Howard K Koh M.D., M.P.H.
Assistant Secretary for Health
U.S. Department of Health and Human Services (HHS)
The State of the American Child: The Impact of Federal Policies on Children
Committee on Health, Education, Labor and Pensions
Subcommittee on Children and Families
United States Senate
Thursday July 29, 2010
Good morning Chairman Dodd, Ranking Member Alexander and members of the Subcommittee. It is my honor to be here today to review the state of children’s health and to present the activities of the Department of Health and Human Services (HHS) to advance the health and well-being of America’s 74.5 million children. The young people of today are tomorrow’s workers, parents and leaders. We must provide them with every opportunity to reach their full potential, which, in turn, requires good health.
First, Mr. Chairman, thank you for your extraordinary service to our nation’s children and families. Over the last 36 years, you have demonstrated an outstanding commitment to developing policies that promote children’s healthy development and guarantee essential health resources. Your leadership has helped millions of poor children receive the care they deserve. You have led so many efforts to build the foundation for health for the youngest and most vulnerable among us. More importantly perhaps, you have long recognized that children’s health is shaped by a constellation of interconnected factors outside of the traditional health realm, including education, family environment and community settings. HHS views “health” through the same broad lens. We share your commitment to ensuring that values of interconnectedness and shared responsibility are part of all of our continuing efforts to respond to the health needs of infants, children, adolescents and their families.
I am pleased to say that the health status of children as a whole has improved significantly over the last few generations. Expanded access to health care and increased commitment to the development of comprehensive and coordinated child health initiatives across life stages have led to this improvement. We at HHS are acutely aware of the many challenges that remain such as childhood obesity prevention, tobacco control and the onset of mental health disorders, and we are working with our federal, state and local partners to address them. That’s why one of the first things President Obama did was sign into law a reauthorization of the Children’s Health Insurance Program (CHIP)— a down payment on comprehensive health insurance reform. And in March of this year, the president signed the Affordable Care Act, putting in place comprehensive reforms that will hold insurance companies more accountable, lower health care costs, guarantee more health care choices, and enhance the quality of health care for all Americans. These new laws will have far reaching positive impacts on our healthcare system and on children’s health and lives for generations to come.
Expanding Access and Improving Quality: Children’s Health Insurance Program Reauthorization Act (CHIPRA) and the Affordable Care Act
Expanding access to private and public coverage:
CHIPRA and the Affordable Care Act greatly expand resources and coverage for CHIP and seek to improve the quality of care, including shifting toward a greater focus on prevention. CHIPRA and the Affordable Care Act combine to provide an additional $69 billion in Federal CHIP allotments through FY 2015. The Centers for Medicare and Medicaid Services (CMS) shows that in FY 2009, 8 million children were enrolled in CHIP, and the funding increases in CHIPRA and the Affordable Care Act will allow States to cover million more children in both Medicaid and CHIP.
Additionally, Secretary Sebelius has initiated the Secretary’s Challenge: Connecting Kids to Coverage, a 5-year campaign that will challenge federal officials, governors, mayors, community organizations, tribal leaders and faith-based organizations to enroll the nearly 5 million uninsured children who are eligible for Medicaid or CHIP but are not currently enrolled.
The Affordable Care Act builds on these commitments. Children will benefit from new rules of the road that insurance companies have to follow, comprehensive reforms that expand access to health coverage, a new emphasis on the quality of children’s care, and important new policies and programs that will put prevention first.
Beginning this year, health insurance companies will be prohibited from excluding children from coverage because of pre-existing conditions. Additionally, insurance companies will no longer be allowed to impose lifetime dollar limits on essential benefits, nor will they be permitted to cancel coverage when an individual gets sick just because of a mistake in her paperwork.
To move toward a system where all children have access to health insurance, the new law not only extends CHIP through Fiscal Year 2015 and provides additional funding, but also strengthens both Medicaid and CHIP by raising Medicaid’s Federal income eligibility floor to 133 percent of the federal poverty level in 2014 and maintaining existing levels of coverage for children in CHIP. Furthermore, in 2014, families who are not eligible for other affordable coverage will be able to use state insurance exchanges to obtain coverage for themselves and their children.
Improving quality of health care:
To address quality improvement in children’s health care, the Affordable Care Act creates quality priorities and promotes quality measurement for children, as well as reporting requirements for care children receive. The Act outlines provisions to ensure there are an adequate number of medical providers to meet increased future needs. And, coverage in the new State-based insurance Exchanges will include children’s dental and vision coverage, two critical forms of coverage are often not included in coverage packages for children.
Children will also benefit from unprecedented investments in prevention at both the individual and community levels, as essential prevention services are more fully integrated between the clinic and community. At the individual level, new health plans are required to cover recommended preventive services with no cost-sharing for the enrollee. These recommended services include regular well-baby and well-child visits, routine immunizations, and other screenings that are important to keep kids healthy. Additionally, the Affordable Care Act makes a major investment - $1.5 billion over 5 years - in evidence-based home visitation programs designed to improve outcomes - including maternal and child health and development outcomes - for pregnant women and families with young children.
