Mental map of the states

U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) released a report today analyzing substance use and mental health patterns occurring in each state. The report reveals "that there are wide variations among the states in problems like illicit drug use and underage drinking, but that no state was immune from these problems."

State Estimates of Substance Use is based on the 2005-2006 National Survey on Drug Use and Health (NSDUH) and provides state-level estimates for 23 measures of substance use and mental health problems, including underage drinking, use of illicit drugs, serious psychological distress, major depression, and tobacco use. These estimates are based on combined data collected from 136,110 respondents surveyed in 2005 and 2006 (the most recent data available). The report also reveals statistically significant changes that have occurred within each state between 2004-2005 and 2005-2006.

SAMHSA provides not only HTML and PDF editions of the report but table access to individual state reports and data. The HTML version contains additional tables not found in printed or PDF versions.

State Estimates of Substance Use from the 2005-2006 National Surveys on Drug Use and Health. OAS Series #H-33, DHHS Publication No. (SMA) 08-4311, Rockville, MD, 2008.

HTML edition
PDF (64pp/590kB)

Recent GAO reports

From the Government Accountability Office (GAO):

HIGHWAY PUBLIC-PRIVATE PARTNERSHIPS: More Rigorous Up-front Analysis Could Better Secure Potential Benefits and Protect the Public Interest, GAO-08-44 (pdf, 96pp/1.24 MB), Feb. 8, 2008

Highway public-private partnerships show promise as a viable alternative, where appropriate, to help meet growing and costly transportation demands. The public sector can acquire new infrastructure or extract value from existing infrastructure while potentially sharing with the private sector the risks associated with designing, constructing, operating, and maintaining public infrastructure. However, highway public-private partnerships are not a panacea for meeting all transportation system demands, nor are they without potentially substantial costs and risks to the public--both financial and nonfinancial--and trade-offs must be made.....There is no "free" money in highway public-private partnerships.

HEAD START: A More Comprehensive Risk Management Strategy and Data Improvements Could Further Strengthen Program Oversight, GAO-08-221 (pdf, 41pp/632kB), Feb. 12, 2008

This report focuses on the Dept. of Health and Human Services (HHS) Administration for Children and Families' (ACF) oversight of the Head Start program in which 1,600 local organizations receive $7 billion in grants from ACF. GAO recommends that ACF establish better criteria to spot underperforming grantees, to improve the reliability of its data, and to reduce improper payments.


HEALTH INFORMATION TECHNOLOGY: HHS Is Pursuing Efforts to Advance Nationwide Implementation, but Has Not Yet Completed a National Strategy, GAO-08-499T (pdf, 17pp/228kB), Feb. 14, 2008

In 2004 Pres. Bush established the Office of the National Coordinator for Health Information Technology (ONC) with HHS. The key areas of national health IT activities are electronic health records, standardization, networking and information exchange, and health information privacy and security.


STRATEGIC PETROLEUM RESERVE: Options to Improve the Cost-Effectiveness of Filling the Reserve, GAO-08-521T (pdf, 15pp/216kB), Feb. 26, 2008

The Strategic Petroleum Reserve (SPR) was established in 1975. The SPR currently has almost 700 million barrels of crude oil, about 56 days of oil imports, in Texas and Louisiana. The Energy Policy Act of 2005, P.L. 109-58 (pdf, 551pp.), authorized the Department of Energy (DOE) to increase the SPR to 1 billion barrels by 2018. GAO recommends that DOE consider flexible, cost-effective ways when making fill decisions.

Just in...2 on Hawaii

The Hawaii 2050 Sustainability Task Force issued its report on "charting a course for Hawaii's sustainable future." See post from the Hawaii House Blog.

See also FR post from last year on the Task Force and an earlier publication.

