In This Issue

SCHIP Extension Could Mean More Uninsured Children in the Short Run
When Congress and President Bush failed to resolve differences over the State Children's Health Insurance Program (SCHIP), set to expire this past fall, both sides settled for a compromise that would keep the popular program going until March 2009 when a new Congress and new President could revisit the problem. While the compromise reached in December fended off collapse of a widely admired program, a study by Genevieve M. Kenney for the Urban Institute indicates that for at least a short time, the number of uninsured children will increase. That result appears to have been unanticipated. (Editor's note: This increase will follow a 1-million-child increase in the number of uninsured children in the U.S. between 2004 and 2006.) As Kenney reports, SCHIP began in 1997 as a way to provide health coverage for children from families that earned too much to qualify for Medicaid and did not have private health insurance. In 2006, the plan covered about 6.7 million children and 700,000 adults. By most accounts, the program was a success. While increasing numbers of adults became uninsured during that period, more children were protected through SCHIP. According to Kenney, the program began to be seen as a way of expanding health insurance coverage. Under deadline With SCHIP set to expire last October 1, Democrats in Congress twice passed reauthorization bills and twice, President Bush vetoed them. Congress wanted to increase funding and expand the number of eligible children; the President wanted to hold down costs by not expanding the numbers covered. The Democratic bills tried to answer concerns about overall funding, the formula used to distribute money across the states, methods used to reach children not yet covered, and program quality control. Additionally, the Democratic proposals would have expanded the number of children covered. The first bill extended coverage to some adults and to children from families that had incomes above 200 percent of the federal poverty level. The bill would have increased funding much above what President Bush had proposed, which was significantly lower than the Congressional Budget Office said was needed. Kenney noted that besides opposing a funding increase, Congressional Republicans also opposed raising the income limit for eligible families. According to press reports, the opposition contained an undercurrent of the philosophical debate about the government’s role in providing health care, a harbinger of what will likely be at the core of the future debate on health care in general. Various compromise attempts failed in conference to bridge the differences between the two parties. Finally, in December, with the possibility of SCHIP expiring and the holidays nearing, Congress passed a bill extending the current program until March 2009, an extension that will last until four months after the November elections. Children left behind But according to the Urban Institute study, some children still will be left behind until the issue is finally settled. • First, fewer new dollars will be available to the states in fiscal year 2008 -- $6.6 billion compared to $9.125 billion proposed in the scaled-down second bill. States hoping to expand coverage will find that the increase inadequate. • Second, the extension did not include provisions that would have encouraged the states to enroll more children in Medicaid and keep them enrolled in 2008 and beyond. More uninsured children are eligible for Medicaid than SCHIP, but states get less money covering them in Medicaid, that is, the states receive a lower Federal match for their dollars than they do under SCHIP. Thus, the assumption is that states will be reluctant to recruit more children into Medicaid. • Third, in August 2007, the Centers for Medicare and Medicaid Services (CMS) issued a directive placing conditions on states’ ability to use federal funds to cover children whose families earned more than 250 percent of the federal poverty level ($20,650 annually for a family of four). Most states will not be able to meet those conditions. The Congressional extension keeps that directive in force, making any broad expansion of coverage to children in families with more resources less likely. Indeed, the Urban Institute study says, it will be "difficult if not impossible, for states to comply." The result: many states willing to expand coverage will not be able to. "Therefore, instead of seeing the increase in children’s coverage projected under both five-year SCHIP reauthorization bills that were passed by Congress but vetoed by the President, the number of uninsured children will likely increase, at least in the short run," the Urban Institute study says. The proposed 2009 budget submitted to Congress by the White House in January 2008 does increase funding (an additional $15 billion more than what the President proposed last year) but makes none of the policy changes that would encourage coverage for more children. That will not help the children left currently behind, the study says. The study may be found at: http://www.urban.org/UploadedPDF/411628_SCHIPfailure.pdf.
