Assuring Healthy Development for Our Children: Creating Political Will for Action Presentation for First Annual Conference on Special Needs Children Deborah

Assuring Healthy Development for Our Children: Creating Political Will for Action

Presentation for First Annual Conference on Special Needs Children

Deborah Klein Walker, EdDPresident,

American Public Health AssociationVice President, Abt Associates

September 13, 2007Louisville, KY

“Injustice anywhere is a threat to justice everywhere.”

Martin Luther King, Jr.

MCH Goal

• Healthy Children

• Healthy Families

• Healthy Communities

Shaping Effective Public Health Programs and Policies

KNOWLEDGE BASE

POLITICAL WILL

SOCIAL STRATEGYSource: Richmond

& Kotelchuck, 1983

Outline of Presentation

• Evidence – What We Know about Child Health and Development

• Vision – What We Want for Children

• What Is Needed to Achieve the Vision

• Social Strategies Needed to Gain Political Will for Change

Evidence Reviewed

• Health insurance

• Infant mortality

• Obesity and nutrition

• Parenting

• Early childhood

• Schools and education

• Poverty

Health Insurance

Health insurance

leads to

More children with regular source of health care (medical home)

leads to

Higher utilization of well child visits, including immunizations

1918

16161515141313131313131313131312

1111

0

5

10

15

20

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

Projected

U.S. Health Expenditures as Share of GDP Expected to Rise Through Next Decade

Expenditures as percent of gross domestic product (GDP)

Source: Center for Medicare and Medicaid Services, Office of the Actuary, 1998–2003

Administrative Cost Growth Outpaces Total Medical Expenditure Growth

6.2

9.78.5

12.5

9.3

16.3

7.7

13.2

0

5

10

15

20

National health expenditure Administrative costs of private

and public insurance

Annual growth 1997–2000




* Administrative costs totaled $119.7 billion in 2003, nearly double that of 1997.

Source: Smith et al., "Health Spending Growth Slows in 2003," Health Affairs 24 (Jan/Feb 2005).

Percent

Number Uninsured Rose 5.8 Million from 2000 to 2004, with Adults Accounting for All of the Increase

8.6

8.3

30.9

37.5

0 10 20 30 40 50

2000

2004

Under age 18 Ages 18–64

Source: U.S. Census, March 2001 and March 2005 Current Population Surveys.

45.8 million

40million

Uninsured Children in 2005

• 11.6% of all children– 10.8% (ages 0-5)– 10.3% (ages 6-12)– 13.8% (ages 13-18)

• Majority of uninsured (83%) are from families where at least one parent works; Among 70% of uninsured children living with a parent, at least one parent works fulltime year round

• Uninsured children have more unmet needs in medical, dental, vision and mental health care

Campaign for Children’s Health, 2006

Polio Vaccine Field Trials

Components of Health Coverage

• EPSDT; multiple screening and assessment points

• Dental care

• Mental health

• Nutrition counseling and follow-up

• Care coordination

• Education and outreach

Coverage for Disabilities and SHCN across the Lifespan

• Civil rights (ADA, IDEA)

• Entitlements (SSI)

• Grants to states (Title V, DD Act)

• Executive orders (NFI)

• Supreme Court decision (Olmstead)


• Develop meaningful options for transition from the child health and social system to the adult health and social system (ages 14-16 to 25-28)– Health– Education and employment– Transportation and housing– Community supports and participation


• Assure wrap-around insurance “buy-in” for disabilities across the lifespan – Prototype: CommonHealth in MA since

1988– Family Opportunity Act provides

mechanism for all states

SCHIP Issues

• Fully fund SCHIP reauthorization for all children and youth in all states.

• Strenthen federal standard for SCHIP benefits packages to include EPSDT.

