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Three States Will Extend SCHIP to Unborn Children States can provide prenatal care to pregnant women under Medicaid, but in regulations published earlier this year, the U.S. Department of Health and Human Services (HHS) gave states another option. Under the new regulations, states may now provide care to "pregnant women and their unborn children" under the State Children’s Health Insurance program (SCHIP), the 1997 program in which Congress authorized states to insure children from working families who are not poor enough to qualify for Medicaid but are unable to afford private health insurance. By designating unborn children as eligible for SCHIP, the Department of Health and Human Services said it wants to expand coverage of prenatal care to pregnant women, "whose children otherwise would not be eligible for Medicaid or SCHIP coverage until after they were born." So far, three states--Michigan, Rhode Island, and Illinois--have chosen to take advantage of the new option. Michigan said in its application that it expects enrollment in the new SCHIP option to reach more than 5,000 "individuals" with family incomes up to 185 percent of the federal poverty level or $16,613 for an individual and $34,040 for a family of four. Rhode Island will extend eligibility in the first year to approximately 675 persons with family incomes up to 250 percent of the poverty level or $17,960 for an individual and $36,800 for a family of four. Neither state indicated whether it is counting unborn children in those estimates. The most recent state to take advantage of the new SCHIP regulation--Illinois—expects to enroll "more than 41,000," again without designating whether that number counts both the pregnant woman and her unborn child, or just the woman. In announcing its approval of the Illinois plan, the Department of Health and Human Services said, "Under the new regulation, states can offer prenatal care as a state plan option under the SCHIP program. This allows states to quickly expand coverage of prenatal care to pregnant women and their unborn children, who otherwise would be eligible for Medicaid or SCHIP coverage only after they are born." States currently experiencing financial difficulties generally fare better under SCHIP than under Medicaid. The SCHIP program give states a federal match of approximately 70 percent of all SCHIP expenditures, compared with federal contributions of 50 percent or more under Medicaid. Reproductive rights advocates point out, however, that by acknowledging unborn fetuses as "children," the states may be laying groundwork for future litigation aimed at overturning abortion rights. Both Medicaid and SCHIP are administered the Centers for Medicare and
Medicaid Services (CMS) in the Department of Health and Human Services.
A June 11 press release announcing CMS approval of the new SCHIP initiative
in Illinois is available a www.hhs.gov/news.
Children Tell Senators about Life with Diabetes The United States Senate Committee on Governmental Affairs took on an unusual look June 23, with more than 200 T-shirted children spilling into the aisles and chattering happily, clearly enjoying themselves and completely disrupting the usually sober atmosphere of the hearing room. They were members of the Children’s Congress of the Juvenile Diabetes Research Foundation International, and they were in Washington to plead with senators for passage of a bill that would encourage pancreatic islet cell transplantation, which holds promise of being a cure for type 1 diabetes. Currently, the only treatment for type1 diabetes, which occurs when an individual’s pancreas fails to produce insulin, is close monitoring of blood sugar and regular injections of insulin. To make their point, the children told the committee what they know about living with type 1 diabetes. Seven-year-old Sophia Cygnarowicz, diagnosed with juvenile diabetes when she was one, said she has taken four thousand, three hundred, and eighty shots of insulin and has pricked her finger over thirteen thousand times to test her blood sugar. She has just finished first grade, but "going to school is hard when you have diabetes," Sophie told the committee. "When I feel low at school I can’t think well. My teacher gives me sugar tablets and I walk to the nurse’s office to do a blood sugar test. A friend comes with me to make sure I get there o.k. Then I have juice and crackers. It takes me a while before I feel better. I don’t like to miss class." And it’s really tough, she said, to "watch the other kids eat cookies and cakes." Unlike Sophie, who has never known a day without diabetes, 16-year-old Katie Halasz does know, and she also knows how life changed when she was diagnosed in 1999. Her school does not allow her to test her blood in the classroom, and when she "feels low" she has to walk from the third floor, where her classes are, to the nurse’s office on the first floor. She knows it is "very dangerous" to walk down three flights of stairs when you are experiencing a blood sugar high and your vision is blurring, but that’s the way it is, she said. Unfortunately, Katie said, her teachers do not understand that blood sugars can go up for no reason and often accuse her of having eaten a candy bar. "Educating my teachers has been one of my biggest challenges since being diagnosed with diabetes," she told the