A federal/state partnership for health system reform.

In view of the continued lack of consensus regarding health system reform, a new approach is needed to the pluralism that characterizes the U.S. political scene. A two-step strategy can help to break the deadlock around health care financing and provision: a framework around which to shape federal/state responsibility for health care and a process to ensure that policy is translated into action. This strategy, called a federal/state compact for health, builds on actions already under way in several states and represents a process that is both incremental and comprehensive in nature. The federal government would take the lead regarding policy making, financing, and establishing benefits. The states would administer the program with flexibility similar to that existing in Canada's provinces.     

U.S. Funding Is Insufficient to Address the Human Health Impacts of and Public Health Responses to Climate Variability and Change

Background

The need to identify and try to prevent adverse health impacts of climate change has risen to the forefront of climate change policy debates and become a top priority of the public health community. Given the observed and projected changes in climate and weather patterns, their current and anticipated health impacts, and the significant degree of regulatory discussion underway in the U.S. government, it is reasonable to determine the extent of federal investment in research to understand, avoid, prepare for, and respond to the human health impacts of climate change in the United States.

Objective

In this commentary we summarize the health risks of climate change in the United States and examine the extent of federal funding devoted to understanding, avoiding, preparing for, and responding to the human health risks of climate change.

Discussion

Future climate change is projected to exacerbate various current health problems, including heat-related mortality, diarrheal diseases, and diseases associated with exposure to ozone and aeroallergens. Demographic trends and geophysical and socioeconomic factors could increase overall vulnerability. Despite these risks, extramural federal funding of climate change and health research is estimated to be < $3 million per year.

Conclusions

Given the real risks that climate change poses for U.S. populations, the National Institutes of Health, Centers for Disease Control and Prevention, U.S. Environmental Protection Agency, and other agencies need to have robust intramural and extramural programs, with funding of > $200 million annually. Oversight of the size and priorities of these programs could be provided by a standing committee within the National Academy of Sciences.     

Selected myths guiding the Reagan Administration's health policies

This article analyzes four major assumptions that guide the Reagan Administration's health policies: 1) the Administration received an overwhelming popular mandate to reduce the federal role in the U.S. health sector; 2) the size and growth of federal social (including health) expenditures are contributing to the current economic recession; 3) the costs to business of federally imposed health and safety regulations have contributed to making the U.S. economy less competitive; and 4) market intervention is intrinsically more efficient than government intervention in regulating the costs and distribution of health resources. Based on these assumptions, the main characteristics of the Reagan Administration's health policies have been 1) a reduction of federal health expenditures and, very much in particular, expenditures to the poor, handicapped, and elderly; 2) a weakening of federal health and safety regulations to protect workers, consumers, and the environment; and 3) the further privatization and commodification of medical services. This article shows that there is no evidence to support the assumptions on which these policies are based. Quite to the contrary, all available evidence shows the opposite: 1) the majority of Americans want an expansion of federal health expenditures and a strengthening of federal health regulation; 2) U.S. government expenditures and regulations are much more limited than those of other countries whose economies are performing more satisfactorily; and 3) those countries with larger government interventions have more efficient health care systems than the American one, where the "free market" forces are primarily responsible for the allocation of resources. Thus, major Reagan Administration health policies are based on myth rather than reality.     

Linking public health, housing, and indoor environmental policy: successes and challenges at local and federal agencies in the United States

We describe the successes and challenges faced by federal and local government agencies in the United States as they have attempted in recent years to connect public and environmental health, housing, community development, and building design with environmental, housing, and building laws, codes, and policies. These policies can either contribute to or adversely affect human physical and mental health, with important implications for economic viability, research, policy development, and overall social stability and progress. Policy impediments include tension between housing affordability and health investment that causes inefficient cost-shifting, privacy issues, unclear statutory authority, and resulting gaps in responsibility for housing, indoor air, and the built environment. We contrast this with other environmental frameworks such as ambient air and water quality statutes where the concept of "shared commons" and the "polluter pays" is more robust. The U.S. experiences in childhood lead poisoning prevention, indoor air, and mold provide useful policy insights. Local programs can effectively build healthy homes capacity through local laws and housing codes. The experience of coordinating remediation for mold, asthma triggers, weatherization, and other healthy housing improvements in Cuyahoga County, Ohio, is highlighted. The U.S. experience shows that policymakers should adopt a prevention-oriented, comprehensive multi-disciplinary approach at all levels of government to prevent unhealthy buildings, houses, and communities.     

Combining service marketing and strategic alliances in health care

With or without federal health care reform to impact the delivery of health care services in the U.S., hospitals must commit to service marketing and strategic alliances as a fundamental business strategy. Service marketing not only differentiates the provider, but with the proper programs in place, it may actually facilitate the formation of strategic alliances. The combination of these strategies will be particularly effective in preparing for any health care policy change.     