• Provide funding for states to implement improved outreach and stremlined enrollment activities.

http://www.apha.org/advocacy/activities/schip/





BUT

• Health insurance is necessary but not sufficient to guarantee good health outcomes

• Other barriers to access and utilization of health services need to be identified and addressed in the child care health system

Public Health Nurses

Infant Mortality Rate, Massachusetts: 1842-2001

0

50

100

150

200

250

1840 1860 1880 1900 1920 1940 1960 1980 2000

Year

Dea

ths

per 1

,000

live

bi

rths

Massachusetts Department of Public Health, Bureau of Health Statistics, Research and Evaluation

7.27.1

6.25.9

5.75.75.75.7

5.65.6

5.55.5

5.35.3

5.25.2

54.9

4.84.7

4.64.6

4.24.1

43.6

3.23.5

0 1 2 3 4 5 6 7 8

UNITED STATESCuba

IrelandPortugalGreece

IsraelEngland and Wales

SpainBelgium

Northern IrelandNew Zealand

ScotlandCanada

ItalyCzech Republic

NetherlandsAustralia

AustriaSwitzerland

DenmarkGermany

FranceSingapore

FinlandNorway

JapanSweden

Hong Kong

Comparison of National Infant Mortality Rates: United States, 1998

Deaths per 1,000 Live Births

28th in the world

Infant Mortality Rates by Race of Mother: United States, 2003

13.5

6.85.75.6

0

2

4

6

8

10

12

14

16

Black Hispanic White All Races

Dea

ths

per

1,00

0 L

ive

Bir

ths

Infant Mortality Rates, 1950-2000

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

1950 1960 1970 1980 1990 2000

Year

Dea

ths

per

1,00

0 li

ve b

irth

s

0.0

0.5

1.0

1.5

2.0

2.5

3.0

B/W

Rat

io

WhiteBlackB/W Ratio

Infant Death Rates by Mother’s Education, 1995

02468

101214161820

<HighSchool

High School SomeCollege

Collegegrad. +

Education

Dea

ths

per

1,00

0 po

pula

tion

0

0.5

1

1.5

2

2.5

3

B/W

Rat

io

WhiteBlackB/W Ratio

INTERVENTION POINTS TO IMPROVE BIRTH OUTCOMES

• Pre-Pregnancy Activities

• Prenatal Interventions

• Perinatal Interventions

• Post-Natal Interventions

Infant Incubator

Obesity* Among U.S. Adults 2001

Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. Data from Behavior Risk Factor Surveillance System (BRFSS)

Source: Willet et al., New Eng J Med, 1999

•Prevalence has nearly quadrupled in American children

•2.5-fold increased risk of overall mortality

•4-fold risk of cardiovascular mortality

•5-fold risk of diabetes

•Risk of hypertension, gall bladder disease, and some cancers

Source: Willet et al., New Eng J Med, 1999

Overweight and Obesity

1.4

1.8

2.3

5:066:07

7:04

36%45%

58%

Hours of TV Hours of TV Viewed DailyViewed Daily1960-19921960-1992

Millions of Millions of Person-Miles Person-Miles

in in Automobiles, Automobiles, 1970-19901970-1990

Percent of Percent of Workforce in Workforce in Sedentary Sedentary

Occupations Occupations 1950-19961950-1996

Environment and Obesity

Suburbs disconnected Suburbs disconnected and pedestrian-unfriendlyand pedestrian-unfriendly

Poor Nutrition & Physical Inactivity

• Only 2% of children eat a healthy diet consistent with federal nutrition recommendations

• 3 out 4 high school students eat less than recommended 5 or more servings of fruits & vegetables

• 35 % of teenagers are physically inactive

Interventions to Address Childhood Obesity

• Multisector environmental approach needed to support culture change in healthy eating and physical activity (5-2-1-Almost None)– Day care– Schools– Primary care– Community (built environment, food portions,

farmer’s markets, etc.)– Social marketing– Workplace

WIC: America’s Premier Public Health Nutrition Program

• Started in 1972 as a Congressionally-legislated pilot project, taken nationwide in 1974

• Greatest single point of nutrition and health care access for low-income mothers, infants and children

• Over 30 years of preventing maternal and child health problems and improving long-term health of mothers and children

How WIC Helps

• Improved birth outcomes and savings in health care– Every $1 spent on pregnant women in WIC

produces up to $4.21in Medicaid savings for newborns and their mothers

– Reduced incidence of low-birthweight by 25% and very low-birthweight by 44%

• Improved diet and diet-related outcomes– Lower risk of maternal obesity at the onset of

subsequent pregnancy– Participation in WIC improves healthy eating index

scores

High/Scope Study of Perry Preschool

• In early 1960s, 123 children from low-income families in Ypsilanti, Mich.

• Children randomly selected to attend Perry or control group.

• High-quality program with well trained teachers, daily classroom sessions and weekly home visits.