committee. Speaking for all the children, Mary Tyler Moore, international chairman of the Juvenile Diabetes Research Foundation, said, "I’ve had juvenile diabetes for more than 35 years now, and I’m tired of it." She asked the committee not to be misled by the drive and energy of the children in the hearing room. "Each of these children and I need to be a mathematician, a physician, a personal trainer, and a dietitian all rolled into one, just to stay alive," she said. Moore expressed appreciation for some $1.14 billion in special funds Congress has promised through fiscal year 2008 for diabetes research in the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in the National Institutes of Health. But noting that pancreatic islet cell transplantation currently is the best hope for curing diabetes, she pointed out that organ donations fall far short of supplying the number of human pancreases needed for transplantation, and research on stem cells that might develop into pancreatic islet cells is lagging because of "the restrictions of current Administration policy" on stem cell research. To give impetus to the search for a cure for type 1 diabetes, witnesses urged passage of legislation introduced in the Senate in March by Senators Susan Collins (R-ME) and Patty Murray (D-WA), the Pancreatic Islet Cell Transplantation Act of 2003 (S. 518), which would provide federal funding to collect the data necessary to move islet cell transplantation from an experimental procedure to standard therapy. Similar legislation (H.R. 1068) has been introduced in the House of Representatives. Both bills can be read and followed on the Congressional Record website at http://thomas.loc.gov. -------------------------------------------------- Clinical Depression—It’s Not Just for Adults The Journal of the American Medical Association gave special attention in a recent issue to clinical depression in adults, which it identified as "a major public health problem that calls for awareness on the part of virtually all physicians." An epidemiological study found a lifetime prevalence of major depression in 16 percent of adults, with not more than one-quarter of them having received even "minimally adequate" treatment. But the study also found that the age of onset for adult depression was often in the teens; and an accompanying article in the Journal reported the results of recent research into depression in even younger children, including children in elementary school. At one time it was thought that prepubertal youth were not capable of being depressed, but that notion has now been overturned by studies that showed children experience feelings that can only be described as "major depression," and even preschoolers present symptoms such as sadness and lack of energy that also characterize depression in teenagers and adults, said Journal writer Rebecca Voelker. It’s known that adolescent depression grows up to be adult depression, but it is not yet clear whether childhood depression leads to teen depression and then to adult depression, in a single stream. But the basic diagnostic criteria and defining characteristics of depression are the same in children and adolescents as in adults, according to the National Institutes of Health (NIH), though some symptoms may be more obvious at certain developmental stages. Symptoms identified by NIH as being common in children and adolescents include:
In childhood, boys and girls seem to be at equal risk for depressive disorders, though during adolescence girls are twice as likely as boys to develop depression. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age. Treatment In a fact sheet for physicians, the National Institute of Mental Health (NIMH) notes that while scientific literature on treatment of children and adolescents with depression is far less extensive than that concerning adults, a number of studies, mostly conducted in the last four to five years, have confirmed the short-term efficacy and safety of treatments for depression in youth. The NIMH notes that treatment often involves short-term psychotherapy, medication, or a combination of those, together with targeted interventions in the home or school. Using medication is controversial, but studies of some of the newer anti-depressants such as selective serotonin reuptake inhibitors (SSRIs) have shown them to be safe and efficacious for short-term treatment. Currently, the NIMH is conducting large-scale controlled clinical studies to compare the long-term effectiveness of several drugs and psychotherapy; information about the trials is available at www.nimh.nih.gov/studies/index.cfm. The federal agencies caution, however, that even a physician needs help in dealing with severe depression in children, and general practitioners or pediatricians are urged to consult with mental health professionals in diagnosing or prescribing for the condition. For further information, a National Institutes of Health publication "Depression in Children and Adolescents," is available at www.nimh.nih.gov/publicat/depchildresfact.cfm. -------------------------------------------------- What’s Next for HIPAA? Most health care providers have been required for almost three months to protect the privacy of their individually identifiable health information, but it is not clear how well a new federal law—the Health Insurance Portability and Accountability Act (HIPAA), which