Health and Health Care in Schools
Vol 3, No 7 – September 2002


Final HIPAA Regulations Set Privacy Protections for Health Information

On August 14, the U.S. Department of Health and Human Services issued final regulations for the privacy section of the Health Insurance Portability and Accountability Act (HIPAA), an extensive federal law that requires health care providers to keep confidential the personally identifiable health records of individuals. The new regs revise in part final regulations for the law that were issued in December 2000.

The regulations note that some problems may arise as health care providers try to mesh HIPAA requirements with other federal laws that protect individual privacy, including the 1974 Family Educational Rights and Privacy Act, which requires schools that receive federal funds to keep confidential the “education records” of students. The Office for Civil Rights, which will administer the HIPAA regulations, noted that “individually identifiable health information of students under the age of 18 created by a nurse in a primary or secondary school that receives federal funds and that is subject to FERPA is an education record, but not protected health information.”

The regulations are silent on school-based health centers (SBHCs), but in cases where school-based health centers are sponsored by HIPAA-covered entities such as hospitals, health departments, and community health centers, it appears they are subject to the HIPAA privacy requirements, including safeguarding student health records and limiting disclosure of protected information.

Details of the August 14, 2002, and December 28, 2000, final HIPAA regulations are described in an InFocus paper on this website. The full text of the regulations published in the Federal Register August 14 can be read and downloaded at http://www.access.gpo.gov/su_docs/aces/aces140html.

The full text of the regulations published in the Federal Register December 28, 2000, can be read and downloaded in PDF form at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?
dbname=2000_register&docid=f:28der2.pdf


HHS Allows Use of Unspent SCHIP Funds for Childless Adults

Despite an opinion from the U.S. General Accounting Office that the move will reduce funds available to other states for child health coverage, Secretary of Health and Human Services Tommy Thompson August 23 approved a request from New Mexico to use part of its SCHIP funds to insure childless adults ages 19 to 64 with family incomes at or below 200 percent of the federal poverty level. Under the waiver, the state will also offer SCHIP-funded coverage to the parents of children enrolled in either SCHIP or Medicaid.

An earlier waiver allowed the state of Arizona to use SCHIP funds for uninsured childless adults, as well as parents of SCHIP- or Medicaid-enrolled children. California has been given permission to use SCHIP funds to insure parents of children enrolled in SCHIP or Medicaid.

Thompson explained that the waivers are part of the Bush administration’s “Health Insurance and Accountability Initiative,” a Medicaid/SCHIP waiver approach intended to give states “greater ability to design health insurance programs to meet the health insurance needs of their low-income populations.”

Although New Mexico will use SCHIP funds as the primary source of funds for the new program, a press release announcing the waiver emphasized that “covering children is the top priority of the SCHIP program.” “We are continuing to work with states to ensure that maintaining and expanding coverage for children is the top priority for SCHIP,” said Tom Scully, administrator of the Center for Medicare and Medicaid Services in HHS. But Scully added, “We also want states to use the waiver opportunity to expand health coverage to low-income adults who otherwise would not be eligible.”

New Mexico currently covers children up to 235 percent of the federal poverty level. The August 23 waiver announcement did not indicate the percentage of eligible children in the state who are currently enrolled in either SCHIP or Medicaid.

Under the waver, New Mexico will use its unexpended SCHIP funds to subsidize health insurance coverage through private, employer-sponsored insurance. The state will contract with managed care organizations to develop a benefits package that employers will then offer to their low-income uninsured workers. The coverage will be financed with state and federal funds, employer contributions, and employee premiums ranging from $20 to $35 a month.

In a report issued August 8 (see News Alert, 8-8-02), the General Accounting Office, the investigative arm of Congress, analyzed the effect waivers such as those granted to New Mexico, Arizona, and California will have on the distribution of SCHIP funds. The report pointed out that current law requires that any funds not spent by states on child health coverage be redistributed to states that have fully used their SCHIP allotments. Permitting some states to direct unspent funds to adults will reduce the amount of redistribution to other states, the report noted. The GAO also told the Senate Finance Committee that it believes the waivers are inconsistent with the intent of Congress when it created SCHIP as an insurance plan for children.

