The State of the Health Professions

U.S. Health and Human Services Secretary Tommy Thompson and Education Secretary Rod Paige joined forces at a Washington, D.C., junior high school February 22 to encourage school children to consider careers in nursing and the health professions. It was the kickoff of a major national campaign called "Kids into Health Careers," aimed at filling what Paige described as "the critical need for qualified nurses" in the years ahead.

At the same time they were touting nursing as a career, the secretaries also noted that not all of the health career opportunities expected to materialize in the future will require advanced college degrees. Some, they pointed out, "are attainable through six-month certificate programs." For starters, students were referred to a tool kit available from the federal government that has information on more than 270 health careers, including nurse, physical therapist, X-ray technician, sports therapist, and emergency medical technician, together with information on the level of education needed to pursue specific health careers, salary outlook, and resources for financial assistance.

Thompson indicated that organizations that receive health professions grants from the Health Resources and Services Administration (HRSA) "will be required to reach out to schools in their local communities to get more kids involved in the health professions."

Sparking HHS' heightened interest in nursing is the final report of a 2000 National Sample Survey of Registered Nurses, which shows the rate of nurses entering the profession has slowed over the past four years. The survey, conducted every four years by HRSA, showed that:

• The average age of registered nurses is increasing. In 2000, only 31.7 percent were under 40 years old, and fewer than 10 percent were under 30.
• While the U.S. population as a whole increased by nearly 10 percent between 1996 and 2000, the rate of nurses entering the workforce in that time period was just 4.1 percent, down from 14 percent in the previous four years.
• There were an estimated 2,696,540 active, licensed RNs in the United States in 2000, an increase of only 137,666 nurses from 1996.
• 81.7 percent, or 2,115,815 of active licensed RNs were actually employed in nursing.
• 12.3 percent of all RNs reported being from ethnic or racial minority backgrounds.
• 5.9 percent of RNs employed in nursing were men, up from 5.4 percent in 1996.

In addition to their long-range effort to interest young people in health careers, the Bush administration is offering some financial incentives. The President's proposed 2003 budget asks for $15 million, a 50 percent increase from this year, for the Nursing Education Loan Repayment Program, which repays a substantial portion of the education loans of nurses who agree to work for two years in designated public or nonprofit private health facilities.

Also, Secretary Thompson announced February 28 that the National Health Service Corps will offer a record $89.4 million in scholarships and loan repayments to doctors and other health professionals, including doctors, nurses, and dentists, who serve in rural and inner-city areas that lack adequate access to health care.

And Thompson called attention to a request in President Bush's 2003 proposed budget for a $114 million increase, to $1.5 billion, for community-based health centers, as part of a long-term strategy to add 1,200 new and expanded health center sites over the next five years and ultimately to double the number of patients treated at them. Thompson noted that half of the patients treated at health centers have no insurance, and many others are inadequately covered.

Critics of the President's proposed 2003 budget point out, however, that it reduces funding for some programs that prepare health professionals. Under the heading "Health Professions," for example the proposed budget allocation of $110 million would represent a reduction of $278 million from this year; and the budget proposes a cut of $85 million in a program that supports health professionals training in free-standing children's hospitals.

And in an announcement February 27, the Health Resources and Services Administration rescinded a January 29 call for applications for Public Health Training Centers grants, which are supposed to "improve the nation's public health system by strengthening the technical, scientific, managerial, and leadership competencies and capabilities of the current and future public health workforce."

"Based on FY 2002 funding, there are insufficient funds available for new public health training centers," HRSA said.

The2000 nursing survey report is available at www.bhpr.hrsa.gov/nursing. Information about "Kids into Health Careers" is available at www.bhpr.hrsa.gov/kidscareers.

Note: Hearings are being conducted by congressional committees on the President's proposed spending plans for next year, and the numbers are subject to change.