Hawaii 2050 Sustainability Plan (pdf, 99pp/9.6MB)
(HC79 E5 H25 2008)

--------

In Healthcare Hawaii Style, Frank L. Tabrah, M.D., writes of his lengthy medical experience in Hawaii, beginning as a plantation doctor in Kohala on the Big Island, and the evolution of medical care in the islands. Dr. Tabrah sees in the health care system that developed from the plantation communities promising elements for national universal health care. From the Preface:

Proponents of National Health plans and single-party payment systems will find much in the universal coverage of the plantation years and the success of mandatory health coverage since 1974 to ponder in solving our health care crisis.

See review from the Star Bulletin.

Healthcare Hawaii Style, Model for the Nation? How the Aloha State Leads the Way Toward Universal Healthcare
(RA447 H3 T32 2007)

ERISA's impact on insurance reform

The Employee Retirement Income Security Act (ERISA) is the federal law that governs private-sector retirement and health plans. ERISA pre-empts all state laws relating to employee benefit plans, including health insurance, with exceptions under the commonly called "savings" and "deemer" clauses. (ERISA specifically exempted the Hawaii Prepaid Health Care Act, chapter 393, Hawaii Revised Statutes, in the form it was passed in 1974, a few months before ERISA itself was enacted.) As states are attempting to legislate health insurance reform to cover the uninsured, they have come up against ERISA's pre-emption provision.

The Employee Benefit Research Institute (EBRI) issued a study on the challenges presented by ERISA to such state laws, especially "fair share" laws that require employers who provide little or no health coverage to pay into a state fund. The report concludes, in part:

Given the current pre-emption structure, as states continue to pass incremental regulations and benefit mandates on insured plans, it seems clear that more employers will be forced to consider self-insuring their health benefit plans, simply as a response to the significantly growing regulatory costs. And, as the cost of insured coverage rises, smaller employers may consider dropping coverage entirely.

As the administration of President George W. Bush comes to an end, and the fiscal demands on a deficit-plagued federal government continue to increase, it seems clear that political prospects are slim that the next president and the next Congress will enact a publicly funded universal-care health care system covering all Americans. But the alternative--greater state regulation of employment-based health care, which remains the bedrock of the current system--could ultimately prove to be self-defeating if employers decide to get out of the game.

ERISA Pre-emption: Implications for Health Reform and Coverage (pdf, 16pp/740kB)

End-of-life care

The Government Accountability Office (GAO) published a report on end-of-life care in four states: Arizona, Florida, Oregon, and Wisconsin. GAO relied on studies from the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality (AHRQ) to identify six key components of end-of-life care:

• Care management to coordinate service delivery
• Services to assist individuals in noninstitutional settings
• Pain and symptom management
• Family and caregiver support
• Communication among individuals, families, and program staff
• Assistance with advance care planning

GAO interviewed providers of the following programs in the four states that incorporate these key components: Program of All Inclusive Care for the Elderly (PACE), Arizona Long Term Care System (ALTCS), Wisconsin Partnership Program (WPP), and palliative care programs.

End-of-Life Care: Key Components Provided by Programs in Four States, GAO-08-66 (pdf, 27pp/364kB), December 14, 2007 (released Jan. 14, 2008)

Respite care

The Hawaii Legislative Reference Bureau (LRB) reviews how respite care programs and states define "respite care." The Bureau researched other states' respite care programs, particularly those that offer respite care options to caregivers who are caring for older adults or adults with chronic illnesses. Finally, the Bureau looked at how five states assess their respite care programs.

A new study in response to House Concurrent Resolution 187, House Draft 1 (Hawaii Regular Session, 2007):

Gimme A Break: Respite Care Services In Other States
(2007, pdf, 70pp/1MB)

Feds blow it

The federal government failed dismally in The American Lung Association's annual report card on federal and state tobacco control legislation and policies to tighten regulation of tobacco and discourage smoking. Reuters reports that the study also found states falling far short.

"While many states have failed to make meaningful progress at protecting their most vulnerable citizens, the tobacco companies are spending billions of dollars annually marketing their deadly products," the report reads.

