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Testimony on Early Childhood Development and Learning by The Honorable Donna E. Shalala
U.S. Department of Health and Human Services

Before the Senate Labor Committee
April 18, 1997


Mr. Chairman, this is the season when life begins again. We know what changes come with spring. But what makes an infant bloom to healthy childhood? And a child bloom to healthy adulthood? As a recent Time magazine noted, we're starting to learn the answers. Or more to the point, we're starting to unravel the mysteries of how the minds of infants and children develop. That was the purpose of yesterday's White House Conference on Early Childhood Development and Learning -- to share what we know, and to inspire people from around the country to find answers to what we don't know.

This much is certain: The earlier we intervene on behalf of children the better. Because the fact is, for children, health care delayed can become a healthy future denied. And none of us want that. That is why we need to build a strong foundation for children before they're even born with strong families, safe communities, and good prenatal care.

How do we achieve those goals? Yesterday's conference, broadcast to sites across the country, gave us some answers. It featured leading researchers and child experts who have spent their professional careers studying how the human mind unfolds, and highlighted model programs that support parents and improve early childhood development. The conference brought to light research and the every day experiences of parents and care givers -- both of which tell us that a child's environment during the early years is critical to his or her success in school and later in life. Early intervention means less illness and disability, and more learning, development and productivity. But the conference must be the beginning of this discussion -- not the end. So I am pleased to be here during this time of renewal to talk about how HHS is helping families help their children navigate safely to adulthood.

Let me say, Mr. Chairman, government does not raise children -- parents raise children with the help of family members and communities. But government does have a role to play. In particular, we must better understand the needs of children; identify which needs are not being met; and then tailor assistance to meet those needs. That is how we can help build the strong foundation children need to not just survive, but thrive.

And that is why we are proposing important investments in children and families, including an expansion of health care coverage for children. The fact is, this Administration is committing record resources to children's health -- with our focus on the unmet health needs and disadvantaged children.

Now I would like to describe for you some of what we are doing and what we propose to do to promote the health of all children, and to assure their access to needed health care services.


No strategy to promote children's health can be complete until we can guarantee children access to the health care services they need. And this will not be accomplished until we guarantee that all children have adequate health insurance coverage.

Nearly 10 million children -one in seven--are uninsured in America today. These children are members of our communities, our neighbors. Most of these children are in working families, but millions of working parents cannot afford health insurance. Nearly 90 percent of uninsured children have a parent who works. Two thirds live in families with income above the poverty level.

Our goal is to improve the insurance and access needs of all of these children, but the costs of doing so are prohibitive. Before the end of this century we intend to make significant steps to meet that goal. Because there is no single reason why these children are uninsured, however, no single solution exists. We will need to cast a comprehensive net, working with State government as well as the private sector.

We welcome the opportunity provided by the Hatch/Kennedy Children's Health legislation, Senator Daschle's proposal, Senator Specter's bills, and other congressional efforts to dedicate significant resources for a children's health insurance expansion this year. A growing number of proposals introduced in the Senate and House of Representatives demonstrate bipartisan support on this important issue. The stage is set for action this year. We can do it if we are willing to work together.


Medicaid is a critical safety net providing vital health services to low income children. It currently covers approximately 18 million children - or one out of every five. Last year, Medicaid insured 64 percent (9.8 million) of all children with incomes below the poverty level and 45 percent (14.1 million) of all children under 200 percent of poverty. Medicaid pays for about one-third of deliveries in the United States and covers over 90 percent of children with HIV/AIDS.

While children comprise over half of all Medicaid beneficiaries, they account for only 20 percent of Medicaid spending. Federal and State Medicaid expenditures for children were $30 billion in FY 1995.

For all its contributions to children's health coverage, the promises of Medicaid are not all fulfilled. Part of our efforts to expand children's health insurance, therefore, focus on strengthening Medicaid's reach.

First, we must fulfill the promise of Medicaid for children who are already eligible under current law. An estimated 3 million children currently are entitled to Medicaid coverage but are not enrolled in the program.