The GAO report, “Medicaid and SCHIP: Recent HHS Approvals of Demonstration Waiver Projects Raises Concerns” can be read online at www.gao.gov/newitems/d02817.pdf.)


AAP Issues Clinical Report on Giving Care for Head Lice

In a clinical report published in September, the American Academy of Pediatrics (AAP) is again urging schools to rethink “no nit” policies for return to school when children have had head lice infestation.

“A child should be allowed to return to school after proper treatment,” says an article in the September issue of the journal Pediatrics. “Some schools have had ‘no nit’ policies under which a child was not allowed to return to school until all nits were removed. Numerous anecdotal reports exist of children missing weeks of school and even being forced to repeat a grade.” The article points out that both the AAP and the National Association of School Nurses discourage continued use of no nit policies.

That’s not to say that parents should not remove nits whenever possible, since nit removal may reduce diagnostic confusion, decrease the possibility of unnecessary retreatment, and, for nits within 1 centimeter of the scalp, decrease the small risk of reinfestation. But the life cycle of the head louse makes it unlikely that nits found more than one centimeter from the scalp are going to be viable, the article points out

That cycle begins with the adult louse–the size of a sesame seed and usually pale gray in color. The female lives a brief three to four weeks, and lays approximately 10 eggs or nits a day, attaching them firmly to the hair shaft close to the scalp with a glue-like substance. The eggs are incubated by body heat and hatch in 10 to 14 days. Once the eggs hatch, the nymphs leave the shell casing, grow for about 9 to 12 days, and mate, and then females lay eggs. If not treated, this cycle may repeat itself every three weeks. While the louse is living on the head, it feeds by injecting small amounts of saliva and taking tiny amounts of blood from the scalp every few hours. It’s the saliva that creates an itchy irritation and the most telling symptom of head lice infestation—scratching. Rarely, an individual may develop impetigo from the scratching, but that’s probably the worst than will happen, since the head louse, unlike the body louse, does not transmit any disease agent.

But try telling that to parents upset about a lice infestation and unconvinced that, as the article points out, “all socioeconomic groups are affected.” The article notes one exception–black children are somewhat less likely to have head lice, because their hair shafts are typically oval-shaped and harder for lice to grasp. And there’s no evidence that hair length or frequent brushing or shampooing have anything to do with infestation, though it’s true that persons who brush frequently rarely have more than a dozen live lice, whereas individuals in cultures with different grooming practices may have a hundred or more.

“The gold standard for diagnosing head lice is finding a live louse on the head,” the article points out—but this can be difficult, because a healthy louse can move fast— crawling, not hopping, at speeds of up to 30 centimeters a minute. And once aboard, “a healthy louse is not likely to leave a healthy head.”

It’s probably impossible to totally prevent head lice infestations, since children have frequent head-to-head contact with one another, the primary means of transmission. So the AAP’s Committees on School Health and Infectious Diseases list the numerous pediculicides currently available, with detailed instructions for treatment, along with other topical and oral agents and some “natural” products that are in wide use. Among the cautions: it’s not a good idea to use flammable material such as gasoline to kill lice, and products intended for use on animals should never be used on humans. “Removal of nits after treatment with a pediculicide is not necessary to prevent spread, because only live lice can cause an infestation,” though individuals may want to remove nits and dead or empty egg cases, for aesthetic reasons.

School Control Measures

In advice to schools, the clinical report says, “Because of the lack of evidence of efficacy, classroom or school-wide screening for head lice is strongly discouraged.” A better procedure is to periodically provide information to families of all children on the diagnosis, prevention, and treatment of head lice, urging them to check if a child shows symptoms. “School screenings do not take the place of these more helpful checks,” though “It may be helpful for the school nurse or other trained person to check a child’s head if he or she is exhibiting symptoms.”

As to what to do if a child is found to have one or more live head lice, the authors say a child with a head lice infestation is likely to have had it for a month or more before it is discovered, so he or she should remain in class but discouraged from close head contact with others. “Common sense should prevail when deciding how ‘contagious’ an individual child may be (a child with a hundred versus a child with two live lice).” The best thing to do may be to notify the parents of all the children in the index child’s classroom, encouraging that all children be checked at home and treated if appropriate before returning to school the next day.”

