Financing nutrition services in a competitive market

Budget deficits and inflationary medical care costs threaten nutrition services, which until recently have been funded largely by federal, state, and local revenues. Nutritionists and dietitians responding to demands in the marketplace should develop innovative programs and pursue new sources for financing through the private sector, third-party payers, business/industry health promotion, and consumer fees for their services, as well as targeted federal, state, and locally funded food assistance, nutrition education, and health care programs. Trail-blazing dietitians are successfully offering their services in health maintenance organizations (HMOs), hospital or industry fitness programs, private practice, voluntary health agencies, and official agency programs. With the new federalism, nutritionists must articulate their role in comprehensive health care and market their services at the state and local levels in addition to the federal level. Nutrition services are defined to include assessment, planning, counseling, education, and referral to supportive agencies. Data management, managerial, and marketing skills must be developed for dietitians to compete effectively. Basic educational preparation and continuing education for practicing professionals must develop these competencies.     

Occupational health training of local health department personnel: a curriculum model and implications of training

The Occupational Safety and Health Act of 1970 assigns to the federal government specific responsibilities for regulating safety and health in industry. At the same time, occupational health programs have traditionally been, and continue to be, one responsibility of local and state health agencies. In California, local health agencies are required to provide occupational health services in larger jurisdictions. Professional level positions which may be required include: Occupational health physician, occupational health nursing consultant, industrial hygienist or occupational health sanitarians, industrial hygiene engineer, and industrial hygiene chemist. Frequently a local health agency may satisfy its occupational health requirements by training a registered sanitarian to become an occupational health sanitarian.     

AIDS funding: competing needs and the politics of priorities

Despite the Department of Health and Human Service's 1983 claim that AIDS is the nation's "number one health priority," funding for AIDS research, prevention, and treatment remains inadequate. Worse, it is often marshaled from or juxtaposed against other necessary health allocations. Consequent AIDS-related resource crises include diverting funds for research on other diseases to AIDS investigations, propping up AIDS prevention efforts at the expense of traditional sexually transmitted disease control programs, and pitting the health needs of AIDS patients against the needs of those seeking other urgent health services, e.g., prenatal care. While this forced competition typically is blamed on fiscal constraints, examination of federal spending priorities suggests that it results principally from Reagan Administration policies. This Administration has consistently boosted military spending at the expense of social and health services, and has deliberately undermined efforts to obtain sufficient and new allocations for AIDS. In order to avert political divisions spurred by competition for currently scarce resources, AIDS and other health activists together must argue that excessive military allocations must be shifted to health research and services, and that a national health program must be implemented, if AIDS programs are to be funded appropriately without jeopardizing other necessary health initiatives.     

Leadership and Funding: Changes Ahead for Agricultural Safety and Health

For the last several decades, financial support for agricultural safety and health programs and professionals has primarily been covered by public dollars through federal and state government grant programs and appropriations. This federal and state funding provided a tremendous boost to farm safety and health professionals and program efforts for 30+ years and has provided the foundation and structure for current agricultural safety and health efforts and activities. However, there is reason to question long-term sustainability of a sufficient level of federal and state dollars for agricultural safety and health. Public funding for agricultural safety and health has never quite kept up to inflation, but even more ominous is that the entire agricultural safety and health program has been proposed for elimination each year by the White House budget beginning with the fiscal year 2012. It seems prudent, perhaps even imperative, for the agricultural safety and health community to find alternative support mechanisms. We suggest that now is a great time for agricultural businesses, services, and organizations to step up their financial support. Fortunately, several positive examples have recently surfaced within the agricultural community. As the agricultural industry continues to be a dominant enterprise in the United States, the integration of significant funding and the role of leadership from within the industry must continue to expand.     