Through a dynamic public/private effort and in partnership with the States, we need to reach out to these children. We will seek State expertise on "best practice" models that are working to enroll children and State advice on barriers to effective enrollment, such as inadequate public knowledge and cumbersome application processes. We also will explore with states innovations that can simplify the eligibility process, such as computerized eligibility determination systems, mail-in applications and streamlined applications to determine eligibility in multiple programs. We also will reach out to private managed care organizations and insurers, public and private health care providers, advocacy groups and foundations to develop strategies to find and enroll these children.

Second, we propose that once enrolled in Medicaid, children are guaranteed a full-year of health coverage. Currently Medicaid eligibility is determined on a monthly basis. This process is expensive, cumbersome, and causes significant disruptions in access to health care for poor children. For families with incomes very close to Medicaid limits, coverage is disrupted when incomes rise even slightly. In order to guarantee more stable coverage for children, we propose to provide States with the option to permit continuous Medicaid coverage for children for one year after eligibility is determined.

Child health advocates and private health plans support this proposal. Guaranteeing 12-month continuous eligibility will improve continuity of coverage for children. In addition, it will reduce the administrative burden on Medicaid officials, health care and social service providers, and families.

Third, in addition to these reforms, we know Medicaid coverage will continue to expand with the scheduled phase-in of coverage of adolescents in families below the federal poverty level.

State Partnership Grants

To Teach uninsured children beyond the Medicaid safety net, we propose to dedicate $3.75 billion over the next five years in state partnership grants to help cover children in families with earnings that are too high to qualify for Medicaid, but too low to afford private insurance. We believe this program will provide coverage for an additional one million children. Our proposal builds on successful efforts undertaken by a number of states. For example:

Florida's Healthy Kids program, a school enrollment-based comprehensive preventive care program, has nearly 35,000 children enrolled statewide. Florida parents pay a sliding-scale premium; income eligibility is established through free or reduced school lunch eligibility. To participate, children must be uninsured and ineligible for Medicaid. Although coverage is based on children aged 5-19 in participating schools, coverage is also offered to their younger siblings. The Florida program has received a grant from the Robert Wood Johnson Foundation to promote replication in other states.

Pennsylvania has expanded coverage to low-income children ineligible for Medicaid through public-private cost sharing programs-- one funded by Blue Cross/Blue Shield and private donations, and the other (the Children's Health Insurance Program in Pennsylvania) funded by a state cigarette tax. The program currently serves over 50,000 children with a waiting list of over 5,000 more. In combination, the programs provide coverage for children up to age 19 in families with incomes below 235% of the federal poverty level.

In July 1995, Minnesota care was providing coverage to approximately 44,000 children. Minnesota care is a publicly funded state program that covers some uninsured adults as well as children. Established in 1992, the program provides a comprehensive benefit package of coverage for children from families whose incomes are below 275% of the federal poverty level, are uninsured, and are ineligible for employer-subsidized insurance.

Under our State Partnership Grant program, for children not otherwise eligible for Medicaid, States may apply for finds to initiate or expand these types of programs. States have the flexibility to establish age, income and geographic guidelines, eligibility criteria, benefits, copayments, and premiums up to the full cost of the program.

States also will be required to include features in their programs to prevent substitution of public funds for private employer-sponsored insurance. To date, State children's health insurance programs have employed a variety of such features to address the problem of "crowding out" of employer health coverage.

Workers Between Jobs

Finally, we must build on the health insurance reforms enacted last year under this Committee's leadership. We must ensure that once working families obtain health insurance, they are able to maintain coverage through periods of economic hardship without risking imposition of new pre- existing condition exclusions. The Kassebaum-Kennedy health insurance reform law guarantees individuals access to coverage without preexisting conditions limitations when they move from one group insurance plan (including Medicaid) to another. People also are guaranteed access to individual health insurance policies if they have maintained continuous group coverage for a period of 18 months. Unfortunately, many families who become temporarily unemployed lose their group health coverage and cannot afford to maintain it under the options guaranteed by COBRA. Therefore, the Administration proposes to enable States to extend financial assistance to purchase health insurance coverage for up to 6 months for families whose workers are between jobs. This program will provide coverage for over 3 million working Americans and their families, including 700,000 children.