The report tracked progress on tobacco regulation and reported on gains, losses and issues stalled throughout 2007. According to The American Lung Association website:

The Lung Association's report card grades each of the 50 states, the District of Columbia and Puerto Rico on their tobacco control policies in smokefree air, cigarette tax, tobacco prevention spending, and youth access to tobacco products. The report grades federal tobacco control efforts on cigarette tax, giving the FDA authority over manufactured tobacco products, cessation and ratification of the international tobacco control treaty.

Hawaii faired much better than the federal government and many states, receiving A's and B's in the Association's four areas of analysis:

1. Tobacco Prevention & Control Spending (A)
2. Smokefree Air (A)
3. Cigarette Tax (B)
4. Youth Access (B)

For 2007, The American Lung Association

recognizes Hawaii for increasing its cigarette tax by $0.20 to $1.80 per pack, and for funding its tobacco control program above the minimum level recommended by CDC for the first time.

The American Lung Association State of Tobacco Control 2007
(2007, HTML)

Press Release (HTML)

State Summary for Hawaii
(HTML)

Rising health costs affect health care use

The Employee Benefit Research Institute (EBRI) recently published its 2007 Health Confidence Survey. Its major findings:

• Most Americans getting hit with higher health costs: 63 percent with health insurance coverage report an increase in their share of costs.
  
  
• Effects on household finances: These increases have hurt household finances, in particular, a decrease in contributions to retirement and other savings and difficulty paying for basic necessities and other bills.
  
  
• Wellness programs supported in concept: Although 82 percent are positive about wellness programs in general, they are less comfortable with specific programs that employers might offer, and are suspicious of employer motivations for offering these types of programs.
  
  
• Unhappiness with the health care system: 60 percent rate the health care system as fair or poor; many feel the health care system needs a complete overhaul (24%) or major changes (47%).
  
  
• Strong support for employer mandate: 91 percent support an employer mandate. 42 percent believe that all employers, regardless of size, should be required to provide and contribute to health insurance coverage for their workers.

2007 Health Confidence Survey (pdf, 12pp/144kB)

Recent CBO reports

Testimony on Approaches to Reducing Carbon Dioxide Emissions       (pdf, 16pp/116kB), Nov. 1, 2007

The Director of the Congressional Budget Office (CBO) testified before the House Budget Committee on reducing CO2 emissions. He advocated an incentive-based approach as more economically efficient than "command-and-control" policies. Two main incentives would be taxes (to regulate the price of emissions) or a cap and trade system (to regulate the quantity of emissions). Of the two, a "well-designed tax would yield higher net benefits."


The Long-Term Outlook for Health Care Spending
      (pdf, 35pp/552kB), November 2007

This study gives CBO's projections of health care spending over the next 75 years under current federal law. In view of rising health costs, CBO assumes that employers, households, and insurance firms, to avoid reducing consumption of other goods and services, will change their behavior, e.g., higher cost sharing, increased utilization management, reduced insurance coverage by employers, and greater scrutiny of new technologies.

See related FR post, "Medicare and nursing homes" (8/1/07)


Long-Term Unemployment (pdf, 34pp/476kB), Oct. 2007

Unemployment lasting more than six months has increased. This report examines such long-term unemployed workers during 2001-2003 - their characteristics, sources of income, and subsequent activities.

States and nation fail women's health

The National Woman's Law Center (NWLC) and Oregon Health & Science University Center for Women's Health (OHSU) jointly released a nation and state-by-state report card on the "current state of women's health status and health policies."

First, for the bulk of indicators of the status of women's health, the nation as a whole and the individual states are falling further behind in their quest to reach national goals for women's health.