To ensure quality and safety of pediatric medications, the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act have stimulated pediatric studies of therapies intended for the pediatric populations. As a result, labeling has been changed for almost 400 medications to include information to guide safe use in children. Before 1997, a majority of medications (approximately 80%) that were prescribed to pediatric patients were not studied in children.
At the community level, the Affordable Care Act invests $15 billion over the next ten years in public health and prevention programs through the creation of the Public Health and Prevention Fund to promote improved health outcomes. Its activities will complement the work of the first-ever National Prevention and Health Promotion Strategy, which will emphasize prevention and well-being – identifying and prioritizing actions across government and between sectors to benefit Americans of all ages.
By expanding and sustaining the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe, HHS is working to transform our health care system to keep children healthy and reduce the likelihood that children will develop chronic disease later in life. As part of this historic commitment, the Department has leveraged the Communities Putting Prevention to Work (CPPW) program, funded through the American Recovery and Reinvestment Act (ARRA). This program expands the use of evidence-based strategies and programs, mobilizes local resources at the community-level, and strengthens the capacity of states. Through its four distinct but unified initiatives, CPPW will: increase levels of physical activity; improve nutrition; decrease obesity rates; and decrease smoking prevalence, teen smoking initiation, and exposure to second-hand smoke. The initiative’s strong emphasis on policy and environmental change at both the state and local levels supports an expanding definition of “health” for the public.
Defining “Health” and Healthy Children
The definition of “health” in childhood has evolved significantly over time. A century ago, when infectious diseases posed the greatest threat, “health” was viewed as the absence of disease or premature mortality. Today, “health” in general, and children’s health in particular, is now viewed in a broader developmental context. A 2004 Institute of Medicine (IOM) report, Children’s Health, The Nation’s Wealth, proposed a new definition to reflect these new realities:
Children’s health should be defined as the extent to which an individual child or groups of children are able or enabled to: a) develop and realize their potential; b) satisfy their needs; and c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.
This broader definition incorporates not only the physical absence of disease, but also highlights healthy development throughout life stages which recognizes the critical roles of mental and social well-being. As shown in the Centers for Disease Control and Prevention’s (CDC) Adverse Childhood Experiences study, psychologically difficult events in childhood are linked with a range of later physical and behavioral health problems, including smoking, suicide, heart and lung disease, physical injury, diabetes, obesity, unintended pregnancy, sexually transmitted diseases, and alcoholism (Felitti Et Al. 2002). Indeed, as noted by the World Health Organization (WHO), “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
This “social determinants” approach to health is the vision behind the Department’s Healthy People initiative – a national health-promotion and disease-prevention agenda that, for the last three decades, has articulated overarching goals, emerging public health priorities and tracked movement toward specific targets. In the coming decade, Healthy People 2020 proposes four overarching goals: 1) achieve health equity, eliminate disparities and improve health for all groups; 2) eliminate preventable disease, disability, injury and premature death; 3) promote healthy development and healthy behaviors across every life stage; and 4) create social and physical environments that promote good health for all. As we prepare for the next decade, implement the Affordable Care Act, and enter a new era of prevention, HHS will continue using the Healthy People framework as a public health roadmap to unify our national dialogue about health, including children’s health, motivate action, and encourage new directions in health promotion.
Wrapping up Healthy People 2010 activities permits an assessment of the status of children’s health in relation to targets set a decade ago. Preliminary analyses indicate that the nation has either progressed toward or met the target on a number of objectives for children. These figures, detailed below, reflect movement on a host of diseases, conditions, risk factors, and behaviors for the growing population of U.S. children.
State of Children’s Health: Data snapshot and Progress Toward Healthy People 2010 Targets:
The number of children in the U.S. is increasing. In 2009, there were 74.5 million children in the U.S., 2 million more than in 2000. This number is projected to increase to 101.6 million by 2050. In 2009, the population of children was evenly divided over three age groups: 0–5 years (25.5 million), 6–11 years (24.3 million), and 12–17 years (24.8 million). Children’s racial and ethnic diversity is projected to grow in the decades to come: by 2023; less than half of all children are projected to be White, non-Hispanic. By 2050, 39 percent of U.S. children are projected to be Hispanic (up from 22 percent in 2009), and 38 percent are projected to be White, non-Hispanic (down from 55 percent in 2009).
Similar to the Healthy People framework which is used to motivate action on children’s health activities and improve health outcomes, the Forum on Child and Family Statistics releases an annual report using statistical data from 22 federal agencies on the well-being of U.S. children and families. This year’s report demonstrates a number of key positive trends including: a decline in the percentage of preterm births (for the second straight year); an increase in health insurance coverage rates for children; a decline in the adolescent birth rate after a two-year increase; and teen smoking rates at their lowest levels since data collection began for the report.