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Why Eligible Children Lose or Leave SCHIP

States seem to be doing better than they thought they were at keeping eligible children enrolled in the State Children's Health Insurance Program (SCHIP), according to a study released in February by the National Academy for State Health Policy (NASHP).

NASHP worked over a period of two years with seven states—Alabama, Arizona, California, Georgia, Iowa, New Jersey, and Utah—to learn why families did not re-enroll their children in SCHIP. In telephone interviews of 3,780 parents, and in six focus groups with parents in three of the states, they found that more than two-thirds of the parents had discontinued their families' participation in SCHIP not out of inattention or failure to pay premiums, as had been suspected, but simply because they were no longer eligible. Many had found private insurance coverage, or family incomes had increased since initial enrollment.

One of the flaws in many state programs seems to be that there is no simple way for parents to notify SCHIP when they discontinue participation, leading the states to assume that coverage lapses are the result of failure to renew or missed payments. Some parents do forget to do the paperwork, the study concedes, and while paying premiums is generally not a problem, some families said there were times they could not make the payments. And some lapsed families were simply not aware that they needed to renew annually, indicating that states need to do more to educate families about the renewal process.

Some unexpected insights emerged from the study. The two-thirds of non-renewing parents who left because they believed they were no longer eligible overwhelmingly rated their experiences with SCHIP as excellent or very good, and said they valued the program for its affordability, comprehensiveness, and quality. Many (83 percent) of the parents who now have private insurance said that if they could, they would like to return to SCHIP.

Overall, the study suggests states consider the following ideas to improve SCHIP retention:

• Strengthen efforts to follow up with lapsed families to find out why they left the program and whether they are still eligible.
• Better educate families about the renewal process.
• Improve communication between SCHIP staff and enrolled families to ensure quicker responses to parents' problems and questions.
• Expand premium payment flexibility for families when they are experiencing economic or personal problems.
• Provide additional training and support for SCHIP staff to assist with keeping eligible families enrolled in the program.

Copies of the report, "Why Eligible Children Lose or Leave SCHIP," can be ordered by e-mail at info@nashp.org or from website www.nashp.org.

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HHS Defines 'Poverty' in 2002

The federal poverty guidelines that determine whether families are eligible for Medicaid and the State Children's Health Insurance Program, as well as reduced-price or free school meals and a variety of other federal health and social benefits, were updated in February for the current calendar year.

For the 48 contiguous states and the District of Columbia, a family unit is considered to be in poverty if it has the following income:

1 person - $ 8,860

2 persons - $11,940

3 persons - $15,020

4 persons - $18,100

5 persons - $21,180

6 persons - $24,260

7 persons - $27,340

8 persons - $30,420

Because the overall cost of living is higher in Alaska and Hawaii than in the 48 contiguous states, the poverty threshold is also higher in those two states.

Figures for Alaska are:

1 person - $11,080

2 persons - $14,930

3 persons - $18,780

4 persons - $22,630

5 persons - $26,480

6 persons - $30,330

7 persons - $34,180

8 persons - $38,030

Figures for Hawaii are:

1 person - $10,200

2 persons - $13,740

3 persons - $17,280

4 persons - $20,820

5 persons - $24,360

6 persons - $27,900

7 persons - $31,440

8 persons - $34,980

Some states or programs use multiples of these figures as eligibility guidelines—legislation introduced this month to upgrade SCHIP, for example, calls for defining a low-income child eligible for SCHIP as one with a family income 250 percent of the poverty index.

The federal Department of Health and Human Services, which issues the poverty guidelines, notes that there is no universal administrative definition of "family" or "family unit" that is valid for all programs. But in general, a family is defined as "a group of two or more persons related by birth, marriage, or adoption, who live together; all such related persons are considered as members of one family. For instance, if an older married couple, their daughter and her husband and two children, and the older couple's nephew all lived in the same house or apartment, they would all be considered members of a single family."

