drug-related medical costs. My budget request for NTH includes an additional $25 million, for a total of up to $50 million, to improve information available for prescribing pharmaceuticals to children. NIH is focusing its efforts on drugs that are no longer under patent. The request for the Food and Drug Administration (FDA) includes $12.3 million to increase Americans' access to safe, effective, and less expensive generic drugs and a $1 million increase to expand the range of drugs available over-the-counter. The HHS budget includes a series of improvements in the financing of childhood vaccines to meet three goals — 1) improve vaccine access for currently eligible children, 2) restore tetanus and diphtheria booster vaccines (Td, DT) to the Vaccines for Children (VFC) program, and 3) build a national stockpile of childhood vaccines. Legislation will be proposed to improve access to VFC vaccines for children already entitles to them. The budget proposes to expand the number of access points for underinsured children - those whose private insurance does not cover the immunizations - by allowing them to receive their VFC vaccines at State and local public health clinics. To help protect against future shortages, HHS will, starting in FY 2003, develop a stockpiling strategic plan and begin building a vendor-managed, 6-month supply of all childhood vaccines to be completed by 2006. The budget includes $707 million in FY 2003 to 2006 for the stockpile. Under current-law we can stockpile these vaccines. I a lso propose to restore the tetanus and diphtheria booster shots to the VFC program by removing outdated price caps that are so low for some vaccines that vendors will not bid on VFC contracts. The budget also contains $100 million to ensure the nation has an adequate supply of influenza vaccine in the event of a p andemic. Due to the constant changes in the circulating influenza strains, we cannot stockpile influenza vaccine, and the current manufacturing methods could not meet the Nation's needs in the event of a pandemic. Funds will be used for activities to ensure a year-round influenza vaccine production capacity and the development and implementation of rapidly expandable production technologies. We will work closely with industry to accomplish these goals. Patient safety is a major focus of AHRQ's research portfolio and instrumental in reducing medical costs. In FY 2001 , w e made awards to 94 grantees in five areas to begin the first of three years of research to improve patient safety across healthcare settings. Nearly half of these demonstration projects are focusing on the use of computers and information technology to 3 5 prevent medical errors and to improve reporting of medical errors data Through these projects, grantees are piloting potential error-reducing technologies like personal digital assistants (PDAs) for electronic prescription writing, as well as Computerized Physician Order Entry (CPOE), a technology that helps to ensure that patients receive the right medication, at the right dose, at the right time. As a result of these projects, AHRQ's first step in improving patient safety has been to demonstrate the efficacy of certain interventions in reducing medical errors. Our next step must be to take what we have learned and disseminate it t o healthcare providers and networks. We are putting $50 million into a new program at AHRQ that will improve patient safety by increasing investments in hospital information technology. We are also making a commitment to help implement these technologies in health systems that otherwise may not be able to make the capital investment. A focus on small community and rural hospitals will help to bridge the so-called "digital divide" by helping these hospitals catch up with those that are further along. AHRQ's budget proposal also includes $24 million for ongoing activities such as the work of the Patient Safety Task Force and the Patient Safety Data Reporting System integration efforts, as well as plans to initiate challenge grants and a patient safety improvement corps; a $10 million increase for the expansion and enhancement of information collected in the US Census Bureau's Current Population Survey; and a $2 million increase to improve the usability and timeliness of Medical Expenditure Panel Surveys (MEPS) data and help sustain prior year enhancements to the sample size and content of surveys that collect information from medical providers, insurers, and households. We must do everything within our abilities to address the disparities in health care in this Nation. The FY 2004 budget proposes numerous activities to address and alleviate health inequities. Programs that cut across various HHS agencies strive toward bettering the health of our Nation. The FY 2004 budget continues the third year of the President's multi-year initiative to expand access to care for millions of Americans especially those who are uninsured. The budget includes $1.6 billion, a $122 million increase, to provide primary and preventive health care services to nearly 14 million individuals. Almost 40 percent of the patients treated at health centers have no insurance coverage and many others have inadequate coverage. These health centers are located in our most underserved communities. Over half are in rural America. In support of the Health Center Initiative, the President is also seeking to expand the National Health Service Corps by adding $42 million to increase the number of health care providers in rural and underserved areas, to a total field strength of 4,300 people; and provide for 2,400 loan repayments and scholarships. In addition to childhood immunization, the FY 2004 President's budget for the Centers for Disease Control and Prevention (CDC) requests programmatic increases in several areas. I a m seeking a $12 million increase for the breast and cervical cancer program, which supports screenings for low-income, underinsured, and uninsured women between the ages of 50-64, and $5 million to expand School Health Programs to reduce health risks such as tobacco use, poor eating habits and obesity. The budget also includes an increase of $10 million for a Public Health Information Network (PHIN) to integrate and expand CDC's existing networks to establish a consistent exchange of information between public health partners. 4 6 The Substance Abuse and Mental Health Services Administration's proposed budget is $3.4 billion, a net program level increase of $198 million over FY 2003. As part of the President's Drug Treatment Initiative, the budget includes $200 million in FY 2004, a total of $600 million over three years, to establish a new competitive State substance abuse voucher program. This program will assist 100,000 Americans in the first year in obtaining the critical alcohol and drug treatment services they need but lack access to. This effort complements existing alcohol and drug abuse treatment programs by providing consumer choice and broadening the base of treatment providers to include more faith-based providers. Through this new program individuals seeking drug and alcohol treatment and support services will be assessed and then receive a voucher to pay for appropriate community treatment programs. This program will require accountability by linking payment to providers to demonstrated treatment effectiveness measured by abstinence from alcohol and drug use after treatment. The FY 2004 request also includes an increase of $3 1 m illion for the Substance Abuse Block Grant. The Block Grant will provide drug treatment services to 400,000 persons. In the area of mental health, we propose $107 million, an increase of $9 million, for Children's Mental Health Services to serve a total of 1 7,000 children and adolescents with serious mental and emotional disorders along with their families. We are also requesting $50 million, an additional $7 million, for Projects for Assistance in Transition from Homelessness to serve a total of 147,000 homeless individuals. These funds link efforts to move homeless individuals off the streets by providing them with mental health services and substance abuse treatment. FIGHTING HIV/AIDS HIV/ AIDS is one of the most serious challenges facing humanity. No country has been spared. Some have faced widespread devastation. All have citizens whose lives have been destroyed by this horrible disease. Our commitment to ending this pandemic is strong and unwavering. The FY 2004 budget for HHS includes $6.4 billion in discretionary funds within HHS to combat HIV/AJDS. Within this level is $680 million to support a variety of efforts to fight HIV/AIDS in developing nations. For example, our budget includes $150 million to support the Mother-to- Child transmission of HIV/ AIDS prevention initiative. This initiative seeks to treat approximately one million women annually in developing countries in order to reduce transmission of HIV to their children by 40 percent. This is an integral part of the President's Emergency Plan for AIDS Relief, which seeks to stem the death toll from AIDS. Currently, demographers project that, absent strong action, life expectancy will fall from 66 to 33 years in Zambia and from 70 to 40 years in Zimbabwe. The budget also, includes $2 billion for life sustaining care and services for over 530,000 Americans under the Ryan White CARE Act. The Ryan White programs target our resources toward the development of an effective service delivery system by partnering with States, heavily impacted metropolitan areas, faith-based and community-based providers and academic institutions. Our budget includes $739 million to provide drug therapies to approximately 159,000 individuals. These funds will provide Americans living with HTV7AIDS a lifeline to care who might otherwise have to choose between expensive medical treatments and other necessities. These funds will help eliminate those difficult decisions. 5