Experts ask Senate to ease Federal ban on needle exchange

During a June 6, 1996, Senate panel hearing, experts urged the U.S. government to revise a policy that prevents communities from funding needle-exchange programs. The current policy hampers efforts to control the spread of AIDS. Data indicate that at least 4,000 HIV infections could have been prevented in the past 8 years if needle-exchange programs had been widely available in the United States. Donna Shalala, the U.S. Health and Human Services Secretary, refused to certify that the programs will not increase the use of illegal drugs and that they reduce the spread of HIV, although six studies have shown that needle-exchange programs do prevent HIV infection and do not promote drug use. Most other Western nations have implemented harm reduction programs as a central component in their HIV prevention strategy.     

USA government and family planning

The U.S. government has given remarkable support to family planning in the U.S. and abroad within the last 10 years. Until the mid-1960s there were fairly restrictive laws and policies regarding family planning and no government funds were given for this activity. It was not until 1964 that the first federal grant of $8000 was provided for a family planning project. By 1965 it was estimated that health departments in 40 states authorized referral of those needing family planning services. The Family Planning Services and Population Research Act of 1970 was the first explicit family planning legislation passed by the U.S. Congress. About $93 million was budgeted by the federal government for family planning services by 1971, with a proposed budget for 1973 of $155 million. The research budget was $38 million in 1972. The U.S. also increased its commitment to the support of family planning abroad, most of it through USAID. $96 million was allocated to population and family planning assistance abroad by the U.S. government in 1971.     

State agency policy and program coordination in response to the co-occurrence of HIV,chemical dependency,and mental illness

The co-occurrence of HIV infection, chemical dependency, and mental illness challenges federal and state governments to develop flexible and coordinated health policy and financing for public health services. State agencies play a critical role in the organization and support of these services at the local level. With emerging stress upon state government budgets and concomitant increasing need for publicly funded services, state agency coordination may be an important policy safety net to assure services for populations at the margins of health systems. Despite this important potential role, nothing is known about the degree to which state HIV, substance abuse, and mental health agencies coordinate policies and/or programs in response to these co-morbid conditions. OBJECTIVE: This study sought to establish a conservative and initial understanding of state HIV, substance abuse, and mental health agency coordination of policy and program in response to the co-occurrence of HIV, chemical dependency, and mental illness. METHOD: Estimation of coordination was accomplished through the comparison of three surveys conducted among state substance abuse directors (1998), state AIDS directors (1999), and state mental health directors (2000). Data from 38 states were reviewed. RESULTS: The most frequently reported state agency activities included coordinating funding, engaging in integrative planning activities, and conducting staff cross-training. When compared for association with state characteristics, coordination among state agencies was found to be associated with Early Intervention Services (EIS) designation, higher rates of AIDS generally, higher rates of AIDS among African Americans, and higher rates of AIDS among Hispanic populations. Given the limitations of comparing three disparate surveys, we determined the estimate of interagency coordination to be conservative and preliminary. CONCLUSION: While this study was useful as an initial step toward identifying state interagency policy and program coordination in response to the co-occurrence of HIV, chemical dependency, and mental illness, there were methodological challenges that should be addressed in future studies of state agency coordination. Several recommendations were advanced.     

Environmental assessment of the Indian health service

The Indian Health Service (IHS), an agency within the U.S. Department of Health and Human Services, was responsible for providing federal health services to 1.51 million American Indian and Alaska Natives in 2000. Several opportunities related to health care exist for the IHS: potential public and private collaborations, continuation of the Clinton Administration's legacy of meaningful tribal consultation, and increasing the numbers of American Indian physicians, nurses, and other health related professionals. Modifications in federal programs such as Medicare and Medicaid pose a serious threat to the IHS because the IHS relies on these programs to offset the overall lack of funding. This article provides a framework for identifying the ways in which the external environment affects and determines the IHS' strategic responses to ensure competitiveness within the U.S. health care market. Value chain analysis will be used to evaluate the competitive advantages and disadvantages of the current IHS internal environment.     

At conference, Satcher emphasizes the need for sexual abstinence

U.S. Surgeon General David Satcher said that young people should abstain from sex until they are in a meaningful relationship. His comments were made at the United States Conference on AIDS. His advice differed in tone from that of his predecessor, Jocelyn Elders, who suggested teaching masturbation to sexually active young people to lessen the risk of HIV infection. The federal government supports condom use to prevent HIV transmission, but does not mandate introducing condoms in sex education classes. Satcher said it is up to individual communities to set those standards for their sex education programs.     

Handlungsprogramme zur Pr?vention und Gesundheitsf?rderung

Background

A wide range of action programs in the field of prevention and health promotion have been developed by the federal government, federal governmental departments and higher federal authorities. This analysis had two objectives. The first was to identify and demonstrate federal level action programs for prevention and health promotion, while the second was to examine similarities and differences between their content with children and adolescents serving as the target group. Not only was this population group chosen because its health is of great significance but also because of the diversity of programs available for children and adolescents.

