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

1. Assuring Healthy Development for Our Children: Creating Political Will for Action Presentation for First Annual Conference on Special Needs Children Deborah Klein Walker, EdD President, American Public Health Association Vice President, Abt Associates September 13, 2007 Louisville, KY

2. �Injustice anywhere is a threat to justice everywhere.� Martin Luther King, Jr.

3. MCH Goal Healthy Children Healthy Families Healthy Communities

5. Outline of Presentation Evidence � What We Know about Child Health and Development Vision � What We Want for Children What Is Needed to Achieve the Vision Social Strategies Needed to Gain Political Will for Change

6. Evidence Reviewed Health insurance Infant mortality Obesity and nutrition Parenting Early childhood Schools and education Poverty

7. Health Insurance Health insurance leads to More children with regular source of health care (medical home) leads to Higher utilization of well child visits, including immunizations

8. Increase of 4 million revivals the increases that triggered last national debate on need for federal policy action Notable that about half the increase in the past two years in income groups above poverty. . All of the increase from decline in private coverage. Public still expanding in the last 2 years..Increase of 4 million revivals the increases that triggered last national debate on need for federal policy action Notable that about half the increase in the past two years in income groups above poverty. . All of the increase from decline in private coverage. Public still expanding in the last 2 years..

9. Administrative Cost Growth Outpaces Total Medical Expenditure Growth

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

11. Uninsured Children in 2005 11.6% of all children 10.8% (ages 0-5) 10.3% (ages 6-12) 13.8% (ages 13-18) Majority of uninsured (83%) are from families where at least one parent works; Among 70% of uninsured children living with a parent, at least one parent works fulltime year round Uninsured children have more unmet needs in medical, dental, vision and mental health care Campaign for Children�s Health, 2006

13. Polio Vaccine Field Trials

15. Components of Health Coverage EPSDT; multiple screening and assessment points Dental care Mental health Nutrition counseling and follow-up Care coordination Education and outreach

16. Coverage for Disabilities and SHCN across the Lifespan Civil rights (ADA, IDEA) Entitlements (SSI) Grants to states (Title V, DD Act) Executive orders (NFI) Supreme Court decision (Olmstead)

17. Coverage for Disabilities and SHCN across the Lifespan Develop meaningful options for transition from the child health and social system to the adult health and social system (ages 14-16 to 25-28) Health Education and employment Transportation and housing Community supports and participation

18. Coverage for Disabilities and SHCN across the Lifespan Assure wrap-around insurance �buy-in� for disabilities across the lifespan Prototype: CommonHealth in MA since 1988 Family Opportunity Act provides mechanism for all states

19. SCHIP Issues Fully fund SCHIP reauthorization for all children and youth in all states. Strenthen federal standard for SCHIP benefits packages to include EPSDT. Provide funding for states to implement improved outreach and stremlined enrollment activities.

21. BUT Health insurance is necessary but not sufficient to guarantee good health outcomes Other barriers to access and utilization of health services need to be identified and addressed in the child care health system

22. Public Health Nurses

23. Infant Mortality Rate, Massachusetts: 1842-2001

26. Infant Mortality Rates, 1950-2000

27. Infant Death Rates by Mother�s Education, 1995

29. INTERVENTION POINTS TO IMPROVE BIRTH OUTCOMES Pre-Pregnancy Activities Prenatal Interventions Perinatal Interventions Post-Natal Interventions

30. Infant Incubator

33. Obesity* Among U.S. Adults 2001

34. Overweight and Obesity

36. So where has the change occurred? It�s been mostly in utilitarian or purposeful, so-called lifestyle activity --in other words, the time spent walking and biking for transport, or active time spent while at work or on the job. Our jobs, our recreation, our activities of daily living have become much more sedentary -- computers, computer games, TV, keep us off our feet. And over the past several decades, in our quest for the easiest and most convenient ways to do things, we�ve found innovative ways to remove physical activity from the simplest aspects of life -- such a climbing stairs, mowing the lawn, walking or bicycling to nearby destinations, delivering memos by walking from desk to desk vs. email, and even opening doors in public buildings. So where has the change occurred? It�s been mostly in utilitarian or purposeful, so-called lifestyle activity --in other words, the time spent walking and biking for transport, or active time spent while at work or on the job. Our jobs, our recreation, our activities of daily living have become much more sedentary -- computers, computer games, TV, keep us off our feet. And over the past several decades, in our quest for the easiest and most convenient ways to do things, we�ve found innovative ways to remove physical activity from the simplest aspects of life -- such a climbing stairs, mowing the lawn, walking or bicycling to nearby destinations, delivering memos by walking from desk to desk vs. email, and even opening doors in public buildings.