“If pediatricians and schools take the lead in reacting in a calm manner, parents will be able to focus on appropriate treatment without getting unduly upset.

 

The AAP clinical report, “Head Lice,” by Drs. Barbara Frankowski and Leonard Weiner of the AAP’s Committee on School Health, was published in the September 2002 issue of the journal Pediatrics.

Further information about head lice is available from the Center for Health and Health Care in Schools at www.healthinschools.org/sh/sissues.asp.
Trends in Childhood Asthma Prevalence, Health Care Utilization, and Mortality

An analysis of asthma prevalence in children from birth to 17 years of age during the years 1980 to 1999 found that the asthma burden was borne disproportionately by black children throughout the period. Racial disparities were largest for asthma hospitalizations and mortality. For example, in one of the study years—1998-99—black children were three times as likely to be hospitalized; and in another year—1997-98—they were four times as likely to die from asthma.

More recent data suggest that the burden from childhood asthma may have reached a plateau lately, after many years of increasing, but racial and ethnic disparities remain large, say the authors of a report published in August. Drawing their data from four national surveys and data compilations, they looked specifically at the number of asthma attacks reported by parents, the number of visits to private physicians for childhood asthma treatment, the childhood asthma hospitalization rate, and the number of child deaths reported on death certificates as resulting from asthma or asthma complications.

By all those measures, childhood asthma prevalence increased dramatically during the past two decades, they noted, for reasons that are not clear but may include better diagnosis or changing environmental exposure (both indoors and outdoors). They also suggest that some of the racial and ethnic disparities they found may be the result of lack of racial/ethnic data in hospital discharge records and other medical records for children, or self-reporting of race in surveys.

But combining the findings of the four instruments with many other studies from other sources, the authors say, the racial and ethnic disparities persist. For one thing, risk of asthma hospitalization and mortality has been found to be correlated with minority race and living in poverty. “Although most poor children have access to a source of asthma care, poor and minority children with asthma are less likely to receive care in a high-quality setting with continuity of care and less likely to be prescribed or to use maximally effective preventive therapy. Such differences in utilization or an access to health care are likely to contribute to the racial and income disparities in asthma morbidity that have been widely described in the literature.”

To date, the statistics on asthma prevalence in children have been taken from national surveys, but the authors note that there are regional and local variations in asthma prevalence, hospitalization, and mortality, and they urge that more state-specific information be collected, using standardized questions so the data can be compared.

The report “Trends in Childhood Asthma: Prevalence, Health Care Utilization, and Mortality,” by Drs. Akinbami and Schoendorf of the National Center for Health Statistics, was published in the August 2002 issue of the journal Pediatrics. Reprints are available from akinbami@cdc.gov.


In the Courts

Court Rules Against Religious Abstinence Education

A federal district court ruled July 24 that it violated the U.S. Constitution’s First Amendment separation of church and state for the Louisiana Governor’s Program on Abstinence (GPA) to provide federal abstinence education funds to religious organizations that tied abstinence to their religious beliefs. Among the examples cited in the court ruling: the Lafayette, Louisiana, diocese used abstinence education funds to support prayer at abortion clinics, pro-life marches, and pro-life rallies, as part of a chastity program titled “God’s Gift of Life.” Another organization, the Rapides Station Community Ministries, cited the virgin birth as illustrating God’s preference for sexual purity as a way of life. The U.S. District Court for the Eastern District of Louisiana noted that these and other religiously affiliated institutions submitted both grant applications and required monthly reports that made clear government aid was used to fund specifically religious activities. The court ordered the Governor’s Program on Abstinence to “cease and desist from disbursing GPA funds to organizations or individuals that convey religious messages or otherwise advance religion in any way …” The GPA was also ordered to install an oversight program that will review the materials grantees use, and to conduct closer monitoring of programs.

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New Jersey Court Cites U.S. Supreme Court Ruling on Drug Testing

The Superior Court of New Jersey August 12 rejected an argument that the state’s constitution provides greater protection against unreasonable search and seizure than does the U.S. Constitution. Citing the U.S. Supreme Court’s decision in Pottawatamie County v. Earls last June, which held that random, suspicionless testing for drugs of students who participate in extracurricular activities is not unconstitutional under the U.S. Constitution, the court ruled that a similar program in New Jersey’s Hunterdon Central High School does not violate students’ constitutionally protected privacy interests. The case was Joye v. Hunterdon Central Regional High School Board of Education.