As we work to guarantee health insurance coverage for children, we must al o work to build an early foundation to anchor their lives. Through our public health efforts we can prevent disease, promote health and development, and maintain healthy communities in which our children can grow and thrive. The key to effective public health is early intervention. For children, early interventions must begin even before birth. That is why our child health programs integrate growth and development services from pre-conception to childhood, beginning with our efforts to prevent one of the worst preventable public health tragedies, infant mortality.

Infant Mortality

Although infant mortality rates in the United States have declined, we have much work left to do. For example, infant mortality rates remain disturbingly high among minority babies and in disadvantaged communities. This is why NIH continues to invest in clinical research to advance the health of young babies. It is why 34 States have exercised their option to expand Medicaid coverage for pregnant women in order to assure greater access to lifesaving and cost effective prenatal care. And it is why the Administration is adopting new initiatives and expanding existing programs to combat infant mortality. Let me describe two of our key initiatives.

Healthy Start Demonstration Projects: Healthy Start demonstration grants fund an outreach program designed to reduce infant mortality in communities where the rate is twice the national average. The demonstration program, which started in 1991, is helping high risk women and families in 22 communities reporting some of the highest infant mortality rates. Healthy Start will include 30 new communities this year.

Healthy Start demonstration projects may succeed because they use the talent and experience of local residents to overcome barriers to receiving prenatal care. What kinds of barriers? Lack of awareness of the importance of prenatal care on the part of high risk mothers, as well as problems with: too few health care providers; lack of accessible transportation; and lack of clinic hours during the evenings or on weekends. Teaming up with the community has helped to lower the infant mortality rate among high-risk populations. Healthy Start also features an aggressive public information campaign to raise awareness of infant mortality and promote prenatal care and other healthy behaviors.

Back to Sleep: Sudden Infant Death Syndrome (SIDS) - the mysterious and unexplained sudden death of a sleeping baby - is the nightmare of every parent with a newborn. SIDS is the leading cause of death in infants between one month and one year of life. Although we have not yet unlocked the secret to SIDS, experts report that the position of an infant during sleep appears to be a major contributing factor. Infants who sleep on their back have a much lower risk of dying from SIDS than infants who sleep on their stomach.

Consequently, HHS recently launched an expanded public information campaign that builds on the 'Tack to Sleep Campaign" launched in 1993, to teach parents, day care workers, baby sitters, grandparents, and other care givers to lay sleeping infants on their backs. Our early campaign contributed to a 30% drop in SIDS deaths, and we intend to continue this progress. To help spread the word, Mrs. Gore has joined our campaign. And so has Gerber Foods. The company agreed to place "Back to Sleep" messages on all Gerber infant cereal boxes.

Childhood Immunization

The next step in the fight to protect children's health is immunization. Because of important scientific breakthroughs, we can now protect young children against many serious -- often life threatening - illnesses. But only if children actually get the shots they need.

Thanks to persistent public health measures, access to childhood immunizations has improved significantly. And thanks to a partnership between the Clinton Administration and Congress, federal funding for childhood immunizations has doubled since 1992. The President's FY 1998 budget includes nearly $800 million for childhood immunization programs. Under the President's leadership we have launched a comprehensive Childhood Immunization Initiative. This initiative utilizes several strategies: (1) improving immunization services for needy families; (2) reducing vaccine costs for lower-income and uninsured families; (3) increasing community outreach, participation and partnerships; (4) improving systems for monitoring diseases and vaccinations; and (5) improving vaccines and vaccine use.

The strategy is paying off. In 1992, only 55 percent of two-year-olds were properly immunized. By 1996, 76 percent of the nation's two-year-olds received the full recommended series of vaccines. Today the number of preschool children properly immunized in the United States is at an all time high. Moreover, childhood vaccine-preventable diseases are at or near record lows. For example, in 1995 the reported cases of measles were the lowest since reporting began in 1912.

While childhood immunization rates are at an all-time high, nearly I million children under age 2 still have not received the full series of vaccinations. One goal of the Childhood Immunization Initiative is to increase vaccination levels for 2-year-olds to at least 90 percent for 2000, for the initial and most critical doses, and to reduce most diseases that are preventable by childhood vaccination to zero by 2000.