It's equally difficult to define "income," the announcement notes, and this year HHS isn't even trying, leaving it to individual programs to determine which kinds of non-cash aid-food stamps or college scholarships, for example-are to be considered as "income" in determining eligibility.

This year's poverty guidelines were published in the Federal Register for February 14, 2002, and can be read at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_register&docid=02-3627-filed

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IN CONGRESS

Legislation Would Allow States to Insure Pregnant Women Under SCHIP

Bills introduced in both the United States Senate and the House of Representatives would give states the option of covering low-income, uninsured pregnant women under a child health plan and would provide an enhanced federal match for states that continuously enroll infants during the first year of life. The bills would also increase SCHIP income eligibility to 250 percent of the federal poverty level.

The changes to the State Children's Health Insurance Program law were introduced in the Senate last June 12 by Senator Jeff Bingaman (D-NM) and more recently in the House by Representative Ted Strickland (D-OH), as a proposed "Start Healthy: Stay Healthy Act."

In addition to the changes in SCHIP, the bills deal with increasing the federal match under Medicaid for states that meet certain conditions, among them that the state:

• Has a child health plan with the highest income eligibility standard permitted as of January 1, 2002, doesn't limit the acceptance of applications, and provides benefits to all children in the state who apply and meet eligibility standards;
• Uses a uniform, simplified application form;
• Coordinates the enrollment process so a family need interact with only one agency to determine if a child is eligible for benefits under either Medicaid or SCHIP, and uses the same verification policies under both;
• Doesn't impose an assets test for eligibility;
• Has 12-month continuous enrollment;
• Has no waiting period longer than six months;
• Offers payment rates sufficient to enlist providers so that care and pediatric, obstetrical, gynecologic, and dental services are available under the plan at least to the extent that they are available to the general population in the geographic area.

The bills would increase SCHIP appropriations, making $3.5 billion available in fiscal 2003, rising to $4.5 billion by fiscal year 2007; and they would amend both SCHIP and Medicaid to give states the option of covering children through ages 20 or 21, instead of the current 19 years.

Pregnancy Aid

The Bingaman/Strickland proposals spell out that SCHIP coverage would take care of a pregnant woman for services related to the pregnancy, including prenatal, delivery, and postpartum services, for at least 60 days following the end of the pregnancy. At the date of the child's birth, the child would be deemed to have applied for child health assistance under the state plan and would remain eligible through the first year of life regardless of the mother's circumstances.

The emphasis on insuring the pregnant woman herself during the term of pregnancy and making the child eligible at birth differs from a proposal described earlier this year by Health and Human Services Secretary Tommy Thompson, who said he plans to offer new regulations for SCHIP that would allow states to insure the unborn fetus as a child, in order to ensure prenatal care.

The proposed regulations have not yet been published in the Federal Register, but Thompson's announcement caused concern among abortion rights advocates that identifying an unborn as a child for purposes of SCHIP would have implications for the wider legal debate about abortion.

The Bingaman bill, introduced last June 12, is S. 1016. Strickland and 25 co-sponsors introduced H.R. 3729 on February 12 this year. Both bills have been referred to committees, and no further action has been taken.

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Bill Would Divert Mentally Ill Children from Juvenile Justice

Noting that increasing numbers of children with mental disorders are entering the juvenile justice system, Senator Paul Wellstone (D-MN) February 26 introduced legislation intended to divert the children away from the justice system and toward community-based services, including mental health and substance abuse services, where they can receive treatment.

"Children with mental illness are largely untreated in the current system," Wellstone said, and "the difficult and sometimes deplorable conditions that prevail in detention centers and youth prisons exacerbate the problems of these children."

Wellstone's bill, the "Mental Health Juvenile Justice Act of 2002," would provide federal funds for training judges, probation officers, and others on identification and need for treatment of mental disorders and would provide funds to communities to develop treatment programs. It would also give federal courts tools to remedy abusive conditions in state facilities in which juvenile offenders and mentally ill prisoners are being held.