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State May Not Require Church Membership for Exemption from Immunization

A federal district court in Arkansas ruled July 25 that a state law that allows parents to claim religious exemption from immunization for their children is unconstitutional because it requires that the protesting parents be members of “a recognized church or religious denomination.” Under the law, the Arkansas Department of Health decides whether to grant a religious exemption by considering several factors, including the permanent address of the applicant’s church, the number of members, the times and places of regular meetings, the written church constitution or plan of organization, the written theology or statement of beliefs, and any legal documents the church has filed with government entities. The church or denomination must also specify in writing that immunization conflicts with its religious tenets and practices. “The form requests everything but information concerning the applicant’s pew-seating preferences,” the court noted.

A father who is not a church member had brought suit against the Department of Health after his daughter was suspended from school on October 1, 2001, for failing to receive the age-appropriate immunizations required by Arkansas law and for not having qualified for religious exemption under the statute.

The federal court said in its ruling that it is constitutional for a state to have immunization requirements, and to offer a religious exemption from those requirements, but the exemption itself must pass constitutional muster, which Arkansas’s did not, since it benefited only persons who were members of churches.

The case was McCarthy v. Boozman.

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Case Questions Rubella Vaccination in Pregnancy

When Burlington County, New Jersey, health officials and the Riverside Board of Education organized and operated a free immunization clinic at Riverside High School in 1975, in response to an outbreak of measles and rubella, Debra Wright, a senior, received a rubella vaccination when she was either pregnant or soon to become pregnant. After a daughter was born with congenital rubella syndrome, Wright sued, charging the immunization clinic had failed to ascertain prior to her vaccination whether she was pregnant. Product information for the rubella vaccine at that time recommended that pregnant women not be given the vaccine.

The case has been in the courts ever since, with a ruling in August this year sending it back for a further trial that will consider whether rubella vaccine can cause congenital rubella syndrome in an infant.

The case, in the Supreme Court of New Jersey, is Kemp v. State of New Jersey.


Worth Noting

Having Pets Before Age One May Decrease Child Allergies

By the time they were of school age, children who had lived from birth to age one in a household with two or more dogs or cats were 66 to 77 percent less likely to have any common allergies than children who were exposed to only one or no pets in their first year, according to researchers who reported their findings in the August 28 issue of the Journal of the American Medical Association. The striking thing, the researchers said, is that early, multiple pet exposure appears to protect not only against pet allergies but also against other common allergies, such as allergy to dust mites, ragweed, and grass. The researchers followed 474 children from birth to six or seven years of age, when they were tested for antibodies to common allergens.

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Folk Remedies, Candies Cause Childhood Lead Poisoning

The Centers for Disease Control and Prevention reported August 9 that elevated levels of lead were found in Hispanic children in California who had been given greta, a Mexican folk remedy for stomache or intestinal disorders that usually contains high levels of lead. High blood lead levels were also found in children who had eaten candy made in Mexico that was wrapped in wrappers containing lead. Health care providers should be aware of these and other atypical sources of lead, and community members should be educated about potential sources of lead poisoning for children, the CDC said. The report, “Childhood Lead Poisoning Associated with Tamarind Candy and Folk Remedies—California, 1999-2000,” appeared in the August 9 issue of Morbidity and Mortality Weekly Report.

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Healthy Schools Summit Scheduled for October

More than 30 health and education organizations will meet in Washington, D.C., October 7-8, for a Healthy Schools Summit aimed at improving the health of children by making changes at state, district, and local levels to create a healthier school environment. The focus of the meeting will be on better nutrition and physical activity for children. The agenda will include an update on the nutrition and fitness status of U.S. children, and the conference will focus on establishing state teams to develop local actions following the summit.. More information is available at www.actionforhealthykids.org.