Child Care

Millions of children spend all or part of the day in child care. That is why safe and healthy child care services are a pivotal component of our children's health strategy. We are especially pleased that last year's welfare reform bill added significant new funds for child care services and maintained the vital health and safety protections so important to quality care. Last week, the National Institute of Child Health and Human Development released new research indicating that the quality of child care helps the cognitive and language development of young children.

In keeping with this focus, our Healthy Child Care America Campaign promotes partnerships between child care providers and health care services in projects in 46 states and territories. We are in the final stages of funding the remaining states and territories, expanding the campaign to include health professionals, and issuing new streamlined model standards for states and communities.

With the number of parents entering the workforce increasing each year, this Administration is committed to working with Congress and others to assure the availability of safe and healthy child care.

Head Start

The Clinton Administration has made the expansion and improvement of Head Start a top priority over the last three years. Head Start is a proven success, providing children a step up in their development. Funding for Head Start has grown substantially from $2.2 billion in 1992 to $3.98 billion in FY 1997. President Clinton has also proposed to fund Head Start at $4.3 billion in FY 1998, keeping us on track to serve 1 million children and families in 2002.

In 1995, we launched the "Early Head Start" program to expand the proven benefits of Head Start to low income families with children under three years of age and to pregnant women. This initiative builds on the research base discussed yesterday at the White House Conference on the importance of early stimulation and healthy environments . We hope to serve 35,000 infants and their families next year.

All Head Start and Early Head Start Centers are required to have established linkages with health, nutrition and other social services, to ensure the healthy development of young children in those centers. In addition, Head Start and Early Head Start centers engage in Medicaid outreach and referral for EPSDT services.

Maternal and Child Health Block Grant

Approximately 17 million women, infants, children, adolescents, and children with special health care needs are provided services through the Maternal and Child Health Block Grant program. This is a Federal-State partnership, with most of the $681 million appropriated for this program being allocated directly to States to assist in improving the health of mothers and children. More than $1 00 million is set aside for special projects of regional and national significance in areas such as newborn genetic screening, hemophilia, and child health improvement. A smaller amount-- about $ 1 0 million--is set aside for support of community-oriented programs such as home visitations, maternal and child health centers for pregnant women and infants, and maternal and child health services to rural populations.

Safe Communities

Parents shouldn't have to worry that the food or juice they give their children will make them sick or the places where they play could cause them permanent harm. Protecting children from food borne illnesses and environmental hazards in their communities is an important part of our strategy to see that all children get a safe and healthy start in life.

Food Safety: The Centers for Disease Control and Prevention (CDC) estimates that each year as many as 33 million cases of food-borne illness in the United States result in up to 9,000 deaths. These include outbreaks caused by pathogens such as E. Coli, Salmonella, Enteritidis, Vibrio Vulnificus, and Cyclospora. For children, especially younger children, the problem is especially worrisome. The outbreak of hepatitis A among school-aged children in Michigan this month is just one of the many recent cases demonstrating the need for stronger vigilance on food safety.

To respond effectively to these food safety issues, the President has proposed a $43 million inter- agency food safety initiative for FY 1998. We are partnering with U.S. Department of Agriculture to strengthen surveillance systems for food-borne illnesses nationwide and to improve Federal/State coordination when food-borne disease breaks out.

Protecting Children from Environmental Exposures: The President is concerned about the health of children who live near hazardous waste sites. Children are not just small adults. Because they play outside -- digging, splashing and exploring -- they are more likely to come into contact with contaminants in the environment. Also, children are built closer to the ground than most adults. That means they get higher doses per kilogram of toxic dust, soil, and heavy vapors. Toxic exposures released from toxic waste sites can adversely affect or even permanently damage the endocrine, immune, or nervous systems of children when exposure occurs during critical windows in their development.

HHS is working with EPA to promote policies and practices that emphasize child health. EPA is giving special consideration to ensure that environmental health standards are protective for children. Also, EPA is working to expand community right-to-know opportunities so that families have access to vital information about children's environmental health risks. HHS is working with communities to train more doctors to recognize and treat these child health problems. They, in turn, are providing parents and teachers with more complete information on the child health issues surrounding Superfund sites in their communities.