Being Overweight Is a Matter of Independent Preference and Environment for Female African American Adolescents
Childhood obesity has reached epidemic proportions in the U.S., and young African American females are particularly vulnerable. In government statistics from the years 1999 though 2002, 23.6 percent of African American females between the ages of 12 to 19 were overweight, compared to 12.7 percent of whites and 19.9 percent of Mexican Americans. Along with overweight comes a sedentary lifestyle and poor nutrition and again, AfricanAmerican girls are more likely to experience both. Obesity is a problem because it is associated with increases in childhood diabetes and cardiovascular disease, and overweight teenagers tend to have more limited social and economic opportunities. Attitudes The researchers in the Centers for Disease Control and Prevention (CDC) study, from multiple institutions, used a small sample—12 adolescents and their mothers—from a local hospital-based pediatric diabetes screening and prevention program in North Carolina. The subjects were interviewed for attitudes and perceptions toward body image, food and physical activity. The pilot study "sought to qualitatively explore cultural attitudes and perceptions toward body image, food, and physical activity among a sample of overweight African American girls." The research found: • The individual's immediate social and familial circle largely influenced body size and weight, not her peers. • Close friends around the teenagers are more accepting of being overweight and there is little social pressure for the teens to alter their habits. • Nutrition was not a factor in choosing what to eat; texture, taste, appearance and "context" were more important. • Physical activity was limited by time constraints, access to exercise opportunities, and by neighborhood safety. • Structured exercise was limited by its cost and because of the time involved in maintaining personal aesthetics, such as tending to their hair and nails. • Celebrities were not perceived as role models for diet and physical activity habits. According to the study, led by Josephine E. A. Boyington of Shaw University of Raleigh, N.C., the attitudes of the subjects reflects cultural norms. Food choices also reflect values that can compete with healthy foods. As the authors stated, “Family and peer considerations often superseded personal judgment to eat healthfully as the girls strove to preserve cohesion in various social contexts." As one young woman said, "And like who’s going to pass up their grandma’s cooking? She’s cooking like Sunday, and it be like she’s cooking chicken, collard greens, corn bread, and you know it’s your grandma. She's old-fashioned so you don’t . . . you be like, 'Grandma, can you kind of cut back on the grease?'" The subjects seemed to have a different definition of "overweight" than the researchers and did not believe their weight to be a critical issue. Most of all, the subjects told the researchers, they wanted to be “comfortable” with their bodies, and they were comfortable being "big." "I am not like at the obese stage yet," one said, "and I don't think I’m going to be in the obesity stage." All the subjects were selected because they had a body mass index greater than 95th percentile for their age, the federal standard for overweight. Food was judged on how it tasted rather than whether it was good for them. Since fat-free food usually has less taste, they rejected it at schools when offered. "There’s no seasoning [in] the mashed potatoes," one said. "There's no flavor." They also found healthy foods less filling. Celebrity role models The researchers wrote they were surprised at how little influence celebrities had on the young women. While they admired Oprah Winfrey who has had weight issues, the admiration centered less on what she looked like than on what she had accomplished. The subjects appeared far more impressed by the comedienne Mo'Nique who promotes her large size and appeared to the young women to be a more realistic role model. Future interventions Admitting the number of subjects was small and that the results could not be generalized, the researchers said that health professionals attempting to stem the wave of obesity among African American adolescents needed to consider the findings when establishing programs. "Future intervention efforts should assess girls’ knowledge, perceptions, and self-efficacy levels related to nutrition and physical activity to inform program design,” they wrote. "Assessments should specifically target identifying girls' perceptions of context specific barriers (availability, cost, access, safety, health status) and facilitators (preferred foods, activities, role models) of adopting healthy behaviors." The authors suggest that "approaches favoring school- or home-based physical activities have not been well explored in this population and may be useful for these girls, who perceived lack of opportunities because of limited access to activities and because of unsafe neighborhoods. Furthermore, concerns about personal aesthetics indicate that activities perceived as less disruptive might be more easily adopted than those perceived to be aesthetically costly." The study, "Cultural Attitudes Toward Weight, Diet, and Physical Activity Among Overweight African American Girls" by Josephine E. A. Boyington and colleagues is found at http://www.cdc.gov/pcd/issues/2008/apr/07_0056.htm?s_cid=pcd52a36_e.