Maternal, Infant and Child Health and Early and Middle Childhood
Perhaps the most notable development is that following years of increases, the Nation’s preterm birth rate declined for the second straight year, from 12.8 percent in 2006 to 12.7 percent in 2007 to 12.3 percent in 2008. Decreases in preterm birth rates between 2007 and 2008 were seen for each of the three largest race and ethnicity groups: White, non-Hispanic; Black, non-Hispanic; and Hispanic women. Still, 1 out of every 8 babies in the U.S. are born preterm, and the U.S. preterm birth rate is higher than in most developed countries.
After decades of decline, the recent stagnation in the U.S. infant mortality rate has generated concern among researchers and policy makers. The U.S. infant mortality rate did not decline significantly from 2000 to 2005, showed a slight decline from 2005 to 2006, and a non-significant increase from 2006 to 2007. In 2007, a total of 29,138 infant deaths occurred in the U.S., and the U.S. infant mortality rate was 6.75 infant deaths per 1,000 live births, compared with 6.89 in 2000. Furthermore, there persist significant disparities in infant mortality rates among racial and ethnic minorities.
Maintaining and enhancing the success of childhood vaccination is crucial to ensuring children’s long-term health and public health. Increased immunization rates over the last century have improved children’s health and increased life expectancy. Today, childhood vaccination rates are at near record high levels but they can still improve.
Autism is more prevalent than previously believed, affecting one out of every 110 American children.
Chronic diseases continue to affect a large percentage of children. For example, nearly 1 in 10 children (9%) have asthma, which includes children with active asthma symptoms and children with well-controlled asthma. The percentage of children with current asthma increased slightly from 2001 to 2008.
Childhood obesity is another major public health challenge: 1 in 3 U.S. children are over-weight or obese. Additionally, a third of children born in 2000 are expected to develop weight-related diabetes in their lifetime. Combined data for the years 2005–2008 indicate that Mexican-American and Black, non-Hispanic children were more likely to be obese than White, non-Hispanic children. Obesity impacts children in almost every facet of their life, not just health. According to the White House Task Force on Childhood Obesity’s Report to the President, severely obese children have a level of health-related quality of life (a measure of their physical, emotional, educational and social well-being) well below their peers that are not overweight. Obesity rates are related to poor eating patterns: in 2003–2004, on average, children's diets were out of balance, with too much added sugar and solid fat and not enough nutrient-dense foods, especially fruits, vegetables, and whole grains. The average diet for all age groups met the standards for total grains, but only children ages 2–5 met the standards for total fruit and milk.
Unintentional injuries—such as those caused by burns, drowning, falls, poisoning and road traffic—also remain the leading cause of morbidity and mortality among children in the U.S. Each year, among those 0 to 19 years of age, more than 12,000 people die from unintentional injuries, and more than 9.2 million are treated in emergency departments for nonfatal injuries.
Injury and violence are the leading causes of death for adolescents. For example, motor vehicle crashes are the leading cause of death for U.S. teens, accounting for more than one in three deaths in this age group. In 2008, nine teens ages 16 to 19 died every day from motor vehicle injuries. Per mile driven, teen drivers ages 16 to 19 are four times more likely than older drivers to crash. Fortunately, teen motor vehicle crashes are preventable, and proven strategies can improve the safety of young drivers on the road. In 2008, about 3,500 teens in the United States aged 15–19 were killed, and more than 350,000 were treated in emergency departments for injuries suffered in motor vehicle crashes. Young people ages 15-24 represent only 14% of the U.S. population; however, they account for 30% ($19 billion) of the total costs of motor vehicle injuries among males and 28% ($7 billion) of the total costs of motor vehicle injuries among females.
Today’s adolescents face a variety of challenges and stresses. By far, the largest challenges to this age group are the dangers of drugs and alcohol, and the onset of mental health disorders. Illicit drug use among youth remained unchanged from 2008 to 2009. In 2009, 8 percent of 8th-graders, 18 percent of 10th-graders, and 23 percent of 12th-graders reported illicit drug use in the past 30 days. These statistics represent declines from peaks of 15 percent for 8th-graders and 23 percent for 10th-graders in 1996 and 26 percent for 12th-graders in 1997. However, the proportion of 8th graders who disapprove of trying marijuana or hashish once or twice increased from 69 percent in 1998 to 76 percent in 2004, exceeding the Healthy People target of 72 percent. An emerging substance use issue of concern is the non-medical use of prescription drugs among teens. Past-year nonmedical use of substances such as Vicodin and OxyContin increased during the last 5 years among 10th-graders and remained unchanged among 8th- and 12th-graders. Nearly 1 in 10 high school seniors reported non-medical use of Vicodin; 1 in 20 reported abuse of OxyContin.5
Alcohol use is an ongoing public health concern. Between 1999 and 2009, heavy drinking declined from 13 percent to 8 percent among 8th graders, from 24 percent to 18 percent among 10th graders, and from 31 percent to 25 percent among 12th-graders. For students in grades 9 through 12, riding with a driver who has been drinking achieved its Healthy People target. In addition, a nationwide legal standard of .08 percent blood alcohol concentration (BAC) maximum levels for driving while intoxicated (DWI) enforcement and prosecution was achieved. This standard represents an effective tool in the effort to combat drunk driving. Research has found that passage of a 0.08 percent BAC per se law (which makes it an offense in and of itself to drive with a BAC measured at or above .08, whether or not the driver or operator exhibits visible signs of intoxication), particularly when accompanied by publicity, results in a 6 percent to 8 percent reduction in alcohol-related fatalities. In spite of these gains, underage drinking remains a serious threat to the health and safety of adolescents. On average, 28 % of youth aged 12 to 20 drank alcohol in the past month. These underage drinkers consumed, on average, more drinks per day (4.9) on the days they drank than persons aged 21 or older (2.8).