In addition to establishing an early foundation for children, we must help chart their course to navigate from childhood to adulthood -- to provide them safe passages through adolescence.

Too often in the past, policymakers grouped children of all ages together. We've taken a more sophisticated approach - by tackling the unique land mines that keep many of our adolescents from making smart choices with the only lives they'll ever have.

Teenage Smoking

An overwhelming body of public health data show that young people continue to become addicted to nicotine, and that one out of every three will die prematurely as a result of tobacco use. President Clinton is taking unprecedented steps to reduce children's use of tobacco products.

Every year, tobacco-related cancer, respiratory illness, heart disease, and other health problems take the lives of 400,000 Americans-- the vast majority of whom began smoking before their 18th birthday. Consequently, in August 1996, the Administration approved the boldest proposal ever put forward to remove cigarettes and tobacco products from our children's lives. The goal of this initiative is to cut tobacco use among our young people by half over 7 years by reducing the ready access that teenagers have to tobacco products and by lessening the pervasive appeal that these products have for potential underage users. To support the activities surrounding this over-all goal, we propose to spend $70 million in FY 1998 to help States comply with regulatory requirements, and provide financial and technical support to States for tobacco control and cancer prevention activities.

Preventing Teen Pregnancy

Although on the decline, teenage pregnancy remains a serious problem to be addressed. Each year, about 200,000 teenagers age 17 or younger have children. These babies often weigh too little and are at high risk for death. They are also likely to be poor. About 80 percent of children born to unmarried teenagers who dropped out of high school and are poor, compared to just 8 percent of children born to married high school graduates aged 20 or older.

We also know that teens with disabilities are at very high risk of becoming pregnant or being sexually abused. Thus part of our Teen Pregnancy initiative is to identify the specials needs of these young people and develop special considerations for the programs that serve them.

In January, this Department released the National Strategy to Prevent Teen Pregnancy. This broad-based strategy includes nearly $65 million for abstinence education programs. The key principles of the strategy are: (1) Parental and adult involvement; (2) Abstinence and personal responsibility; (3) Clear strategies for the future; (4) Community involvement; and (5) Sustained commitment.

Substance Abusv

The Clinton Administration has developed a comprehensive drug strategy, with a particular focus on preventing substance abuse by young Americans. In addition to its broad research agenda and funding for drug treatment and prevention, HHS is targeting resources toward public education of American's young people about the dangers of drug use. Our outreach strategy to the media and entertainment industries will secure their help in communicating the facts about marijuana and other illegal drugs to young people.

HHS-supported research has shown that marijuana is the most commonly used illicit drug in America. Recently, there has been a resurgence in marijuana use among 12- to 17-year-olds with rising usage rates every year since 1991. As much a cause for concern is an increasing feeling among adolescents that there is little or no risk to themselves or others in their abusing drugs.

To attempt to reverse these trends, the Department is increasing the resources dedicated to preventing marijuana and other substance abuse. The HHS Youth Substance Abuse Prevention Initiative is working to combat these rising usage rates with an aggressive communications strategy to reach young people early with the message of prevention and opportunity. This initiative will allow HHS to mobilize and leverage Federal and State resources, raise awareness and counter peer pressure messages, and measure outcomes.

Approximately $63 million will be dedicated to State Incentive Grants in FY 1998. To qualify for these grants, Governors are required to develop comprehensive Statewide strategies for reducing youth substance abuse. In designing their plan, states may propose their own approaches but will be offered a menu of effective substance abuse prevention strategies and programs that are based on scientific research.

Physical Activity/ Overweight

Another area of significant concern for future generations of healthy Americans is the growing lack of physical activity in children and the rising prevalence of overweight kids. Nearly half of young people aged 12 to 21 years and more than one-third of high school students are not vigorously active on a regular basis. Just last week, a new study was released that examined the prevalence of overweight among American preschool children from 1971 through-I 974 and 1988 through 1994. This study indicated that the prevalence of overweight increased among 4- and 5- year-olds during that time. As a nation, we are failing to instill increasingly passive generations of our children with the habit of staying active and fit.