The Report Card examines status and policy indicators in four categories:

1. Women's Access to Health Care Services
2. Addressing Wellness and Prevention
3. Key Health Conditions, Diseases and Causes of Death for Women
4. Living in a Healthy Community

Hawaii, though ranked 7 in comparison to other states, received an overall grade of Unsatisfactory. Lowest Hawaii marks were in Addressing Wellness and Prevention, failing with a low 37th place in "Screenings". Only the top three states (Vermont, Minnesota, Massachusetts, respectively) received other than Unsatisfactory with a score of Satisfactory Minus.

In its summary, the report states:

• The nation still receives an overall grade of unsatisfactory.
• No state received an overall grade of satisfactory.

Making the Grade on Women's Health: A National and State-by-State Report Card
(October 2007, HTML interactive)

Hawaii's Report Card (HTML)
National Report (HTML)
Key Findings (HTML)

Less than half for our children

The New England Journal of Medicine current issue includes a study on the quality of care for children in the United States.

On average, according to data in the medical records, children in the study received 46.5%...of the indicated care. They received 67.6%...of the indicated care for acute medical problems, 53.4%...of the indicated care for chronic medical conditions, and 40.7%...of the indicated preventive care.

According to this study, previous results were limited to select groups (e.g., Medicaid recipients), involved self-reporting by caregivers and guardians, or were collected from data on the overall adult population.

In an attempt to address the limitations of previously published studies of the quality of care provided to children, we developed a comprehensive method for evaluating quality on the basis of information in medical records.

Deficits in the quality of healthcare for children "are similar in magnitude to those previously reported for adults." The results were surprising because the participants were more likely to be white and to have private insurance.

The researchers have found no national commitment to improve children health care.

Expansion of access to care through insurance coverage, which is the focus of national health care policy related to children, will not, by itself, eliminate the deficits in the quality of care.

The Quality of Ambulatory Care Delivered to Children in the United States
(The New England Journal of Medicine, October 11, 2007, pdf, 9pp/136KB)

Abstract available (HTML)

Breast cancer and early puberty

The younger girls are when they get their first periods, the greater their risk of breast cancer later in life. In fact, first menstruation (menarche) before age 12 raises breast cancer risk by 50 percent compared to menarche at age 16.

The Breast Cancer Fund recently published their report reviewing current scientific literature on the timing of puberty and examining "the nutritional, psychosocial and environmental factors that contribute to its timing." The report's author, Sandra Steingraber, Ph.D., writes:

We know that endocrine disrupting chemicals are a possible cause of early puberty but we also know that exposure to these chemicals in utero or early in life can also lead to low birth weight and obesity, which are themselves possible causes of early puberty.

Key findings include possible risk factors of early puberty:

• depression
• eating disorders
• suicide attempts
• early alcohol abuse
• violent victimization
• teenage sexual activity
• lower academic achievement

Dr. Steingraber recommends particular actions to protect the young:

• Combat childhood obesity by promoting breastfeeding early in life and supporting school-based healthy school lunch and obesity prevention programs for older children
• Support efforts to improve access to healthy foods in urban, low-income areas
• Eliminate fetal exposures to toxic chemicals in our everyday lives
• Support the phase-out of endocrine disrupting chemicals
• Support organic agriculture at home and in schools

The Falling Age of Puberty in U.S. Girls: What We Know, What We Need to Know
(August 2007, 73pp/pdf, 1.3MB)

Advocate's Guide
(August 2007, 9pp/pdf, 1MB)

Health care dollars - state by state

Health Affairs published today their study on state health care spending, presenting "updated per capita health spending estimates by state of residence for 1991-1998 and new estimates for 1999-2004." Examining the "huge variations in personal health spending among states," (New York Times, September 18, 2007), the authors feel "can yield new perspectives on recent state health spending trends and provide context for policy discussions,"

Finally, these data can shed light on differences in state health care delivery and consumption and on the demographic and economic factors that contribute to health care spending patterns.

Health Affairs is a peer reviewed journal of health policy thought and research:

Every article Health Affairs has ever published is available online at www.healthaffairs.org. The 25-year archive is fully searchable. All back content is free access after three years. Selected content is free access at time of posting...