Also, despite progress in reducing tobacco use, nearly 3,900 kids try their first cigarette each day, and 1,000 of those children become daily smokers. Tobacco dependence is recognized as a pediatric disease because 90% of tobacco users begin using before 18 yrs of age. Recent Morbidity and Mortality Weekly Report data from CDC on tobacco found that for three measures of cigarette use (ever smoked cigarettes, current cigarette use, and current frequent use), rates among high school students began to decline in the late 1990s, but the rate of decline slowed during 2003-2009. However, indicators of exposure to second-hand smoke in children have decreased from 88 percent in the years between 1998 and 1994 to approximately 53 percent in 2007-2008. But this still represents a significant risk because routine exposure to second-hand smoke increases the probability of lower respiratory tract infections, asthma, and sudden infant death syndrome.
Mental health disorders also often have their onset during the teen years. In 2008, 8.5 percent of youth aged 12-17 years old had a major depressive episode in the past year. In fact, half of all lifetime cases of mental illness begin by age 14 and ¾ by age 24. In this sense, adolescence is a particularly vulnerable period for the onset of mental disorders.
Early sexual activity is also associated with emotional and physical health risks. Youth who engage in sexual activity are at risk of contracting sexually transmitted infections (STIs) and becoming pregnant. In 2007, 48 percent of high school students reported ever having had sexual intercourse. In the same year, among those reporting having had sexual intercourse during the past 3 months, 16 percent reported the use of birth control pills to prevent pregnancy before the last sexual intercourse, and 62 percent reported use of a condom during the last sexual intercourse.
The Healthy People midcourse review:
At the Healthy People 2010 midcourse review, progress was made toward achieving or exceeding targets for the nation’s maternal, infant, and child health objectives. We can cite achievements throughout the life course of the young child through to young adulthood, including:
Preconception care - Folic acid intake: The proportion of women of child-bearing age consuming the recommended daily intake of folate increased. Median red blood cell (RBC) folate levels for non-pregnant females aged 15 to 44 years exceeded the Healthy People target of 220ng/ml.
Preconception care - Smoking cessation: The proportion of women who have abstained from smoking during pregnancy increased, moving toward the target of 99 percent.
Perinatally acquired HIV: The target for the number of new cases of perinatally acquired AIDS was exceeded: new cases declined from a baseline of 82 new cases in 2002 to 57 cases in 2003, surpassing the target of 75 cases. Prevention of perinatal HIV transmission requires routine HIV screening of all pregnant women and the use of appropriate antiretroviral and obstetrical interventions that begin during the pregnancy and continue through the first few months of the infant’s life. Together, these actions can reduce the rate for mother-to-child HIV transmission to 2 percent or lower.
Breastfeeding: Rates increased for immediate and 6- and 12-months post partum.
Immunizations:A number of Healthy People vaccination objectives reached their targets, including those related to diphtheria, polio, hepatitis, bacterial meningitis, pneumococcal infections, and meningococcal disease (for adolescents). Perinatal hepatitis B prevention programs and the routine hepatitis B vaccination of children have also resulted in a decline of cases of chronic hepatitis B virus infections in infants and children aged 2 years and under – achieving 63 percent of the targeted change. Additionally, just as the objectives related to the vaccinations themselves are important, so are the objectives related to evidence-based strategies for raising vaccination coverage rates. The proportion of public and private health care providers who have measured childhood vaccination coverage levels and the proportion of children participating in population-based immunization registries moved toward their targets.
Sudden infant death syndrome (SIDS): Despite significant declines in rates since 1990, SIDS remains the third leading cause of infant death. Clear reductions occurred in infant deaths and deaths attributed to sudden infant death syndrome. Reported rates for SIDS declined by 15 percent between 1999 and 2002. From its original baseline of 35 percent, the proportion of infants being put to sleep on their backs met the Healthy People target of 70 percent.
HHS Activities to Improve Child Health Outcomes
Multiple agencies within HHS are working to maximize the impact of available resources to respond to the current and emerging physical, mental and social health needs of children and their families. In the rest of the testimony, we use the lifespan framework to review the current status of these activities:
Maternal, Infant, and Child Health and Early to Middle Childhood
Current program activities and accomplishments
Infant mortality: HHS is analyzing reasons for the recent stagnation in infant mortality rates, possible causes of preterm birth, issues in the coding and reporting of sudden and unexplained infant deaths, and strategies for preventing maternal illness and death. Given the high preterm birth rate, and the lack of substantial decline in the infant mortality rate in the U.S., a comprehensive public health research agenda that investigates the social, genetic, and biomedical factors contributing to preterm birth and existing racial and ethnic disparities would inform policies and activities. A National Summit on Preconception Care was convened by CDC and its partners in June 2005, and there have been subsequent conferences focused on preconception care in 2008 and preconception health in 2010. National recommendations to coordinate services are forthcoming and are expected to lead to improved pregnancy outcomes and reduce costs associated with adverse perinatal outcomes.