A Farm Safety Surcharge on Food:

Even though agriculture is one of the nation's most dangerous occupations, it is relatively ignored by federal occupational safety efforts. The federal budget deficit makes adequate funding of new federal agricultural safety programs unlikely. This paper proposes that a new federal agricultural safety program should be developed, with funding coming from a value adds surcharge on the farm value of food. The costs to consumers would be negligible (only $1.88 per year per family.) but such a surcharge would be equitable and would generate over $48 million annually for agricultural safety programs. Several key elements for any new federal agricultural safety program are then discussed     

Mental healthcare: expand with caution. There is more involved than financial incentives

Increased needs, insurance coverage, and physical expansion are evidence of mental healthcare's growth. Greater societal acceptance, the demand for more local care with deinstitutionalization, and liberal reimbursement have expanded mental health services. However, reduced federal funding and competition demand specialization in such areas as geriatric services. Ambulatory services make mental healthcare more affordable and accessible. Providers must target populations who use such outpatient care and study local trends before planning these programs. Inpatient mental health services continue to expand, although at a slower rate. Thus organizations and professionals have begun selective contracting, and capitation reimbursement based on case management is developing. Providers considering expansion or initiation of mental health services confront competitive marketing and must recognize trends in outpatient, chronically ill patient, and after-care services. Strategic planning is essential to uncover opportunities and potential risks. Other issues to consider include the psychiatrist shortage, uncertain payment systems, and a possible reversal of growing mental health services and declining acute care needs.     

Environmental health services in primary care centers

Primary Health care centers supported by the Public Health Service through the Community Health Center and Migrant Health Centers programs are now required to provide environmental hazards directly related to clinical findings, but correcting community and occupational environmental problems may be pursued through appropriate agencies. State and local health departments will play key roles in the program in providing professional expertise in environmental health, assisting patients in taking corrective action, and assisting in the coordination with state, local, federal and voluntary agencies. Some primary care centers in areas of great need and limited resources will have their own environmental health professionals, but most will depend on local health departments for this specialty.     

Increasing access to care for the uninsured: considering the options in California counties

We interviewed California county health agency staff and administered a 58-county survey in 2002 and 2004 to inventory programs designed to improve access to care for the uninsured, and to assess county ability to meet the needs of California's uninsured during slow economic periods. Most counties have established means to connect people to existing public insurance programs and services have been expanded. Growth in new health care insurance programs for children and modest growth for adults are apparent. Counties pursue funding opportunities by a variety of strategies (e.g., leveraging of existing funding to secure new funds such as federal Healthy Community Access Program (HCAP) grants). While counties vary in their resources, political will, and barriers to care, they share a strong commitment to access to care. The implications of local efforts for state and federal policymaking are significant. In the absence of federal or state reform, county initiatives, particularly children's coverage expansions, may coalesce into state-level reform. Second, the state may move closer to access to health care for all as it recognizes the complementarity of county programs.     

Integrating the Life Course into MCH Service Delivery: From Theory to Practice

To describe the efforts of a community-based maternal and child health coalition to integrate the life course into its planning and programs, as well as implementation challenges and results of these activities. Jacksonville-Duval County has historically had infant mortality rates that are significantly higher than state and national rates, particularly among its African American population. In an effort to address this disparity, the Northeast Florida Healthy Start Coalition embraced the life course approach as a model. This model was adopted as a framework for (1) community needs assessment and planning; (2) delivery of direct services, including case management, education and support in the Magnolia Project, its federal Healthy Start program; (3) development of community collaborations, education and awareness; and, (4) advocacy and grass roots leadership development. Implementation experience as well as challenges in transforming traditional approaches to delivering maternal and child health services are described. Operationalizing the life course approach required the Coalition to think differently about risks, levels of intervention and the way services are organized and delivered. The organization set the stage by using the life course as a framework for its required local planning and needs assessments. Based on these assessments, the content of case management and other key services provided by our federal Healthy Start program was modified to address not only health behaviors but also underlying social determinants and community factors. Individual interventions were augmented with group activities to build interdependence among participants, increasing social capital. More meaningful inter-agency collaboration that moved beyond the usual referral relationships were developed to better address participants’ needs. And finally, strategies to cultivate participant advocacy and community leadership skills, were implemented to promote social change at the neighborhood-level. Transforming traditional approaches to delivering maternal and child health services and sustaining change is a long and laborious process. The Coalition has taken the first steps; but its efforts are far from complete. Based on the agency’s initial implementation experience, three areas presented particular challenges: staff, resources and evaluation. The life course is an important addition to the MCH toolbox. Community-based MCH programs should assess how a life course approach can be incorporated into existing programs to broaden their focus, and, potentially, their impact on health disparities and birth outcomes. Some areas to consider include planning and needs assessment, direct service delivery, inter-agency collaboration, and community leadership development. Continued disparities for people of color, despite medical advances, demand new interventions that purposefully address social inequities and promote advocacy among groups that bear a disproportionate burden of infant mortality. Successful transformation of current approaches requires investment in staff training to garner buy-in, flexible resources and the development of new metrics to measure the impact of the life course approach on individual and programmatic outcomes.     