Method

The analysis commenced with a review of the literature that identified action programs in the area of prevention and health promotion. Of these, five having children and adolescents as the target group were selected and arranged according to the public health action cycle. The criteria used to compare these action programs were program inception, target groups, contributors, financial resources, fields of operation, projects and evaluation.

Results

Of the action programs in the sector of prevention and health promotion 14 exist at the federal level. The five selected action programs with children and adolescents serving as the target group exhibited considerable complexity and content overlap in the criteria of contributors, financial resources, fields of operation and projects.

Conclusion

An important need for action exists to clarify the responsibility and the scope of duties as well as to improve the coordination and organization of action programs between the federal governmental departments and higher federal authorities as well as within health policy structures.     

AIDS education and incarcerated women: a neglected opportunity

Attitudes and perceptions about health, AIDS, and the need for AIDS education were explored among inmates in a women's prison in the southeastern U.S. Forty short-term inmates participated in a series of focus group interviews. A separate sample of sixteen women completed a 103-item questionnaire. Focus group participants expressed concern about AIDS within prison, sexual activity between inmates, and the institution's policy of housing seropositive women with the general inmate population. Close to half (44%) of the survey respondents believe that they were likely to be exposed to HIV in prison; most (81%) felt that AIDS education programs should discuss female homosexual activity, and nearly all respondents (94%) felt that inmates should be given an HIV antibody test upon entering prison. The study's findings confirm the need for tailoring AIDS education and prevention activities for incarcerated women.     

The political economy of federal health programs in the United States: an historical review.

In the 1960s the federal government of the United States added a wide range of new health programs--Medicare, Medicaid, health manpower training, occupational safety, and others--to its long-established support for biomedical research and hospital construction. Total federal health outlays rose from $5 billion in 1965 to almost $37 billion in 1975. This paper describes the legislative history of federal health programs and reports the recent trends in expenditures by functional category. The expenditures of major programs are related to the populations they serve and data are presented to document the enormous inflow of resources to medical care during the last 10 years. This inflow has been induced by the structural changes in the medical care market first set in motion by private health insurance, and accelerated by the new federal programs. Designing some way to control it is a major problem in health policy for the late 1970s.     

Federal Expenditures on Maternal and Child Health in the United States

The goals of this study are to estimate federal maternal and child health (MCH) expenditures and identify their sources. This analysis is intended to provide a broad view of MCH funding appropriations and a basis for discussion of whether funds could be better utilized for the benefit of the population served. Data on federal maternal and child health expenditures for fiscal year (FY) 2006 were derived from examining federal legislation, department/agency budgets, and various web-based program documents posted by federal agencies. Based on selected criteria, we identified programs targeting children under 21 or pregnant/parenting women within the United States. The funding levels of agency programs for maternal and child health activities were determined and the programs briefly summarized. The identifiable funding for maternal and child health programs in FY 2006 approached $57.5 billion dollars. Funding sources for maternal and child health were concentrated within the U.S. Department of Health and Human Services, but spread across several different agencies within the department and in the Departments of Defense, Education, Agriculture, Housing and Urban Development, and the Environmental Protection Agency. Multiple agencies and offices often funded related activities, without evidence of a common underlying strategy. Federal maternal and child health funding mechanisms may lead to a fragmentation in maternal and child health activities. The funding and service delivery apparatus would benefit from an integrative MCH infrastructure approach to pediatric research, service delivery, and data collection/access that incorporates life-course and social/environmental determinants perspectives.     

Behavioral health funding for native Americans in Arizona: Policy implications for states and tribes

This article examines the principal structures and mechanisms used by federal and state government to fund the behavioral health needs of Native American Indians. Using Arizona as a case study, the article provides an overview of both federal and state programs, especially Medicaid, discussing the problems and strengths of each. The article concludes with a discussion of the policy implications of these programs for both states and tribes, focusing on issues concerning administrative complexity, tribal sovereignty, improving behavioral health services, and assignment of financial risk.     

Health, housing, and public policy

With federal funding of affordable housing declining, health care and housing organizations must work together to advocate sound policy and reasonable funding in this realm. Federal agencies like the U.S. Department of Housing and Urban Development (HUD) and the U.S. Department of Agriculture traditionally have been the primary source of low income housing funds. But key housing programs like HUD's Section 8 have lost a significant amount of funding. Through advocacy efforts, health care and housing organizations can urge legislators to retain or restore these vital programs. They also can support the preservation of affordable housing units in order to counterbalance the trend of these homes being "lost to the market." Also, health care and housing agencies can partner to enhance housing services. Vulnerable populations-such as the elderly, individuals at risk for homelessness, those with disabilities, and the mentally ill-can benefit greatly from the supportive services that health care organizations can offer.