SIDS: The national “Back to Sleep” campaign is educating physicians and caregivers about the risks associated with prone sleeping (sleeping with stomach facing down). As a result of the campaign and other SIDS prevention education, the proportion of infants being put to sleep on their backs has doubled since the baseline in 1996, but the rate has leveled off in recent years.
Prenatal care: HHS is a partner for Text4Baby, a free mobile information service designed to promote maternal and child health. An educational program of the National Healthy Mothers, Healthy Babies Coalition (HMHB), Text4Baby provides pregnant women and new moms with information to help them care for their health and give their babies the best possible start in life. Women who sign up for the service by texting BABY to 511411 (or BEBE in Spanish) will receive free text messages each week, timed to their due date or baby’s date of birth. CDC is also promoting the Baby-Friendly Hospital Initiative, a global program sponsored by the WHO and the United Nations Children’s Fund (UNICEF), to encourage and recognize hospitals and birthing centers that offer an optimal level of care of lactation according to the WHO/UNICEF Ten Steps to Successful Breastfeeding for Hospitals.
Folic acid intake: Consumption of folic acid by women of childbearing age has been shown to reduce the rate for neural tube defects (NTD). HHS, through the Food and Drug Administration (FDA) and CDC, has emphasized food fortification with folic acid to help prevent NTDs. In addition to food fortification, CDC has several ongoing folic acid education projects designed to reach affected populations.
Smoking cessation: Federal partnership activities aimed at reducing tobacco use among pregnant women are under way, including efforts to strengthen states’ capacities to develop, implement, and evaluate tobacco prevention and cessation programs for women of reproductive age.
Perinatally acquired HIV: The Health Resources and Services Administration (HRSA) continually monitors the number and proportion of babies tested who are born to HIV-positive mothers enrolled in programs funded under Title XXVI (HIV Health Care Services Program) of the Public Health Service Act, the number of children receiving care and treatment, the number of pregnant HIV-positive women in care, and the number of pregnant women on prophylaxis. The reduction of babies born infected with HIV is also apparent in programs authorized under Title XXVI. This decline is attributable, in part, to the emphasis placed on testing high-risk women of child-bearing age, enrolling those women testing positive into primary care, and ensuring that pregnant women are provided with appropriate primary care for therapy and prenatal care through providers under Title XXVI.
Breastfeeding: Multiple initiatives support breastfeeding, from the federal level down to the community level. Among federal initiatives that encourage breastfeeding are the “National Breastfeeding Awareness Campaign,” the Healthy Start Initiative, and HRSA’s Title V Maternal and Child Health Block Grant Program. Additionally, the Affordable Care Act requires employers to provide a reasonable break time and place for breastfeeding mothers to express milk for one year after their child’s birth. HHS is working with other federal departments and public and private employers to help mothers receive the support they need to breastfeed in the workplace.
Immunizations: HHS, led by CDC, supports state-based immunization efforts that make vaccines available to financially vulnerable children and adolescents, as well as adults when funds are available. Additionally, a significant investment $300 million was made through ARRA in supporting state- and local-based programs to ensure vaccination efforts reached underserved groups. Funds will also support programs to increase public awareness and knowledge about the benefits of vaccination, as well as the risks of vaccine-preventable diseases. Additional funds were also allocated to assess the impact and effectiveness of newly recommended vaccines and monitor vaccine safety.
HRSA’s Title V Block Grants for maternal and child health: HRSA’s Maternal and Child Health (MCH) Block Grant program is a key federal effort that focuses solely on improving the health of all mothers and children. The partnership between the federal government and states ensures that the needs of mothers and children, including children with special health care needs, are addressed. Specifically, the program seeks to: 1) assure access to quality care, especially for those with low-incomes or limited availability of care; (2) reduce infant mortality; (3) provide and ensure access to comprehensive prenatal and postnatal care to women (especially low-income and at risk pregnant women); (4) increase the number of children receiving health assessments and follow-up diagnostic and treatment services; (5) provide and ensure access to preventive and child care services as well as rehabilitative services for certain children; (6) implement family-centered, community-based, systems of coordinated care for children with special healthcare needs; and (7) provide toll-free hotlines and assistance in applying for services to pregnant women with infants and children who are eligible for Medicaid. The program’s wide range of activities include support for MCH research, training of MCH providers, genetic services and newborn screening and follow-up, sickle cell disease, hemophilia, universal newborn hearing screening, and early childhood systems of services that bring together health, education and social services.