The use of the National Public Health Performance Standards to evaluate change in capacity to carry out the 10 essential services

Nationally, environmental public health programs have been struggling to find ways to measure their capacity to carry out the 10 essential public health services. The ability to make this kind of measurement is crucial to showing the benefits of local, state, and federal funding of environmental public health programs, It is also crucial to the continuation of this funding. One local health department in Pennsylvania, the Allegheny County Health Department, implemented use of the National Public Health Performance Standards as a mechanism for measuring current performance in carrying out the 10 essential services as well as to set a benchmark for improving capacity in areas of environmental health practice. By using these standards as a tool for assessing current performance, the health department was able to focus on strengthening areas in which little or no capacity was reported. This process made it possible to set priorities and allocate resources to improve the delivery of environmental health services. The tool was re-used two years later to measure the impact this capacity-building activity had on improving the ability of the environmental health program to carry out the 10 essential services.     

The program implications of administrative relationships between local health departments and state and local government.

A typology of organizational arrangements between state and local public health agencies was used as a framework within which the organizational environment of the local health department was studied for its effects on program development and implementation by local public health departments. Data collected in a national sample of local health officers were used in measuring the effect of four different patterns of administrative relationships on the selected characteristics of local health department programs. Important differences were observed among the four organizational types with regard to constraints on programs and program priorities, and health officers' perceptions of the primary functions of local health departments and sources of local health department funding. These findings were then used as a baseline from which to consider the possible impact of recent federal health budgetary proposals (specifically, block grants) both on existing patterns of intergovernmental relations and on the funding and operation of local health department programs. It was determined that the most likely general development arising from these proposed changes in federal budgetary policy is that the administrative control of state health agencies over those at the local level is likely to be enhanced. Other likely developments include changes in the programs and priorities of local health departments related to reductions in overall funding levels for human services and forced competition for fewer dollars by an enlarged constituency.     

The Early Years of Title V: Extending and Improving Care for Children with Special Health Care Needs, 1935–1941

This historical study examines the early years of the federal program of services for children with physical disabilities in the United States (US) during the 1930s, known today as services for Children with Special Health Care Needs (CSHCN). Established as part of the Social Security Act (SSA) of 1935, the Crippled Children Services (CCS) program was one of the first medical programs for children supported by the federal government. Under the SSA, states and territories quickly developed state-level CCS programs during the late 1930s. The US Children’s Bureau administered the program for the federal government and helped states to incorporate preventive services and interdisciplinary approaches to service provision into state-level CCS programs. Factors that influenced the implementation of these programs included the availability of matching state funds, the establishment of state programs for crippled children prior to the SSA, and the accessibility of qualified health care professionals and facilities. The early efforts of this federal program on behalf of children with disabilities can be seen in services for CSHCN today.     

Adolescents and access to health care.