Through regular physical activity, young people can improve their cardiovascular endurance and muscle strength, help control weight and reduce fat, and help build healthy bones. Regular physical activity can also reduce anxiety and stress and increase self-esteem. If maintained into adulthood, regular physical activity reduces the risk of dying prematurely, dying of heart disease, and developing diabetes, high blood pressure, and colon cancer.

To reinstate the importance of physical activity to our overall health, the Centers for Disease Control and Prevention has developed Guidelines for School and Community Programs to Promote Lifelong Physical Activity Among Young People. These guidelines will provide educators, sports and recreation professionals, health professionals, community leaders, and parents with concrete steps they can take to help young people adopt and maintain physically active lifestyles. These guidelines are being mailed to experts and professionals throughout the country to promote physical activity among young people.

Also, the President's Council on Physical Fitness and Sports, in cooperation with The Ad Council, produced a 30-second public service announcement challenging teenagers and pre-teens to make exercise or physical activity a part of their lives. In a message prominently featuring the back side of blue jeans, young people hear a message delivered in a voice they can relate to "Get Off It," and take it around the block or take it on a bike ride.

Girl Power!

Girls and boys experience some aspects of early adolescence in different ways, because they encounter different social, cultural, physiological and psychological challenges. Providing safe passages for young girls, therefore, requires strategies devised especially for them.

This year we have launched a national public education campaign called "Girl Power!" designed with input from girls themselves to provide positive messages, accurate health information and support for girls ages 9 to 14. Studies show that many girls tend to lose self confidence during this pivotal age, becoming less physically active, performing less well in school, and neglecting their own interests and aspirations. It is also during these years that girls become more vulnerable to negative outside influences and to mixed messages about risky behaviors.

Cigarette use among eighth-grade girls has jumped 45 percent between 1991 and 1995. Marijuana use is up among our teenagers, with the rate rising faster with girls than with boys. Alcohol use is also high. Along with substance abuse comes other risks such as depression and sedentary lifestyles. These problems have a greater impact on girls than boys.

The goal of the Girl Power! campaign is to galvanize parents, schools, communities, religious organizations, health providers, and other caring adults to make regular, sustained efforts to reinforce girls' self confidence, through positive messages, meaningful opportunities and accurate information about key health issues. We currently have over 100 private and public partners, including young, visible leaders like Olympic Gold Medalist Dominique Dawes.


Approximately 14 to 20 percent (8 to 13 million) of all American children experience mental and emotional disturbances. Included in this group are 3.5 million youth -- 5 percent of the American child and adolescent population -- who have serious emotional disturbances.

Children's Mental Health Services

Since 1992, the Comprehensive Community Mental Health Services for Children and their Families Program has worked with communities to plan, develop and implement comprehensive, community-based, coordinated, family-focused, and culturally competent systems of care for these children. In FY 1997, approximately $70 million will be distributed to 22 grantees -States, local governments, Native American reservations and tribal organizations -- to provide an array of community-based services organized to care for children with serious emotional, behavioral, or mental disorders of sufficient duration to meet the diagnostic criteria specified in DMH-IV, resulting in functional disturbances.

These grants assist communities in developing local systems of care that collaborate mental health with child welfare, education, juvenile justice, and other appropriate agencies. The program also ensures that under-developed or non-existent services, such as respite care, day treatment, therapeutic foster care, school-based services, emergency services, and diagnostic and evaluations services, are funded.

Starting Early/Starting Smart

While significant progress has been made identifying and meeting the mental health and substadivides us. And the fact is, we have never been a house divided against itself when it comes to the goal of raising healthy children. We love our children. We sacrifice for our children. And we want to learn more about our children -- how they grow, what they need, and what we can do as their parents, families and friends to help them reach a happy and prosperous adulthood.

As I mentioned earlier, government cannot step into the shoes of these individuals. But government can provide some of the tools, some of the research, and some of the support that families need to raise healthy children.

That is what we are trying to do. From prenatal care to preventing teenage smoking to expanding health insurance coverage for children and adolescents, the Clinton Administration is dedicated to giving every child not just spring to remember -- but a lifetime of good health.

Thank you.

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