In working to improve access to healthcare, the MCH Block program has been able to increase both the number of children served by the States under Title V (to 35 million in FY 2008) and the number of children receiving services under Title V of the Social Security Act who have Medicaid and CHIP coverage. Increased coverage under Medicaid and CHIP for children receiving Title V services better assures access, availability, and continuity of care to a wide range of preventive and acute care services.
Childhood Obesity: HHS is partnering with the First Lady in promoting the “Let’s Move” campaign to end the epidemic of childhood obesity in the next generation. Based on four pillars of helping parents make healthy choices, creating healthy schools, providing access to healthy and affordable food, and promoting physical activity, the initiative is helping schools, communities and families address the epidemic.
HHS’s early actions to implement elements of the White House Childhood Obesity Task Force Plan include efforts to prevent childhood obesity in child care settings – a pivotal phase in children’s lives. While each state creates and enforces its own child care licensing standards, HHS, though the Administration on Children and Families, plans to roll out guidance and suggested standards for physical activity and nutrition for child care later this summer. Also, as part of the Head Start Body program, HHS will provide individual grants to Head Start programs to improve or construct playgrounds and outdoor play spaces under the Head Start Body Start National Center for Physical Development and Outdoor Play. HHS is also empowering parents and caregivers with nutritional knowledge, tools and resources to make healthy choices. Over the next year, HHS will: in partnership with the Department of Agriculture, release the new Dietary Guidelines for Americans that provides science-based advice about making food choices to promote health; develop a new Front of Pack labeling system to make it easier for consumers, with a quick glance, to make healthy and informed food choices; and oversee the implementation of menu labeling provisions authorized by the Affordable Care Act. The Affordable Care Act requires owners of retail chain restaurants and vending machines (with more than 20 locations) to post caloric information, which will empower consumers to make healthier choices.
HHS is also implementing community demonstration projects authorized by CHIPRA; the Department will award $25 million in grants to select communities for health care providers to work with schools, community programs, recreation centers and other groups to build seamless community-clinical systems to reduce and prevent obesity among child residents. Additionally, since the White House Task Force established a goal of 100% of primary care physicians assessing body mass index (BMI) at well-child and adolescent visits by 2012, HHS will outreach to State Medicaid Directors to help them better understand the scope of prevention services they should provide to children and encourage BMI assessment and follow-up. Also, HRSA has launched a learning collaborative to significantly increase the health of children and families. Over the next year (through July 2011), faculty experts are helping to design, implement and test information that communities, including grantee community health centers, can use to help children achieve and maintain a healthy weight.
Additionally, HHS is updating the President’s Challenge program to ensure consistency with the Physical Activity Guidelines and make it easier for schools to implement the program. The First Lady has set a goal of doubling the number of children in the 2010-2011 school year who earn a President’s Active Lifestyle Award (PALA). HHS will lead our nation toward achieving this goal. The modernization of the President’s Challenge Youth Fitness Test will begin this year, and HHS will double the number of children in the 2010-2011 school year who earn a PALA award.
Obesity research also continues across the Department. For example, the National Institutes of Health’s (NIH) National Collaborative of Childhood Obesity Research (NCCOR), launched in 2009 in partnership with the CDC and the Robert Wood Johnson Foundation, is accelerating research progress and translating findings into effective solutions at the societal level. NCCOR is designed to coordinate funding efforts, pooling members’ resources for large projects that might not be feasible otherwise. NCCOR recently launched the Envision project ($15 million), which aims to help us understand the complexity of childhood obesity and virtually test environmental and policy interventions through sophisticated computational, systems models. During Fiscal Year 2010, NCCOR also will begin funding a nationwide study to determine the effectiveness of existing community-based strategies and programs.
Childhood Injury Prevention: Through public health surveillance efforts, research and implementation of effective strategies, CDC is working to protect young Americans from the threat of injury and violence. CDC prioritizes its work children and adolescents by focusing on (1) child maltreatment prevention and (2) prevention of child/adolescent motor vehicle related injuries.
Motor Vehicle Injury Prevention: CDC's research and prevention efforts are focused on improving seat belt use and reducing impaired driving, and helping groups at risk: child passengers and teen. Examples include raising parents' awareness about the leading causes of childhood injury in the U.S. and how they can be prevented. For example, CDC launched the initiative titled Protect the Ones You Love: Child Injuries Are Preventable. CDC is also supporting states in the implementation of optimal graduated licensing laws (GDL).
CDC's research and prevention efforts are focused on improving seat belt use and reducing impaired driving, and helping groups at risk: child passengers and teens.
Autism and Developmental Disabilities: Through ARRA, funding for autism research increased from $118 million in Fiscal Year 2008 to $196 million in Fiscal Year 2009. Several HHS agencies and offices are addressing autism spectrum disorders through research, surveillance, public education, and service delivery. HHS and the White House co-hosted a meeting with external stakeholders in recognition of World Autism Awareness Day on April 2, 2010, to learn more about the gaps in addressing the needs of people with autism. The Interagency Autism Coordinating Committee (IACC), a Federal advisory committee established in 2006 through the Combating Autism Act, advises the HHS Secretary and coordinates all efforts within the Department concerning autism. The IACC released the second edition of the Strategic Plan for Autism Spectrum Disorder Research in January 2010. The 2010 Plan adds 32 new research objectives and more fully addresses the needs of people with autism spectrum disorder across the spectrum, from young children to adults, and places new emphasis on both non-verbal and cognitively-impaired people with autism spectrum disorder. On April 30, 2010, Secretary Sebelius announced appointment of five new members to the IACC who add a breadth of expertise and perspectives to the committee.