became effective April 18-- is being complied with. Compliance seems widespread in large health groups, such as HMOs, which are providing patients with required statements of confidentiality practices and generally appear to have taken precautions to safeguard data. The situation may be different in many private practices, however, where HIPAA hasn’t fully penetrated. A survey by HHCS of five medical and dental practices in the Washington, D.C., area, for example, found that none provided the federally mandated notice of privacy practices to patients at a first encounter, as required by HIPAA; and in one waiting room, patient records were still being placed face-up on a counter visible to anyone who cared to look. For schools, protecting the confidentiality of student health information continues to be a puzzle, as administrators try to sort out the complex relationship between HIPAA and the older Family Educational Rights and Privacy Act (FERPA), which protects the privacy of student "education records," including health information that may be part of those records. In writing regulations for the new HIPAA, the Office for Civil Rights in the Department of Health and Human Services deferred to the longer-standing FERPA, saying health information in education records is subject to FERPA protection, not HIPAA. For school-based health centers operated by community health clinics, local hospitals, or HMOs, however, HIPAA is the applicable law, since they are "covered entities" that deliver and bill for medical services. The Office for Civil Rights has so far declined comment on whether school systems that bill Medicaid or private insurers for health care given to students, including students in special education, thereby make themselves subject to HIPAA, since they are performing "HIPAA transactions" as defined in the HIPAA regulations. Schools may encounter HIPAA this fall if they ask private physicians or clinics to give them student immunization records, even if such information-sharing is required by state law. HIPAA sets a floor on privacy protection, and state laws that are less restrictive—which would be the case with laws that allow release of health information not authorized by HIPAA—appear to be superseded by the federal law, though the Office for Civil Rights has not ruled on that point, either. One issue—the financial penalties prescribed for violations of HIPAA—may not as critical as was feared, since the Office for Civil Rights is making clear that it will try to educate violators and obtain compliance, rather than imposing fines; and its enforcement of HIPAA will be "complaint-driven" rather than policed. Health and Health Care in Schools welcomes comments on both HIPAA and FERPA and will continue to update what we know about the two privacy laws. -------------------------------------------------- WORTH NOTING Reports Say Defibrillators Can Be Used on Young Children An article appearing simultaneously in the July 2003 issues of the journals Pediatrics, Circulation, and Resuscitation indicates that newly developed automatic external defibrillators (AEDs) can be used for children as young as ages one to eight who have no signs of circulation. Previously, prehospital care providers and the public were told that AEDs should not be used on children under the age of eight, on the grounds that the instruments deliver adult doses of energy and were designed to read adult heart rhythms only. In the new recommendation, however, the Pediatric Advanced Life Support Task Force International Liaison Committee on Resuscitation says newer AEDs are now available that can correctly analyze pediatric heart rhythms and deliver smaller shocks. The statement recommends that the newer models be made available in public places such as schools. For further information on defibrillation, see the entry below in WORTH NOTING, "Congress Encourages Defibrillation in Schools." A Review of What’s Known about Bullying at School Pioneer research on school bullying has come primarily from other countries, with American researchers rarely examining the extent and effects of school bullying, according to an article published in the May 2003 issue of Journal of School Health. Researchers Joseph Dake, James Price, and Susan Telljohann reviewed what is known about the prevalence of bullying and victimization in U.S. schools at elementary, middle, and senior high levels; the physical and psychological characteristics of bullyers and victims; and the extent to which schools attempt to intervene in or prevent bullying. They recommend more research into the nature of bullying and the level of preprofessional preparation of elementary school teachers regarding bullying, as well as assessment of the perceptions of principals and teachers regarding school-based bullying prevention activities. Response to Smallpox Vaccine in Persons Previously Immunized Persons who were vaccinated against smallpox when they were children had fewer adverse reactions when they were re-vaccinated as part of the current push to immunize health workers, according to an article in the June 25 issue of the Journal of the American Medical Association. Researchers concluded that persons who were vaccinated in the "distant past" can be given diluted smallpox vaccine with little risk of adverse reactions, compared with never-vaccinated persons, possibly due to immunologic memory.