• Tracked participants and control group through age 40.

Perry: Educational Effects

0% 20% 40% 60% 80% 100%

Didn't requirespecial education

Graduated fromhigh school on

time

Age 14achievement at10th percentile +

No-program group Program group

Source: High/Scope Educational Research Foundation

Perry: Economic Effects at Age 40

0% 20% 40% 60% 80%

Have a savingsaccount

Earned $20,000+

Own home

No-program group Program group


Perry: Average Number of Months Served in Prison by Age 40

0 10 20 30 40 50 60

No programgroup

Programgroup

Number of Months


Perry Preschool — Estimated Return on Investment

• Benefit-Cost Ratio = $17 to $1

• Annual Rate of Return = 18%

• Public Rate of Return = 16%

Federal Reserve Bank Research Group, 2004

Brookline Early Education Project

• Interventions include home visits at birth, parent support groups and drop-in center in community

• Comprehensive screening and assessment at multiple time points

• Quality universal preschool at age 3• Sample: 285 infants born in 1973-4

(60% Brookline & 40% Boston; 37% minority and 17% non-English)

Levels of Service

Cost/Child$1,200

$800

$400

Level A Level B Level C

A. Intensive, Monthly Home Visits

B. Moderate, Bi-Monthly Home Visits

C. No Home Visits

BROOKLINE EARLY EDUCATION PROJECTDifficulty in Reading Performance for Highly

Educated Families (Mother is a College Graduate) Assigned to Different Levels of Parent

Education

3.00%9.70%

12.50%19.50%

0.0% 10.0% 20.0% 30.0%

Percentage of Children Having Difficulty

RandomComparison Group(n=87)

BEEP, ParentInitiated Program(n=32)

BEEP, ModerateOutreach to Parents(n=31)

BEEP, IntensiveOutreach to Parents(n=33)

BROOKLINE EARLY EDUCATION PROJECT Difficulty in Reading Performance for Not Highly Educated Families (Mother is not a College Graduate) Assigned to Different

Levels of Parent Education

28.6%

31.6%

52.2%

50.0%

0.0% 20.0% 40.0% 60.0%

Percentage of Children Having Difficulty

Random ComparisonGroup (n=72)

BEEP, Parent-InitiatedProgram (n=23)

BEEP, ModerateOutreach to Parents(n=19)

BEEP, IntensiveOutreach to Parents(n=21)

BEEP 25 Year Follow-up Study

• Found long term impact on life chances, life experience, health and mental health

• Blunted disparities in health outcomes among urban youth

• Majority of parents reported a lasting effect on their parenting skills

“Policies that seek to remedy deficits incurred in early years are much more costly than

early investments wisely made, and do not restore lost capacities even when large costs

are incurred. The later in life we attempt to repair early deficits, the costlier the

remediation becomes.”

James J. Heckman, PhDNobel Laureate in Economics, 2000

Characteristics of Successful Preschool Programs

• Developmentally Appropriate Child-Centered Curriculum

• Parent Involvement and Education• Staff Trained in Early Childhood Education• Appropriate Staff Child Ratios• Good Administrative Structure with Clear

Links to Health, Nutrition, and Social Supports

Parents With Concerns About Their Children Ages 4-35 Months

48 %45 %

42 % 41 %38 %

Behavior Communication Emotional well-being

Getting alongwith others

Learningpreschool skills

National Survey of Early Childhood Health, 2000

42 % 41 %

30 %23 %

54 %

How to HelpLearn

How toDiscipline

ToiletTraining

SleepPatterns

Crying-Whatto Do

Parents Parents WantWant More information More information On:On:

McLearn et al, Arch Pediatr Adol Med 1998, vol. 152.

Success in School

• Academic achievement is necessary but not sufficient for successful child and adult outcomes

• Good health and nutrition is a prerequisite for learning

• Comer Schools document that the entire school environment and culture must change to support child development so all children learn and become productive adults

CBPP 2006 Report

Child Poverty

• Although poverty rate declined in 1990s, it has increased steadily since 2000 from 11.3% to 12.7% in 2004

• Children experienced the sharpest increase; proportion in poverty rose 13.4% from 15.7% (11M) in 2000 to 17.8% (13M) in 2004