The developmental characteristics and health behaviors of adolescents make the availability of certain services--including reproductive health services, diagnosis and treatment of sexually transmitted disease, mental health and substance abuse counseling and treatment--critically important. Furthermore, to serve adolescents appropriately, services must be available in a wide range of health care settings, including community-based adolescent health, family planning and public health clinics, school-based and school-linked health clinics, physicians'' offices, HMOs, and hospitals. National, authoritative content standards (for example, the American Medical Association''s Guidelines for Adolescent Preventive Services (GAPS), a multispecialty, interdisciplinary guideline for a package of clinical preventive services for adolescents may increase the possibility that insurers will cover adolescent preventive services, and that these services will become part of health professionals'' curricula and thus part of routine practice. However, additional and specific guidelines mandating specific services that must be available to adolescents in clinical settings (whether in schools or in communities) are also needed. Although local government, parents, providers, and schools must assume responsibility for ensuring that health services are available and accessible to adolescents, federal and state financing mandates are also needed to assist communities and providers in achieving these goals. The limitations in what even comprehensive programs currently are able to provide, and the dismally low rates of preventive service delivery to adolescents, suggests that adolescents require multiple points of access to comprehensive, coordinated services, and that preventive health interventions must be actively and increasingly integrated across health care, school, and community settings. Unless access issues are dealt with in a rational, coordinated fashion, America''s adolescents will not have access to appropriate health services. Current efforts to minimize current health care expenditures through managed care programs inevitably conflict with efforts to deliver comprehensive preventive services to all adolescents. Use of multiple sites may not represent inadequate access to care. However, as managed care reimbursement continues to expand, school-based clinics and free-standing adolescent health programs increasingly report decreases in reimbursement without a change in demand for services. The Office of Technology Assessment study called for explicit funding and expansion of services for America''s youth; since then, a federal Office of Adolescent Health has been authorized, and, by the time this reaches print, should have received appropriations and been staffed. Dryfoos has called for expansion to nearly 5000 comprehensive programs in the coming years.(ABSTRACT TRUNCATED AT 400 WORDS)     

Family planning funding through four federal-state programs, FY 1997.

CONTEXT: The maternal and child health (MCH) and the social services block grants have long played an important role in the provision of family planning services in the United States. The extent to which states have incorporated family planning services into the newer federally funded, but state-controlled, programs--Temporary Aid to Needy Families (TANF) and the State Children's Health Insurance Program (CHIP)--has yet to be identified. METHODS: The health and social services agencies in all U.S. states, the District of Columbia and five federal jurisdictions were queried regarding their family planning expenditures and activities through the MCH and social services block grants and the TANF program in FY 1997. In addition, the states' CHIP plans were analyzed following their approval by the federal government. Because of differences in methodology, these findings cannot be compared with those of previous attempts to determine public expenditures for contraceptive services and supplies. RESULTS: In FY 1997, 42 states, the District of Columbia and two federal jurisdictions spent $41 million on family planning through the MCH program. Fifteen states reported spending $27 million through the social services block grant. Most of these jurisdictions indicated that they provide direct patient care services, most frequently contraceptive services and supplies. Indirect services--most often population-based efforts such as outreach and public education--were reported to have been provided more often through the MCH program than through the social services program. MCH block grant funds were more likely to go to local health departments, while social services block grant funds were more likely to be channeled through Planned Parenthood affiliates. Four states reported family planning activities funded under TANF in FY 1997, the first year of the program's operation. Virtually all state plans for the implementation of the CHIP program appear to include coverage of family planning services and supplies for the adolescents covered under the program, even when not specifically required to do so by federal law. CONCLUSIONS: Joining two existing--but frequently overlooked--block grants, two new, largely state-controlled programs are poised to become important sources of support for publicly funded family planning services. Now more than ever, supporters of family planning services need to look beyond the traditional sources of support--Title X and Medicaid--as well as beyond the federal level to the states, where important program decisions are increasingly being made.     

Technical workshop report: Working Group I: Occupational health and safety strategies for agriculture

The six workshops in this subgroup--Injuries, Respiratory Diseases, Acute Chemical Toxicity, Cancer, and Health Surveillance--competently outlined the principal health and safety issues in agriculture, documenting the increased and unacceptable morbidity and mortality in farmers and their families. It became evident that although research knowledge is just now unfolding, sufficient data exist to permit comprehensive program planning for research and prevention. It is necessary that farmers and their families be considered an occupational grouping and that specific programs aimed at ongoing risk assessment and early diagnosis are important. At the same time, a more broadly based approach to rural family life enhancement is essential, including the following: 1) education; 2) prevention; 3) family life enhancement; and 4) research. Because of the scope and nature of the problem, program development should include a multidisciplinary approach that involves the local community, state government, university (professional) resources, farm/organizations, and industry.     