37. Poor Nutrition & Physical Inactivity Only 2% of children eat a healthy diet consistent with federal nutrition recommendations 3 out 4 high school students eat less than recommended 5 or more servings of fruits & vegetables 35 % of teenagers are physically inactive

38. Interventions to Address Childhood Obesity Multisector environmental approach needed to support culture change in healthy eating and physical activity (5-2-1-Almost None) Day care Schools Primary care Community (built environment, food portions, farmer�s markets, etc.) Social marketing Workplace

39. WIC: America�s Premier Public Health Nutrition Program Started in 1972 as a Congressionally-legislated pilot project, taken nationwide in 1974 Greatest single point of nutrition and health care access for low-income mothers, infants and children Over 30 years of preventing maternal and child health problems and improving long-term health of mothers and children

40. How WIC Helps Improved birth outcomes and savings in health care Every $1 spent on pregnant women in WIC produces up to $4.21in Medicaid savings for newborns and their mothers Reduced incidence of low-birthweight by 25% and very low-birthweight by 44% Improved diet and diet-related outcomes Lower risk of maternal obesity at the onset of subsequent pregnancy Participation in WIC improves healthy eating index scores

42. High/Scope Study of Perry Preschool In early 1960s, 123 children from low-income families in Ypsilanti, Mich. Children randomly selected to attend Perry or control group. High-quality program with well trained teachers, daily classroom sessions and weekly home visits. Tracked participants and control group through age 40.

43. Perry: Educational Effects

44. Perry: Economic Effects at Age 40

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

46. Perry Preschool � Estimated Return on Investment Benefit-Cost Ratio = $17 to $1 Annual Rate of Return = 18% Public Rate of Return = 16% Federal Reserve Bank Research Group, 2004

47. Brookline Early Education Project Interventions include home visits at birth, parent support groups and drop-in center in community Comprehensive screening and assessment at multiple time points Quality universal preschool at age 3 Sample: 285 infants born in 1973-4 (60% Brookline & 40% Boston; 37% minority and 17% non-English)

48. Levels of Service Intensive, Monthly Home Visits Moderate, Bi-Monthly Home Visits No Home Visits Children were randomly assigned to one of three levels of intensity. In the first two years of life, families in the A group received monthly home visits, families in the B group were visited every other month. There were no home visits for children in the C, group but they had full access to the center and all other benefits of the program. At each evaluation point, specific comparison samples were drawn.Children were randomly assigned to one of three levels of intensity. In the first two years of life, families in the A group received monthly home visits, families in the B group were visited every other month. There were no home visits for children in the C, group but they had full access to the center and all other benefits of the program. At each evaluation point, specific comparison samples were drawn.

51. BEEP 25 Year Follow-up Study Found long term impact on life chances, life experience, health and mental health Blunted disparities in health outcomes among urban youth Majority of parents reported a lasting effect on their parenting skills

52. �Policies that seek to remedy deficits incurred in early years are much more costly than early investments wisely made, and do not restore lost capacities even when large costs are incurred. The later in life we attempt to repair early deficits, the costlier the remediation becomes.�James J. Heckman, PhDNobel Laureate in Economics, 2000

53. Doing this follow-up we certainly learned how much the program was valued by those who participated. Thank you. Doing this follow-up we certainly learned how much the program was valued by those who participated. Thank you.

54. Characteristics of Successful Preschool Programs Developmentally Appropriate Child-Centered Curriculum Parent Involvement and Education Staff Trained in Early Childhood Education Appropriate Staff Child Ratios Good Administrative Structure with Clear Links to Health, Nutrition, and Social Supports

55. Parents With Concerns About Their Children Ages 4-35 Months

56. Source: McLearn, Davis, Schoen, and Parker, �Listening to Parents: A National Survey of Parents with Young Children�, Archives of Pediatrics and Adolescent Medicine, Vol. 152, March 1998. Source: McLearn, Davis, Schoen, and Parker, �Listening to Parents: A National Survey of Parents with Young Children�, Archives of Pediatrics and Adolescent Medicine, Vol. 152, March 1998.