Washington State Supreme Court Rules Random Student Drug Searches Violate State's Constitution
In a decision that could have implications in other states despite U.S. Supreme Court rulings to the contrary, the Washington State Supreme Court has held that random drug testing of students violated their right to privacy and that state's constitution. The federal cases do not control how Washington interprets its state constitution, wrote Justice Richard Sanders for the majority. The U.S. Supreme Court ruled on two occasions that the Fourth Amendment to the U.S. Constitution does not bar random testing of students because of "special needs," the necessity for school districts to fight drug use. The Washington court said that state’s constitution makes no provision for special needs and gives greater emphasis to the right to privacy. Parents of three students, Abraham and Aaron York and Tristan Schneider, at Wahkiakum School District on the banks of the Columbia River in southwestern Washington, sued the school distract after their children were subjected to testing, alleging that the tests violated Article 1, Section 7 of the state constitution. The parents lost in Superior Court and the state Supreme Court took the case directly. Article 1, Section 7 reads: "No person shall be disturbed in his private affairs, or his home invaded, without authority of law." Drug problem According to the court, the county (with a population of only 3,800) has an acknowledged drug issue and has been battling it in the schools since 1994. Students themselves listed teen drug abuse as the number one problem in the county. According to a community survey in 1998, 40 percent of sophomores reported having used illegal drugs, 19 percent of them within the previous 30 days. As a result, the school district implemented random drug testing for athletes. Any student involved in school sports had to agree to produce a urine sample. If they test positive, students are suspended from extracurricular activities and provided counseling. Results are kept private. The York and Schneider teens agreed to testing but their parents, assisted by the Washington American Civil Liberties Union sued, claiming that mandatory tests violated student privacy. Among other things, the parents claimed, the tests would reveal what medications the children were taking. Right to privacy Sanders, in his opinion, said the court was aware of the complex issues but limited its review to the tests’ constitutionality. While the U.S. Supreme Court has ruled twice that such testing did not violate the U.S. Constitution, the wording of the Washington state and U.S. constitutions differs, with the Washington constitution specifically mentioning privacy as a right to be protected. Many states have similar wording. "It is well established," Sanders wrote, "that in some areas, Article 1, Section 7 provides greater protection to persons under the Washington Constitution than the U.S. Constitution…." The unanimous decision said the ruling does not prohibit drug testing with cause. "We require a warrant except for rare occasions, which we jealously and narrowly guard. We decline to adopt a doctrine similar to the federal special needs exception in the context of randomly drug testing student athletes. In sum, no argument has been presented that would bring the random drug testing within any reasonable interpretation of the constitutionally required 'authority of law.' " The nine-member court split on whether random, suspicion-less drug testing was constitutional under "carefully defined circumstances." In a statement to the Seattle Times, Doug Honig of the state's ACLU said "the justices concluded, as we had contended, that it violates the state Constitution to require a student to give their urine without any reason to believe they've done anything wrong." The school district has not made a statement. The ruling may be found at http://www.aclu-wa.org/news/state-supreme-court-rules-against-student-drug-testing.