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Majority of Teens Say Their Schools Are Drug-Free

For the first time in the seven years they have been surveying the attitudes of teens about drugs in schools, the National Center on Addiction and Substance Abuse at Columbia University said August 20 that a majority (62 percent) of 12- to 17-year-olds now believe their schools are drug-free. But teens continue to cite drugs, including alcohol and tobacco, as their biggest concern; 25 percent of students say they have witnessed the sale of illegal drugs on school grounds, and a high percentage of students report that marijuana is easier to buy than either cigarettes or alcohol. The Center can be contacted at www.casacolumbia.org.

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Barriers to Walking, Biking to School

It would be a good thing, exercise-wise, if children in the United States walked or rode their bikes to school, but the majority don’t do that—one-third of all students ride school buses and half are driven to school in private vehicles. The biggest reasons for not requiring children to get to school under their own power are the long distances they have to travel, dangerous motor vehicle traffic, concern about crime, and adverse weather conditions, according to an analysis by the Centers for Disease Control and Prevention. Some communities are addressing the problems by creating safe and accessible routes to school and sponsoring programs such as “Walk to School Day.” The report, “Barriers to Chidren Walking to School—United States, 1999,” appeared in the August 16 issue of Morbidity and Mortality Weekly Report.

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 August News Alerts

The following information appeared during the month of August 2002 in the News Alerts section of this website.

New Medication Found Helpful in Behavioral Disorders of Autism

A clinical trial funded by the National Institute of Mental Health and reported in the August 1 issue of the New England Journal of Medicine found that risperidone, one of a new class of anti-psychotic medications, was successful in treating serious behavioral disturbances associated with autistic disorder in children ages 5 to 17. More information on the trial and other autism research is available on the NIMH Clinical Trials website at www.clinicaltrials.gov/show/NCT00005014.

Resume Routine Schedule for Varicella Vaccine, CDC Says

In a notice in the August 2 issue of Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention said supplies of varicella vaccine (VARIVAXÒ ) in the United States have become sufficient to permit the resumption of the routine schedule as recommended by the Advisory Committee on Immunization Practices. Childcare and school attendance provisions requiring children to receive the varicella vaccine should be reinstituted and recall programs for deferred unvaccinated persons should be instituted, the CDC said. A temporary shortage of varicella vaccine in the U.S. resulted from a voluntary interruption of manufacturing operations by Merck & Co., Inc., the only U.S. manufacturer of varicella vaccine.

Legislation Would Bar N.Y. Schools from Suggesting Ritalin

A New York State legislator is proposing that his state join three others—Connecticut, Texas, and Virginia—that bar teachers, guidance counselors, and others from recommending Ritalin to solve their classroom problems. “If a child is appropriately diagnosed with ADHD, the child would definitely benefit from the medication,” said state assemblyman Felix Ortiz, who has introduced the legislation. “I am not opposed to that at all. But I am opposed to somebody making the recommendation to a parent that their child needs this drug, and the physician sits down and writes a prescription without doing the necessary work on the child.”

GAO Report Criticizes HHS Waivers of SCHIP Rules

In a report to Congress released August 8, the General Accounting Office said waivers of State Children’s Health Insurance Program (SCHIP) rules granted to some states by the U.S. Department of Health and Human Services will reduce the amount of money available to other states for child health coverage under SCHIP. The GAO report noted that waivers granted to Arizona and California allow those states to use unexpended SCHIP funds to cover uninsured low-income adults, including those with no children. The GAO said it believes the waivers are inconsistent with the intent of Congress when it created SCHIP as an insurance plan for children. The GAO report, “Medicaid and SCHIP: Recent HHS Approvals of Demonstration Waiver Projects Raise Cocerns,” is online at www.gao.gov/news.items/d02817.pdf.

HHS Previews Expected 2003 Grants Availability

A preview of competitive grant programs that the Department of Health and Human Services expects to fund in fiscal year 2003 was published in the August 9 issue of the Federal Register. Included are grants expected to be available from the Bureau of Health Professions, the Bureau of Primary Health Care, and the Maternal and Child Health Bureau. Information provided includes eligibility, funding priorities, matching requirements, project periods, review criteria, average expected award size, and application deadlines. The preview points out that funding for some of the listed programs is not requested in the President’s 2003 budget and funding may or may not be provided by Congress in the 2003 appropriations bills now being considered.