58. Success in School Academic achievement is necessary but not sufficient for successful child and adult outcomes Good health and nutrition is a prerequisite for learning Comer Schools document that the entire school environment and culture must change to support child development so all children learn and become productive adults

60. Child Poverty Although poverty rate declined in 1990s, it has increased steadily since 2000 from 11.3% to 12.7% in 2004 Children experienced the sharpest increase; proportion in poverty rose 13.4% from 15.7% (11M) in 2000 to 17.8% (13M) in 2004 Severe poverty overrepresented by children, African Americans and Hispanics

61. Summary of Evidence Related to Child Health and Development Brain development, environment and child development interrelated Supportive families and communities critical Numerous peer-reviewed studies document interventions for promoting child health and development Investments early in childhood lead to productive and healthy adults Few interventions have been taken to scale for ALL children

62. IOM report on quality in health care was concerned with errors of commission but should have been concerned with errors of omission�e.g., Vaccines not given Helmets not worn Interventions not made for abused children William H. Foege, MD, MPH

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

64. Context for 21st Century Vision Global interconnected world Technology advances Rapid communication and information Age of advertising Growing disparities in rich and poor Competitive political environment Social and behavior �new morbidities� Expanded evidence base Lack of political will to invest in children

65. 21st Century Vision All children and youth have supportive families and communities All have supports and nurturing relationships in child care and eduational settings All children and families have comprehensive health care using a single payer system

66. 21st Century Vision All systems a child interacts with are Culturally competent Prevention oriented Family centered Community based Comprehensive Staffed by individuals knowledgable about child health and development

67. 21st Century Vision Used evidence-based strategies for policy, programs and services Involve parents actively Focus on prevention and enabling services Work effectively with other child systems Use a social determinants model of health

68. All child health and development systems use a population-based approach for all children in their system Systems development is achieved using Assessment strategies Policy development strategies Assurance strategies 21st Century Vision

69. Parents are knowledgable and supported in child rearing Parents are prepared emotionally and financially when a child is born All parents receive a �magazine� at birth of first child and continue to receive one throughout 18 years of parenting (belong to the American Association for All Parents � AAAP) 21st Century Vision

70. Business and workplaces support parents Television and radio stations are dedicated to child development and parenting Sustained social marketing related to parenting is supported 21st Century Vision

71. 21st Century Vision There is a strong �point of accountability� for all children at all levels of government All legislation related to families and children are related to this �point of accountability� There is a strong data infrastructure at all levels of government

72. HOW WILL THE 21st CENTURY VISION BE REALIZED ON THE GROUND? WHAT WILL BE THE STRUCTURE AT ALL LEVELS OF GOVERNMENT?

73. Possible Structures for the 21st Century Vision Title V of the Social Security Act? A New Child and Family Act? A New Children�s Bureau at the State and Federal Level? Other

74. TITLE V BLOCK GRANT Social Security Act - 1935 Amended in 1960�s, 1981, 1989, 1996 Federal/State/Local Partnership Point of Accountability for ALL �MCH Population� Available in All States

75. �MCH does not raise children; it raises adults� �All of tomorrow�s productive, mature citizens are located today someplace along the MCH continuum and they are at some point in their creation, either being conceived or born or nurtured for the years to come� -Pauline Stitt

76. EXPAND FUNDING FOR TITLE V

77. FUTURE GOALS FOR TITLE V Funded to Meet All Goals Recognized as Point of Accountability at State and Federal Levels Linked to All Child and Family Service Sectors Supported by General Public Supported by Local, State and National Organizations

78. Expand Title V Fund states to do home visits for all newborns Fund states to prevent teen pregnancy Fund comprehensive data systems for tracking child health and development Fund states to provide school health and day care training and consultation services

79. Expand Title V Conduct evaluation and monitoring for quality in health services Provide services for all women with a prior poor birth outcome Provide early childhood prevention services for mental health