• Severe poverty overrepresented by children, African Americans and Hispanics

Summary of Evidence Related to Child Health and Development

• Brain development, environment and child development interrelated

• Supportive families and communities critical • Numerous peer-reviewed studies document

interventions for promoting child health and development

• Investments early in childhood lead to productive and healthy adults

• Few interventions have been taken to scale for ALL children

IOM report on quality in health care was concerned with errors of commission but should have been concerned with errors of omission—e.g., – Vaccines not given– Helmets not worn– Interventions not made for abused children

William H. Foege, MD, MPH

“Children, it should be repeated, are not pocket editions of adults. Because childhood is a period of physical growth and development, a period of preparation for adult responsibility in public and private life, a program for children cannot be merely an adaptation of the program for adults, nor should it be curtailed during periods of depression or emergency expansion of other programs.”

-Grace Abbott

Context for 21st Century Vision

• Global interconnected world• Technology advances• Rapid communication and information• Age of advertising• Growing disparities in rich and poor• Competitive political environment• Social and behavior “new morbidities” • Expanded evidence base • Lack of political will to invest in children

21st Century Vision

• All children and youth have supportive families and communities

• All have supports and nurturing relationships in child care and eduational settings

• All children and families have comprehensive health care using a single payer system

21st Century Vision

• All systems a child interacts with are– Culturally competent– Prevention oriented– Family centered– Community based– Comprehensive– Staffed by individuals knowledgable about

child health and development

21st Century Vision

– Used evidence-based strategies for policy, programs and services

– Involve parents actively – Focus on prevention and enabling services– Work effectively with other child systems– Use a social determinants model of health

• All child health and development systems use a population-based approach for all children in their system

• Systems development is achieved using – Assessment strategies– Policy development strategies– Assurance strategies

21st Century Vision

• Parents are knowledgable and supported in child rearing

• Parents are prepared emotionally and financially when a child is born

• All parents receive a “magazine” at birth of first child and continue to receive one throughout 18 years of parenting (belong to the American Association for All Parents – AAAP)

21st Century Vision

• Business and workplaces support parents

• Television and radio stations are dedicated to child development and parenting

• Sustained social marketing related to parenting is supported

21st Century Vision

21st Century Vision

• There is a strong “point of accountability” for all children at all levels of government

• All legislation related to families and children are related to this “point of accountability”

• There is a strong data infrastructure at all levels of government

HOW WILL THE 21st CENTURY VISION BE REALIZED ON THE

GROUND?

WHAT WILL BE THE STRUCTURE AT ALL LEVELS OF

GOVERNMENT?

Possible Structures for the 21st Century Vision

• Title V of the Social Security Act?

• A New Child and Family Act?

• A New Children’s Bureau at the State and Federal Level?

• Other

TITLE V BLOCK GRANT

• Social Security Act - 1935

• Amended in 1960’s, 1981, 1989, 1996

• Federal/State/Local Partnership

• Point of Accountability for ALL “MCH Population”

• Available in All States

“MCH does not raise children; it raises adults”

“All of tomorrow’s productive, mature citizens are located today someplace along the MCH continuum and they are at some point in their creation, either being conceived or born or nurtured for the years to come”

-Pauline Stitt

EXPAND FUNDING FOR TITLE V

FUTURE GOALS FOR TITLE V

• Funded to Meet All Goals• Recognized as Point of Accountability at

State and Federal Levels• Linked to All Child and Family Service

Sectors• Supported by General Public• Supported by Local, State and National

Organizations

Expand Title V

• Fund states to do home visits for all newborns

• Fund states to prevent teen pregnancy

• Fund comprehensive data systems for tracking child health and development

• Fund states to provide school health and day care training and consultation services

Expand Title V

• Conduct evaluation and monitoring for quality in health services

• Provide services for all women with a prior poor birth outcome

• Provide early childhood prevention services for mental health

LINK TITLE V TO ALL OTHER MAJOR PIECES OF CHILD AND

FAMILY LEGISLATION

KEY FEDERAL LEGISLATION

• SSA Title V - MCH Block Grant

• SSA Title IV - Welfare, Child Support, Foster Care

• SSA Title XVI - Supplemental Security Income (SSI)

• SSA Title XIX - Medicaid

• SSA Title XXI - SCHIP

• OBRA ‘93 Family Preservation

• Child Care Block Grant

KEY FEDERAL LEGISLATION

• Individuals with Disabilities Education Act (IDEA)