In an effort to better understand risk factors and potential causes of ASD, CDC is currently conducting one of the largest studies in the United States to help identify factors that may put children at risk for ASD and other developmental disabilities. This study, being conducted across a six site network known as the Centers for Autism and Developmental Disabilities Research and Epidemiology (CADDRE), is called SEED, the Study to Explore Early Development. SEED is now nearing the close of the enrollment phase and first publications will be in Fiscal Year 2011
Asthma Control Programs: CDC’s National Asthma Control Program is reducing the number of deaths, hospitalizations, emergency department visits, school or work days missed, and limitations on activities due to asthma. Funding for health departments in 34 states, the District of Columbia, and Puerto Rico to conduct asthma surveillance, maintain and expand partnerships, implement statewide comprehensive asthma plans with their partners, implement interventions to reduce the burden of asthma, and develop and implement an evaluation plan. CDC also funds the state health departments in California, Michigan, Minnesota, Mississippi, Missouri, New York, Oregon, Rhode Island and Washington to conduct in-depth surveillance projects (three of them using Medicaid data), disparities assessments, and interventions, implementation and evaluation.
Surveillance efforts continue: In 2005, CDC implemented its National Asthma Survey (NAS) data collection effort as a call-back survey subsequent to the Behavioral Risk Factor Surveillance Survey (BRFSS). By 2009, participation in the Asthma Call-back Survey (ACBS) had expanded to 35 states, the District of Columbia and Puerto Rico. In 2010, 40 states will use the ACBS to collect data. Before CDC initiated the NAS and ACBS, none of this information was available at the state level. The ACBS data are used by the states to track Healthy People goals, evaluate programs, and plan future activities at the state level.
Early Hearing Detection and Intervention: Prior to the authorization of the Early Hearing Detection and Intervention (EHDI) program in 2000 (under the Children’s Health Act), less than half of the infants in the U.S. were being screened for hearing loss. CDC’s EHDI program provides support on the development and implementation of state-level tracking and surveillance systems to ensure that infants and children with hearing loss are identified early and receive services as soon as possible. Collaborative work with state EHDI programs and other partners to ensure infants receive recommended follow-up diagnostic and intervention services in a timely manner to realize the benefits of newborn hearing screening.
Food allergy: Food allergy is an emerging major health problem that affects approximately 4 percent of U.S. adults and 5 percent of children under five years old, and its prevalence seems to be increasing. Despite the risk of severe allergic reactions to food, and even death, there is no current treatment other than allergen avoidance and treating the symptoms associated with severe reactions. NIH’s National Institute of Allergy and Infectious Diseases (NIAID) remains committed to basic research and clinical studies to advance our understanding of food allergy. NIAID-supported clinical trials continue to demonstrate the potential for immunotherapy to prevent or reverse established food allergies, such as peanut allergy, in children. NIAID also is leading an effort to develop “best practice” clinical guidelines for healthcare professionals for the diagnosis, management, and treatment of food allergies. The guidelines are expected to be published before the end of 2010.
National Children’s Study (NCS): Efforts to promote health and prevent disease are predicated on understanding the causes and timing of, and triggers for, events that affect children’s health. The NIH, joined by a consortium of federal partners, has begun to pilot test recruitment strategies for the NCS, a large, multi-year research study with the goal of discovering and exploring the relationships between the environment (broadly defined), genetics, growth, development and health on 100,000 children from before birth through age 21. Complex environmental interactions and their relationships with critical growth and development periods will be studied, and it is expected that the data gathered will be utilized by researchers for many decades to come, providing insight into what constitutes children’s health, but also childhood precursors of many adult chronic conditions.
Additional research and healthcare quality improvement projects for children: HHS’s Agency for Healthcare Research and Quality (AHRQ) current projects include: testing approaches to deliver effective treatments for children with mental health problems; making medication management child-centered; implementing evidence-based care processes for infants with fever; using computers to automate developmental surveillance and screening; preventing adverse effects of medications during pregnancy; comparative safety and effectiveness of stimulant medication for children with ADHD; and effectiveness of ADHD treatment in at-risk preschoolers. In addition, AHRQ is working collaboratively with CMS to implement CHIPRA through the identification of evidence-based healthcare quality measures for use by public and private programs, and other activities related to improving quality.