Final Privacy Regs Due August 14

The Department of Health and Human Services announced August 9 that final regulations for the privacy section of HIPAA (the Health Insurance Portability and Accountability Act) would be published in the Federal Register on Wednesday, August 14. HHS said it received more than 11,000 public comments after proposed regs were published in March this year, and the final version includes “key revisions” to address public concerns. Most covered entities have until April 14 2003 to comply with the patient privacy rule. To help people comply, HHS said its Office for Civil Rights (OCR) “will continue to conduct outreach and education targeted to health plans, health care providers, consumers, and others affected by the privacy regulation.”

Funds Available for Youth HIV Prevention Research

The Adolescent Trials Network, a multi-center network funded by the National Institute of Child Health and Human Development in the National Institutes of Health, is seeking researchers to work with youth ages 12 to 25 to develop interventions to prevent HIV in at-risk populations. $1 million is available for three to five collaborations; deadline for applications is October 11. Among possible approaches are development of screening procedures for use by healthcare providers to identify youth at risk for alcohol abuse and exposure to HIV, particularly youth in elementary and middle schools, and interventions to improve access to health care by alcohol-using adolescents. For information related to the scientific content of the application, contact dmurphy@mednet.ucla.ecu. For information about the application process, contact cjp@uab.edu.

HIPAA Privacy Regulations Available

Regulations for the privacy section of the Health Insurance Portability and Accountability Act (HIPAA) were published August 14 in the Federal Register at. The privacy regs can also be accessed through the following links: http://www.hhs.gov/ocr/hipaa and http://www.access.gpo.gov/su_docs/aces/aces140html.

Environmental Health Broadcast Scheduled

“Working with Communities for Environmental Health,” a live, interactive satellite broadcast and webcast designed for health educators; public and environmental health professionals, state, county, and local health agencies personnel; nurses and nurse practitioners; health care providers; school health personnel and teachers; managed care group personnel; and college and university personnel will air September 12, from 1:00 p.m. to 3:30 p.m. EDT. Additional information about the program, including continuing education credit, and registration and course materials, is available at http://www.phppo.cdc.gov/phtn/envedu.

Reports on Teen Development

Two key reports released this summer provide extensive data on adolescent health behaviors and the most effective interventions that promote healthy teen development and prevent bad outcomes. The CDC released data from its most recent Youth Risk Behavior Survey study on June 28, 2002. Youth Risk Behavior Surveillance — United States, 2001 reports data, collected February – December 2001. (www.cdc.gov/mmwrhtml/ss5104a1.htm). Child Trends, one of the most reliable sources for research studies related to children, has issued “Encouraging Teens to Adopt a Safe, Healthy Lifestyle: A Foundation for Improving Future Adult Behaviors”. This report is part of a series on American teens. Of particular interest are summary tables that review the research literature and report findings on what works and what doesn’t. (www.childtrends.org/r_resbrief.asp)

Forum Assesses SCHIP After Five Years

The National Health Policy Forum has posted a new publication, “SCHIP Turns Five: Taking Stock, Moving Ahead,” http://www.nhpf.org/pdfs/8-781+(web).pdf. The policy brief uses the occasion of the five-year anniversary of Title XXI of the Social Security Act, the State Children’s Health Insurance Program (SCHIP) to look at the successes of the program as well as some of the obstacles SCHIP will face as it attempts to maintain effectiveness in providing health coverage to uninsured children and families. The paper explores the critical funding impasse created by the downturns in the economy and the financing structure of the SCHIP statute. The paper also considers the prospects for SCHIP’s continued success through bipartisan support in Congress.

SAMHSA to Fund Mental Health Prevention, Intervention for Youth

The Substance Abuse and Mental Health Services Administration (SAMHSA) announced August 22 that if and when 2003 funds become available, it will make grants totaling $1 million to a limited number of cities, counties, or tribal governments to develop prevention and early intervention mental health treatment services at the community level for children, adolescents, and their families. Eligibility is restricted to local governments because mental health services at the local level are the responsibility of local governments, SAMHSA said. Questions may be addressed by e-mail to gritchie@samhsa.gov.

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