• Head Start

• Supplemental Nutrition Program for Women, Infants and Children (WIC)

• Public Health Service Act– Community and Migrant Health Centers

(Sections 329 & 330)– Family Planning (Title X)

CREATE AND ENACT THE “CHILD AND FAMILY” ACT

CHILD AND FAMILY ACT

• “Young Americans” Act

• Supports Office for Children and Families in All Local Areas

• Supports Strong State Point of Accountability

• Supports Strong Federal Point of Accountability

Funding for New Act

• Create a Child and Family (or Invest in America’s Future) Trust Fund

• Use revenue from tobacco and alcohol sales

• Create incentives for business and economic development that support child development

• 1% of all corporate profits go to Trust Fund

Vision for the Future

It will be a great day when children and families get all the money they need and the Pentagon will have to hold a bake sale to buy a bomber.

Shaping Effective Public Health Programs and Policies

KNOWLEDGE BASE

POLITICAL WILL

SOCIAL STRATEGYSource: Richmond

& Kotelchuck, 1983

BE PREPARED WITH A PLAN

TO MEET THE VISION

Learn from the Past

• Child advocates in past fought hard to reduce child labor practices and improve health

• Children’s Bureau began in 1912 as a social agency and later added the MCH component

• Tension among child advocates about which issues take priority has always existed

Leadership Model

Martha May Eliot, MD

• Director, MCH Division, Children’s Bureau (1924-1934)

• Helped draft Title V• 1st woman APHA

president, 1947• Chair, MCH, HSPH

DEVELOP STAFF AND LEADERSHIP FROM MANY

DISCIPLINES AND SECTORS

BE PROACTIVE; CONNECT TO POLITICAL AND SOCIAL AGENDA

OF THE TIMES

Action Steps

• Participate in political campaigns so candidates address children’s issues

• Create a platform for action for legislators and executive leaders

• Create partnerships with all sectors impacting child health and development

Work in All Settings in Communities

• Clinical (e.g., provider offices & clinics)• Schools• Workplaces• Communities• Jails and prisons• Media• Academic institutions• Other

DEVELOP AND ENHANCE LOCAL, STATE AND NATIONAL

COALITIONS, PARTNERSHIPS AND AND NETWORKS FOR

EDUCATION AND ADVOCACY

Building a Child Health Movement

• Consumers• Health Providers• Academic Community• Purchasers• Advocacy Groups• Business• Public Agencies• Consumers & Families• The Public

Advocacy at the State/Local Level

• Just as “all politics is local” (Tip O’Neill), all child health is local as well

• Need strong state public health and child advocacy groups

• Support education and advocacy through statewide networks – e.g.– Children’s Action Networks– Public Health Associations

“Never doubt that a small group of thoughtful citizens can change the world. Indeed, it’s the only thing that ever has.”

Margaret Mead

Leadership is Needed

• AMCHP• ATMCH• March of Dimes• AAP• Children’s Defense Fund• APHA• Others

“Sometimes when I get home at night in Washington, I feel as though I had been in a great traffic jam, the jam is moving toward the Hill where Congress sits in judgment on all the administrative agencies of the government. In that traffic jam there are all kinds of vehicles moving up toward the Capitol… There are all of the conveyances that the Army can put in the street… There are the hayricks and the binders and the ploughs and all the other things the Department of Agriculture manages to put into the streets… I stand on the sidewalk watching it become more and more congested and more difficult, and then because the responsibility is mine and I must, I take a very firm hold on the handles of the baby carriage and I wheel it into the traffic.”

-Grace Abbott, Children’s Bureau, 1935

EACH OF YOU ARE NEEDED; YOU ARE THE LEADERS OF THE

MOVEMENT FOR CHILD HEALTH AND DEVELOPMENT

New York Times October 2, 2010

“CONGRESS PASSES CHILD AND FAMILY ACT”

A new era for Title V of the Social Security Act is passed 75 years after the original

passage of the Title V MCH program and 45 years after the passage of the “Older

Americans Act”.

“He who has health has hope;

he who has hope has everything.”

African Proverb

Deborah Klein Walker, EdD

President

American Public Health Association

[email protected]

“Public Health: Prevent, Protect, Promote”

Documents

Assuring Healthy Development for Our Children: Creating Political Will for Action Presentation for First Annual Conference on Special Needs Children Deborah