The bill, S. 1965, has been referred to the Committee on the Judiciary.

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Bill Would Fund Grants to Educate Health Professionals on Drug Abuse

Many doctors and other health professionals are unprepared to recognize substance abuse in their patients, and a lot of them don't believe treatment works, with the result that only a fraction of addicts now receive pharmaco-therapy treatment, according to Senator Joseph Biden, Jr. (D-DE), who has introduced a bill to educate health professionals on substance abuse and addiction.

Biden pointed out that the Robert Wood Johnson Foundation last year called substance abuse America's number—one health problem. "I don't think that overstates it," Biden said.

Biden's bill, S. 1996, and companion legislation being introduced in the House by Representative Patrick Kennedy (D-MA), would create a grant program administered by the Department of Health and Human Services to train medical professionals to prevent and recognize addiction and refer patients to therapy if they need it.

The bill has been referred to the Senate Committee on Health, Education, Labor and Pensions.

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WORTH NOTING

A Report on Teenage Drinking

An error in statistical interpretation led the Center on Addiction and Substance Abuse at Columbia University to announce February 26 that teens account for 25 percent of all the alcohol consumed in the United States. But after spokesmen for two government surveys --the school-based Youth Risk Behavior Survey and the home-based National Household Survey on Drug Abuse--pointed out that their analyses show teens consume approximately 11 percent of the nation's total alcohol, the Center agreed that it failed to take account of statistical weighting in the survey on which its report is based, which counted teens as 40 percent of the statistical sample while they actually make up only 20 percent of the total U.S. population. Undisputed in the Center's report are other survey findings, including that girls are now as likely as boys to report they take several drinks at a time in order to become inebriated and that binge drinking begins as early as middle school. For further information, about the report, "Teen Tipplers," the Center on Addiction and Substance Abuse can be contacted at www.casacolumbia.org.

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Vaccine Against Deadly Hospital-Acquired Infection

Scientists at the National Institute of Child Health and Human Development (NICHD) and the biologics firm Nabi have developed the first vaccine against Staphylococcus aureus, a major cause of infection and death among hospital patients. The S. aureus bacteria are becoming resistant to the antibiotic most commonly used to treat them, methicillin; and many strains are also now resistant to vancomycin, the only antibiotic known to kill the methicillin-resistant type, placing many hospital patients at risk of deadly infection. Report of the new vaccine appeared in the New England Journal of Medicine February 14.

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Reducing Asthma in Inner-City Children

Asthma researchers reporting to the annual meeting of the American Academy of Allergy, Asthma, and Immunology March 4 said two new ways to reduce asthma severity in inner-city children have emerged from a long-term study involving 3,000 children in 12 centers. The first method, called physician feedback intervention, involves periodic reports to the child's doctor about the status of a child's asthma, which can result in changes in treatment. A second approach, called an environmental intervention, reduces asthma severity by identifying and removing triggers such as tobacco smoke or cockroaches from the child's home. The National Institute of Allergy and Infectious Diseases in the National Institutes of Health, which funded the study, maintains a website at www.niaid.nih.gov.

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Reports Emphasize Child Contact Investigations for TB

The importance of conducting contact investigations, especially of children, after a case of tuberculosis is identified is emphasized in two articles and an editorial in the Febuary 26 issue of the Journal of the American Medical Association. High priority should go to investigating possible child contacts, the authors say, because the progress from infection to disease is high among young children and infected children are a reservoir of future infection. "Preventing disease in child contacts of TB cases is such a high priority that it is recommended that children who initially have a negative tuberculin skin test but have contact with an infectious patient should start treatment for assumed latent TB infection." The editorial urges that clinicians promptly report persons with suspected or confirmed TB and take steps to ensure that contacts of those patients have initial and follow-up skin testing, as well as radiographic evaluation if warranted, and that they initiate and complete therapy. Reprints of the editorial are available from Janet Mohle-Boetani,. MD, at jmohlwbo@dhs.ca.gov.