June News Alerts The following information appeared during the month of June in the News Alerts section of this website. Frist Introduces Obesity Control Legislation Senator Bill Frist (R-TN), majority leader of the U.S. Senate, introduced legislation June 3 to "establish grants to provide health services for improved nutrition, increased physical activity, and obesity prevention." Frist’s bill would provide funds to train health professionals to diagnose and treat individuals, including children, who are overweight or suffer from eating disorders; and it authorizes grants to health centers, clinics, health departments, local education agencies, or universities for community-based solutions to increase physical activity and improve nutrition. Introducing his legislation with a group of bipartisan cosponsors, Frist said there is no one solution to the growing epidemic of obesity, and he made clear his bill does not attempt to mandate what Americans eat or drink. "I am all for informed choice," Frist said. "What has happened, though, is that we as a society and as individuals have made choices about eating and activity, gradually and incrementally, without understanding or considering the consequences." He also said the bill "does not intend and should not be considered to stigmatize those who struggle to control their weight." The bill, S. 1172, "Improved Nutrition and Physical Activity Act" or "IMPACT," has been referred to the Senate Committee on Health and Education. The bill can be read in full and tracked on the Congressional Record website, http://thomas.loc.gov. Congress Launches Hearings on Medicaid The first of what are expected to be many congressional hearings on proposals to revise the 40-year-old Medicaid program today looked at how the federal/state health insurance program currently serves some 7 million non-elderly persons with disabilities. The House of Representatives Subcommittee on Health received reports on an experiment under way in three states—Arkansas, Florida, and New Jersey—where persons with disabilities who require home health care are being given a cash allowance to purchase their own personal assistance services. The "Cash and Counseling" program gives disabled persons more control over their lives, the subcommittee was told, and it also appears to save the state and federal governments money, since the payments to individuals are fixed and are not subject to increases as service needs change. Kevin Mahoney, national program director for the Cash and Counseling Demonstration and Evaluation program and a member of the Boston University Graduate School of Social Work, said possible next steps include making the self-controlled home care option permanently part of Medicaid. He noted that the Robert Wood Johnson Foundation and the Department of Health and Human Services, sponsors of the current experiment, are exploring the possibility of expanding the Cash and Counseling approach to other states. Kolbe to Leave as Head of Adolescent and School Health
Lloyd Kolbe, who has headed the Division of Adolescent and School Health (DASH) in the Centers for Disease Control and Prevention for the past 18 years, announced this month that he will leave DASH in August to teach and conduct research in adolescent and school heath at Indiana University. Noting that "DASH’s accomplishments have resulted directly from our collaboration with the national organizations and state and local agencies that serve our nation’s young people," Kolbe said he expects that "our paths will cross regularly in the years to come." The CDC has not yet named a successor to Kolbe as head of DASH. Legislation incorporating Bush administration proposals to significantly change the Medicaid program and reduce financial burdens on states is expected to be introduced in Congress by Representative Billy Tauzin (R-LA), chairman of the House Energy and Commerce Committee. Privately Insured Health Care Costs Continue to Rise Americans who have private health insurance spent 9.6 percent more for inpatient and outpatient hospital care, physician services, and prescription drugs in 2002 than they did in 2001, continuing a rapid growth in health care costs in recent years. Noting that health care spending by the privately insured increased nearly four times faster than the overall U.S. economy in 2002, the Center for Studying Health System Change (HSC) said in a report released today that continuing increases in the cost of health care threaten the affordability of private health insurance. "Unless underlying health care costs slow significantly, health insurance premiums will continue to rise and the number of uninsured Americans will increase," said Paul Ginsburg, coauthor of the study and president of HSC, a research organization funded by the Robert Wood Johnson Foundation. Among the findings:
Legislation and FDA Rules Changes Aim to Speed Generic Drugs to Market Generic drugs, which are almost always less expensive than their brand-name counterparts, will become more readily available to consumers under new regulations being proposed by the federal Food and Drug Administration (FDA). Health and Human Services Secretary Tommy Thompson announced in a press conference June 12 that the FDA will issue regulations limiting the number of challenges a patent-holding drug manufacturer may level against a generic—current rules allow almost unlimited series of 30-month challenges, which have the effect of keeping some generics off the market for years after the original manufacturer’s patent has expired. The new rules will allow only one 30-month delay. The change is expected to save consumers $35 billion over the next 10 years, Thompson said. The new regulations, which will be published in the Federal Register, are expected to go into effect August 18. Congress Unlikely to Make Changes in Medicaid This Year A bipartisan committee of governors named by the National Governors Association to recommend changes in the 40-year-old Medicaid program has reportedly been unable to agree on a recommendation, making it highly unlikely that Congress will take on the controversial Medicaid issue this year. Republican governors on the special committee evidently were willing to go along with Bush administration proposals to convert most of the current program, in which the federal government matches state expenditures, to a federal block grant, while Democratic governors opposed such a change. The administration has proposed a block grant in conjunction with giving states more flexibility in how they allocate their Medicaid funds. The governors’ committee also was reportedly unable to persuade the federal government to assume full financial responsibility for "dual eligibles," meaning elderly persons, often residents of nursing homes, who receive Medicare but are also eligible for