Editor's Commentary: The Continuing Controversy over Autism and Vaccine
Nine-year-old Sara Poling probably does not realize it but her medical case has brought new attention to the old charges that vaccinations can cause autism. Despite well-documented refutations (see below), the Georgia case has become the subject of widespread media attention. Community providers, school nurses and school-based health centers may anticipate inquiries from parents and other caregivers. Early in March, a special federal court that compensates people who may have been harmed by vaccines agreed to pay her family an undetermined amount because Sara developed autism-like symptoms around the time she received the standard childhood immunizations and the inoculations may have aggravated her symptoms. The Internet is now bristling with messages and postings from parents claiming Sara’s case validates their claims that the vaccines can cause autism and the government has conceded the point. The family appeared on CNN's Larry King show and repeated their assertion that the government accepted their argument. The decision has rekindled the dispute over the safety of all immunizations. The American Academy of Pediatrics and public health officials are increasingly concerned that a small but growing number of parents are refusing to get their children inoculated. Diseases once thought controlled are returning. Sara, whose father is a neurologist and whose mother is a lawyer who trained as a nurse, was a bright, normal-behaving child who received her standard vaccinations at the age of 18 months eight years ago. Because that was a bit late, she received all five shots simultaneously. She quickly began screaming and ran a high fever. Then her behavior changed and she demonstrated symptoms much like autism, her family told a news conference. "Suddenly," her mother, Terry said, "my daughter was no longer there." Claim filed The family filed a claim with a special court set up to handle such cases and the government agreed to a payment without hearing any testimony. That led to the belief by many parents of autistics that the government had finally agreed to their position. Hundreds of blogs and websites trumpeted that position. Not so. The U.S. Centers for Disease Control and Prevention (CDC)'s director, Julie Gerberding told a March 6, 2008 news conference, days after the decision, that the case "does not represent anything other than a very special situation." According to the CDC, Sara may not have autism at all. DNA tests have shown she has a genetic disorder called mitochondrial disease, which affects the ability of cells (including brain cells) to use nutrients. Symptoms of mitochondrial disease sometimes match those of autism. Autism itself has no physical manifestations that can be demonstrated in a laboratory, so it is impossible to prove whether the girl has the disorder. The vaccines could have caused a fever that exacerbated the mitochondrial disease. Or, the worsening could have simply been coincidental. The Associated Press reports there have been similar cases, so that while Sara's case is rare, it is not unique. The medical establishment maintains there is no scientific evidence linking autism and vaccines. Sanjay Gupta, a physician and medical reporter for CNN, said his PubMed search of published research papers came up with 404 studies that specifically denied a relationship. Recent studies in England and Sweden also failed to find a connection. In 2000, the Institute of Medicine at the National Academy of Sciences reviewed all the evidence of a correlation between the disorder and vaccines and found none. The American Academy of Pediatrics came to the same conclusion the same year. Nothing has changed since those reports. Alleged threat of vaccinations However, the furor over immunizations is leading to an unexpected problem: the reemergence of diseases once almost eliminated in America. Last month, according to the New York Times, 12 children fell ill with measles in San Diego. Nine had not been vaccinated because of objections from their parents; the other three were too young to get the shots. One child had to be hospitalized. Measles is virtually unknown in the United States. Every state allows exemptions from laws requiring vaccination for medical reasons; most states permit exemptions for religious reasons. According to the National Conference of State Legislators, 20 states permit parents to claim exemption for personal or philosophical reasons. Johns Hopkins Medical Institutions has reported that in 1991 less than 1 percent of school children were unvaccinated due to parent personal belief refusals. By 2004, the percentage was up to 2.54. Epidemiologists warn that children who are not vaccinated are at risk for preventable diseases, and endanger other children. Some children are too young for vaccinations and are therefore susceptible, and some vaccines, such as measles, are not 100 percent effective. The transcript of the CDC's news conference following the Poling case can be found at: http://www.cdc.gov/media/transcripts/2008/t080307.htm.
Credits: Virginia Robinson, Editor, robinsoneditor@attglobal.net
Health & Health Care in Schools is a monthly journal published in html and PDF versions by The Center for Health and Health Care in Schools. Support for Health & Health Care in Schools is provided by The Robert Wood Johnson Foundation.