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Only Lyme Disease Vaccine Is Pulled from Market

Citing poor expected sales, the maker of the only FDA-approved vaccine against Lyme disease said February 27 that it will discontinue making the vaccine. GlaxoSmithKline had $40 million in sales of the vaccine, Lymerix, during its first year on the market, but the company projected that fewer than 10,000 people would seek vaccination this year. The Food and Drug Administration, which approved Lymerix in 1998, said they have no evidence that the drug is unsafe, but in the absence of vaccination, the FDA is urging people to take precautions against the ticks that spread Lyme disease.

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Many Americans Go Online for Health Information

About 35 percent of U.S. Internet users-40 percent of women and 30 percent of men-visited the Web to search for health information in one sample month last year, the U.S. Department of Commerce reported in February. In a study of Internet use during September 2001, the Commerce Department found that persons over 55 years of age and those with household incomes of more than $75,000 were most likely to have searched for health information on line. The report, "A Nation Online: How Americans Are Expanding Their Use of the Internet," can be read online at www.esa.doc.gov/508/esa/nationonline_020502.pdf. (Acrobat Reader is required.)

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February News Alerts

The following information appeared in February in the News Alerts section of this website.

Health Programs in President's Proposed Budget

A $489 billion proposed fiscal 2003 budget for the federal Department of Health and Human Services sent to Congress by President Bush February 4 includes increases or reductions in funding for a number of health programs. For details, click on http://www.healthinschools.org/feb502_alerts.asp.

TV Program for Teens on Steroid Abuse

A public television special, "Steroids: The Hard Truth," aired in February as part of an ongoing campaign to alert health educators, coaches, parents, and teens to dangers and misconceptions about anabolic steroids. The National Institute on Drug Abuse is distributing public service announcements about the health dangers of steroids, in English and Spanish, to television stations nationwide. A research report on anabolic steroid abuse is posted at www.steroidabuse.org.

Advisory Committee Updates Recommendations on Immunization Practices

A report published February 8 by the Advisory Committee on Immunization Practices updates technical guidance for health care providers who administer vaccines to children, adolescents, and adults. The report also includes a directory of immunization resources. Published as Recommendations and Reports, Morbidity and Mortality Weekly Report, February 8, by the Centers for Disease Control and Prevention, the recommendations can be accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5102a1.htm.

Community Mental Health Funds Available

The Substance Abuse and Mental Health Services Administration (SAMHSA) February 13 announced the availability of $13 million in fiscal 2001 funds for an expected 13 to 16 cooperative agreements to develop comprehensive community mental health services for children and adolescents with emotional disturbance and their families. Eligible to apply for the federal funds are state governments, Indian tribes or tribal organizations, and political subdivisions of states such as cities or counties. Details are at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_register&docid=02-3462-filed.

Senate Approves School Pesticide Management

A farm bill passed by the U.S. Senate February 13 includes an extensive program for pesticide management in schools. There is no similar provision in the House version of the farm bill, so it is one of the issues to be decided in a forthcoming House/Senate conference. The full text of the school pesticide provision was printed in the Senate section of the Congressional Record for December 12 last year, as Senate amendment 2485 to the bill S. 1731. Go to website http://thomas.loc.gov and click on "Bill Status and Summary," then enter the amendment number.

Grants Available for Research on Community-Based Prevention

Applications may be submitted by public and private nonprofit organizations or governments and their agencies for $13 million in fiscal 2002 funds for investigator-initiated research on community-based approaches to health promotion and prevention of disease, disability, and injury. The Centers for Disease Control and Prevention expects to fund 30 awards averaging $450,000 for the first 12 months of a projected three-year project period. Deadline for applications is April 30. Full information, is available at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_register&docid=02-4110-filed