Medicaid because they have exhausted their financial resources. This growing population accounts for a large part of Medicaid expenditures in many states. Meanwhile, financially strapped states got a temporary assist from the federal government, which announced June 13 a one-time increase in the amount of Medicaid matching funds states will get from the federal government in the five calendar quarters beginning April 1 this year and ending June 30, 2004. At the same time, the Centers for Medicare and Medicaid Services (CMS) in the Department of Health and Human Services cautioned that the increase is only "short-term relief" and the administration remains committed to giving states more freedom to decide which populations to serve with their Medicaid funds. A letter describing how CMS will determine the exact increase in each state’s federal share of Medicaid beginning with the current quarter is available on the Web at http://cms.hhs.gov/states/letters. More Attention Urged to Effect of Terrorism on Children A National Advisory Committee on Children and Terrorism that was created as part of bioterrorism legislation passed by Congress last year said in its a report released in June that more attention is being given to protecting bridges and buildings than to safeguarding the health and well-being of children in the event of a terrorist attack. "There are more than 70 million children in the United States today," the committee noted. "In the event of a terrorist attack, these children would be among the most vulnerable populations in our society." The report urges a "comprehensive public health strategy to meet the needs of children" in all terrorism-related initiatives that are undertaken by the federal government or state and local governments, including learning all we can from other nations that have experienced terrorism. The report gives priority to "returning children to normal routines with appropriate supports" following any terrorist incident, with special attention to "those settings where children are normally gathered," such as schools. The full text of the committee’s recommendations can be read online at www.bt.cdc.gov/children. Congress Encourages Defibrillation in Schools A bill previously approved by the U.S. House of Representatives was passed by the Senate yesterday, thereby clearing the legislation for President Bush’s signature. Intended to encourage schools to have the equipment and trained expertise to restart hearts in emergencies, the bill, H.R. 389, Automatic Defibrillation in Adams’s Memory Act, calls for establishment of a clearinghouse "to provide information to increase access to defibrillation in schools" and allows use of grant funds under the Public Health Service Act to support the clearinghouse. President Bush is expected to sign the bill. The American Heart Association (AHA) describes defibrillation as "a process in which an electronic device gives an electric shock to the heart. This helps establish normal contraction rhythms in a heart having dangerous arrhythmia or in cardiac rest." The AHA notes that in recent years small portable defibrillators called automatic external defibrillators or AEDs have become available and the association urges that AEDs be available "wherever large numbers of people congregate," including convention centers, sports stadiums and arena, large industrial buildings, high-rise offices, and large health facilities. FDA Approves New Drug for Allergy-Related Asthma The federal Food and Drug Administration June 20 approved a genetically engineered product for treating allergy-induced asthma that can’t be controlled by inhaled steroids. In clinical trials that included adolescents, the product, omalizumab, marketed as Xolair, was shown to decrease the number of episodes of wheezing, breathlessness, and cough. Approved as a second-line treatment to be used only after first-line treatments have failed, and only for allergy-related asthma, the drug has not been tested for use in children under 12. Xolair is manufactured by Genentech and will be marketed jointly with Novartis Pharmaceutical Corp. The product’s label advises skin or blood tests to determine if asthma is allergy-related, since only people who have asthma caused by allergies can benefit from the new treatment. U.S. Birth Rate at New Low; Teen Births Down Statistics released by the Centers for Disease Control and Prevention June 25 show the U.S. birth rate at the lowest level since national data have been available, with 13.9 births per 1,000 persons in 2002, a decline of 1 percent from 14.1 births per 1,000 persons in 2001 and 17 percent lower than the peak of 16.7 births per 1,000 persons in 1990. Birth rates for teenagers continued a decline that began in 1991, with 43 births per 1,000 females ages 15 to 19 years of age in 2002, a 28 percent decline since 1990. "The reduction in teen pregnancy has clearly been one of the public health success stories of the past decade," said Health and Human Services Secretary Tommy Thompson said. "This fact that this decline in teen births is continuing represents a significant accomplishment." Among other significant findings:
The report is available at CDC’s National Center for Health Statistics website at www.cdc.gov/nchs. SBHCs Not Listed as Eligible for Consolidated Health Centers Grants A June 18 press release from the Health Resources and Services Administration (HRSA) announcing the latest recipients of federal grants under President Bush’s five-year initiative to expand the number of health centers nationwide omits school-based health centers from a list of centers to which grants are made under the program. Previous announcements of grant recipients have listed school-based centers, along with community health centers, health care for the homeless centers, migrant health centers, care for the homeless centers, and public housing primary care centers as programs funded under the Consolidated Health Centers Program. There is no explanation in the June 18 press release of the reason for the omission. Here is the relevant language of the June 18 press release and the same paragraph from a March 24 announcement: June 18, 2003: "HHS’ Health Resources and Services Administration (HRSA) manages the Consolidated Health Centers Program, which funds a national network of community health centers, migrant health centers, health care for the homeless centers, and public housing primary care centers." March 24, 2003: "HHS’ Health Resources and Services Administration (HRSA) manages the Consolidated Health Centers Program, which funds a national network of community health centers, migrant health centers, health care for the homeless centers, public housing primary care centers and school-based health centers." The full text of the June 18 press release is available at www.hhs.gov/news. |