Intergovernmental relations in physician education and health planning: state adoption decisions and the impact of federal programs

This study seeks to explain states' adoptions of programs in health planning and in physician education. It also seeks to further understanding of the impact of federal health planning and education programs on the states. Several theories and models are employed in analyzing the actions of state decision-makers. These include incremental theory, models of the diffusion of innovations, economic resources theory, and a theory of competitive partisanship. The data utilized in this research were principally derived from intensive interviews with "key" state actors and from historical, documentary materials. Only minimal federal impact appears on states' goals in physician education and health planning. Rather, there is evidence of considerable innovativeness among the states prior to Federal program initiatives. A problem-generated search for solutions seems to be a major source of this innovation. Finally, federal program implementation requirements appear to be a major source of federal--state conflict and opposition.     

Options for sustaining school-based health centers

Several methods exist for financing and sustaining operations of school-based health centers (SBHCs). Promising sources of funds include private grants, federal grants, and state funding. Recently, federal regulation changes mandated that federal funding specifically for SBHCs go only to SBHCs affiliated with a Federally Qualified Health Center (FQHC). Becoming a FQHC allows a SBHC to bill Medicaid at a higher rate, be notified about federal grants, and access the federal drug-pricing program. However, FQHCs must bill for services, including a sliding-fee scale based on ability to pay; develop a governance board with a majority of consumer members; provide a set of designated primary care services; and serve all people regardless of ability to pay. Private grants impose fewer restrictions and usually provide start-up and demonstration funds for specific program needs. Such funds are generally time limited, so new programs need to be incorporated into the operational budget of the center. State funding proves relatively stable, but fiscal challenges in some states made these funds less available. Using a variety of funding sources will enable ongoing provision of health care to students. Overall, SBHCs should consider infrastructure development that allows a variety of funding options, including formalizing existing partnership commitments, engaging in a needs assessment and strategic planning process, developing the infrastructure for FQHC status, and implementing a billing system for client services.     

Occupational health services to assist workers' health promotion based on a participatory training program of staff members for public health centers

Work-related health problems among employees of small-scale enterprises and un-employed workers are still serious in Japan. Occupational health services related to their working conditions and environment are limited and more provison needs to be made. Our participatory training program is aimed at allowing staff members of public health centers to provide occupational health services and assist workers' health promotion. In this program, participants examine occupational risk factors affecting workers' health problems with ergonomic check-lists and discuss potential improvements in the workplace. Participants experience practical visits to small-scale enterprises in their communities and the resultant occupational health services are discussed and evaluated at the final step in this program. The essential feature of successful case was that the public health center had coordinated community resources and occupational health services with ergonomic check-lists accepted by small-scale enterprises. This participatory training program is effective from the viewpoint of evaluating occupational risk factors affecting workers' health problems and proposing improvements in the workplace. In order to optimally provide occupational health services for the employees of small-scale enterprises and un-employed workers, the community resources including health facilities and the parties concerned must be organized and utilized effectively.     

Engaging community members in health policy processes: a Mississippi example

Legislation, such as the federal Personal Responsibility and Work Opportunity Reconciliation Act (1996), the Balanced Budget Act of 1997, and the authorization of federally-funded health insurance coverage for children (State Children's Health Insurance or SCHIP) continues the shift of assigning increased power and responsibility for health and human services "safety net" programs from the federal level to the state level. Known as "devolution," this complex shifting of responsibility and accountability continues to evolve with increasing transference of authority, control, and administration of social programs to local governments. Such changes require an informed citizenry and, hence, demand grassroots capacity building activities around public policy issues. This article describes a project designed to build the capacity of community-based organizations in several cities in Mississippi to become involved in health care policy activities. The primary purpose of this project was to inform and organize community members around improving health policies for low-income children and families.