80. LINK TITLE V TO ALL OTHER MAJOR PIECES OF CHILD AND FAMILY LEGISLATION

81. KEY FEDERAL LEGISLATION SSA Title V - MCH Block Grant SSA Title IV - Welfare, Child Support, Foster Care SSA Title XVI - Supplemental Security Income (SSI) SSA Title XIX - Medicaid SSA Title XXI - SCHIP OBRA �93 Family Preservation Child Care Block Grant

82. KEY FEDERAL LEGISLATION Individuals with Disabilities Education Act (IDEA) Head Start Supplemental Nutrition Program for Women, Infants and Children (WIC) Public Health Service Act Community and Migrant Health Centers (Sections 329 & 330) Family Planning (Title X)

83. CREATE AND ENACT THE �CHILD AND FAMILY� ACT

84. CHILD AND FAMILY ACT �Young Americans� Act Supports Office for Children and Families in All Local Areas Supports Strong State Point of Accountability Supports Strong Federal Point of Accountability

85. Funding for New Act Create a Child and Family (or Invest in America�s Future) Trust Fund Use revenue from tobacco and alcohol sales Create incentives for business and economic development that support child development 1% of all corporate profits go to Trust Fund

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

88. BE PREPARED WITH A PLAN TO MEET THE VISION

89. Learn from the Past Child advocates in past fought hard to reduce child labor practices and improve health Children�s Bureau began in 1912 as a social agency and later added the MCH component Tension among child advocates about which issues take priority has always existed

90. Leadership Model Martha May Eliot, MD Director, MCH Division, Children�s Bureau (1924-1934) Helped draft Title V 1st woman APHA president, 1947 Chair, MCH, HSPH

91. DEVELOP STAFF AND LEADERSHIP FROM MANY DISCIPLINES AND SECTORS

92. BE PROACTIVE; CONNECT TO POLITICAL AND SOCIAL AGENDA OF THE TIMES

93. Action Steps Participate in political campaigns so candidates address children�s issues Create a platform for action for legislators and executive leaders Create partnerships with all sectors impacting child health and development

94. Work in All Settings in Communities Clinical (e.g., provider offices & clinics) Schools Workplaces Communities Jails and prisons Media Academic institutions Other

95. DEVELOP AND ENHANCE LOCAL, STATE AND NATIONAL COALITIONS, PARTNERSHIPS AND AND NETWORKS FOR EDUCATION AND ADVOCACY

96. Building a Child Health Movement Consumers Health Providers Academic Community Purchasers Advocacy Groups Business Public Agencies Consumers & Families The Public

97. Advocacy at the State/Local Level Just as �all politics is local� (Tip O�Neill), all child health is local as well Need strong state public health and child advocacy groups Support education and advocacy through statewide networks � e.g. Children�s Action Networks Public Health Associations

98. �Never doubt that a small group of thoughtful citizens can change the world. Indeed, it�s the only thing that ever has.� Margaret Mead

99. Leadership is Needed AMCHP ATMCH March of Dimes AAP Children�s Defense Fund APHA Others

100. �Sometimes when I get home at night in Washington, I feel as though I had been in a great traffic jam, the jam is moving toward the Hill where Congress sits in judgment on all the administrative agencies of the government. In that traffic jam there are all kinds of vehicles moving up toward the Capitol� There are all of the conveyances that the Army can put in the street� There are the hayricks and the binders and the ploughs and all the other things the Department of Agriculture manages to put into the streets� I stand on the sidewalk watching it become more and more congested and more difficult, and then because the responsibility is mine and I must, I take a very firm hold on the handles of the baby carriage and I wheel it into the traffic.� -Grace Abbott, Children�s Bureau, 1935

101. EACH OF YOU ARE NEEDED; YOU ARE THE LEADERS OF THE MOVEMENT FOR CHILD HEALTH AND DEVELOPMENT

102. New York Times October 2, 2010�CONGRESS PASSES CHILD AND FAMILY ACT�A new era for Title V of the Social Security Act is passed 75 years after the original passage of the Title V MCH program and 45 years after the passage of the �Older Americans Act�.

103. �He who has health has hope; he who has hope has everything.� African Proverb

104.  Deborah Klein Walker, EdD President American Public Health Association Debbie.walker@earthlink.net