Current program activities and accomplishments
Tobacco control: On June 22, 2009, the President signed the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) (Public Law 111-31) into law. The Tobacco Control Act grants the FDA important new authority to regulate the manufacture, marketing and distribution of tobacco products to protect the public health generally and to reduce tobacco use by children and adolescents. HHS is directly supporting FDA’s regulation of tobacco products and is promulgating regulations that limit the sale, distribution, and marketing of cigarettes and smokeless tobacco to protect the health of children and adolescents. FDA has also implemented provisions that prohibit the use of certain characterizing flavors in cigarettes, and prohibit manufacturing tobacco products with the descriptors “light,” “mild,” or “low” or similar descriptors.
CDC provides national leadership for a comprehensive, broad-based approach to reducing tobacco use. Essential elements of this approach include state-based, community-based, and health system-based interventions; cessation services; counter-advertising; policy development and implementation; tobacco product research; surveillance; and evaluation. A key goal of CDC’s tobacco control program is to reduce the initiation of tobacco use among children, adolescents, and young adults. CDC will continue to encourage effective, evidence-based efforts to reduce youth smoking rates in the U.S. These include strategies such as counter-advertising mass media campaigns; higher prices for tobacco products through increases in excise taxes; tobacco-free environments; programs that promote changes in social norms; comprehensive community-wide and school-based tobacco-use prevention policies to help reduce smoking; reductions in tobacco advertising, promotions, and commercial availability of tobacco products through implementation of FDA’s regulatory authority; and effectively countering tobacco industry marketing influences.
Division of Adolescent School Health: CDC’s Division of Adolescent and School Health addresses six critical types of adolescent health behavior that research shows contribute to the leading causes of death and disability among adults and youth. These behaviors usually are established during childhood, persist into adulthood, are interrelated, and are preventable. The Division focuses on collecting data to better understand the risks and challenges facing the adolescents of today, as well as develop strategies to prevent disease and promote overall well-being wherever possible.
Office of Adolescent Health: Consistent with the directive contained in the Fiscal Year 2010 Consolidated Appropriations Act (Act), a new Office of Adolescent Health (OAH) has been established within the Office of Public Health and Science of the HHS Office of the Secretary. The President’s budget for Fiscal Year 2010 proposed a new Teenage Pregnancy Prevention initiative to address high teen pregnancy rates by replicating evidence-based models and testing innovative strategies. The Act provides $110 million to support the TPP Program with not less than $75 million for funding the replication of programs that have been proven effective through rigorous evaluation and not less than $25 million for funding demonstration programs to develop and test additional models and innovative strategies.
In the short term, OAH will focus primarily on the implementation of the Teen Pregnancy Prevention program. However, HHS envisions that the Office of Adolescent Health will also address many of the interrelated health needs of adolescents such as mental health, injury and violence prevention, substance abuse, sexual behavior, pregnancy prevention, nutrition, physical activity, and tobacco use, as authorized. The OAH is planning to work with other HHS agencies, including the Substance Abuse and Mental Health Services Administration (SAMHSA), to coordinate adolescent activities within the Department and address the recommendations contained in recent IOM reports on the health needs of adolescents.
Addressing onset of mental health problems: A 2009 IOM report Preventing Mental, Emotional and Behavioral Disorders in Young People, clearly articulated that we have many programs that can prevent problems including substance use and mental disorders. Current SAMHSA programs focusing on prevention, treatment and recovery for youth include:
The Drug-Free Communities Program and Sober Truth on Preventing Underage Drinking (STOP Act): Fund communities to develop coalitions across different sectors of the community – schools, law enforcement, businesses and merchants, health and behavioral healthcare providers, media, faith-based, community leaders – to prevent and reduce substance abuse among youth using a strategic prevention framework and evidence-based population prevention practices.
Safe Schools Healthy Students Program: Addresses the common risk factors associated with substance use and school violence while strengthening factors that promote good mental health. These grants, jointly funded by the Departments of HHS, Education, and Justice, enable local educational agencies to partner with their local mental health, law enforcement, and juvenile justice agencies to support a comprehensive, coordinated plan of activities, programs, and services. Local comprehensive strategies must address five elements, including early childhood social and emotional learning programs. Results from this program indicate a 15% decrease in number of students involved in violent incidents (17,800 in Year 1 of grant to 15,163 in Year 3); decreases in number of students experiencing or witnessing violence, and improved overall sense of safety in the school.
Community Mental Health Services for Children and their Families Program (Children’s Mental Health Initiative): This treatment program for youth with serious emotional disorders has had an impact in nearly 22 percent of the 3,177 counties in the U.S. and has served over 88,000 children with disabling mental health conditions. The program is based on a system of care approach which provides individualized, comprehensive and coordinated, community-based wraparound services to maintain children in their homes and communities and to prevent more costly and restrictive institutional care. Key outcomes from this program include reductions in negative symptoms, improved functioning in school, less involvement with the juvenile justice system, and reduced family stress.
Thank you Mr. Chairman for the opportunity to present this overview about the state of children’s health and well-being in the U.S. HHS is committed to expanding access to health care and increasing our coordination of child health initiatives with our federal, state and local partners to devise, test and implement solutions to the challenges and opportunities ahead. I would be glad to answer any questions you may have.
Last revised: June 18, 2013