Health Spending By State Of Residence, 1991-2004
(available in HTML and pdf, 13pp/140KB)

Medicare and nursing homes

Rising costs in Medicare, Medicaid, and other federal health-related programs represent the central long-term fiscal challenge facing the nation. The Congressional Budget Office (CBO) is therefore increasingly focusing on analyzing the causes of those rising costs and potential policy responses.

Thus begins the preface to a recent report from CBO on Medicare payments to skilled nursing facilities (SNF). In this study, in calculating how Medicare's payment rates impact the volume of SNF services, CBO used two separate analyses: geographic-level and provider-level. In the geographic-level analysis, data came from 3,436 hospital service areas. In the provider-level analysis, volume was the number of Medicare-covered SNF days provided by a facility in a year. Changes in payment rates were calculated using "a Laspeyres-type index" and a mix of patients in the base year and the following year.

The paper found that the volume of SNF services varied positively with payment rates. At the provider level, SNF volume responded only to increases in payment rates, while at the geographic level, SNFs responded to both increases and decreases in payment rates.

Background Paper: The Impact of Medicare's Payment Rates on the Volume of Services Provided by Skilled Nursing Facilities (pdf, 32pp/732kB), July 2007

New for The Reading Shelf

Recently added to The Reading Shelf:

Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry (347 pp.), by Howard Brody, a physician and medical ethicist at the University of Texas.

From the Introduction: This book aims to:

• describe the present relationship between the medical profession and the pharmaceutical industry
• assess that relationship from the standpoint of ethics and policy
• where the problems are identified, suggest positive changes

(New York Times book review)


First Among Nisei: The Life and Writings of Masaji Marumoto (266 pp.), by Dennis M. Ogawa, professor of American Studies, University of Hawaii.

Marumoto was the first Asian to graduate from Harvard Law School and to serve on the supreme court of any state or territory. This account of his life and career is based on oral histories and his writings, which include excerpts from a diary he kept as a 14-year-old and letters he wrote home during World War II.

(Press release in the Advertiser)

Recent GAO reports

INTERNET ACCESS TAX MORATORIUM: Revenue Impacts Will Vary by State GAO-07-896T (pdf, 28pp/624kB), May 23, 2007

In 1998, Congress passed the Internet Tax Freedom Act (P.L. 105-277, Title XI, 112 Stat. 2681-719 et seq.), temporarily barring taxes by state and local governments on Internet access. GAO testified, "Because it is difficult to know what states would have done to tax Internet access services if no moratorium had existed, the total revenue implications of the moratorium are unclear." Bills have been introduced in Congress this year to make the moratorium permanent.

PEDIATRIC DRUG RESEARCH: The Study and Labeling of Drugs for Pediatric Use under the Best Pharmaceuticals for Children Act GAO-07-898T (pdf, 18pp/296kB), May 22, 2007

According to GAO, two-thirds of drugs prescribed for children have not been studied for pediatric use. Under the 2002 Best Pharmaceuticals for Children Act (BPCA), if manufacturers of drugs that are still on-patent (have marketing exclusivity) conduct pediatric studies at the requst of the Food and Drug Administration (FDA), FDA may extend the exclusivity period (no equivalent generic drugs to be marketed) for 6 months. GAO presents testimony on the drug studies conducted under BPCA for on-patent and off-patent drugs, and the impact of BPCA on the labeling of pediatric drugs.

PUBLIC TRANSPORTATION: Preliminary Analysis of Changes to and Trends in FTA's New Starts and Small Starts Programs GAO-07-812T (pdf, 30pp/496kB), May 10, 2007

In 2005, the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU) was signed into law. It authorized the New Starts program in which the Federal Transit Administration (FTA) recommends funding for new fixed-guideway transit projects. New Starts spawned a separate program called Small Starts for smaller transit projects. GAO discusses changes in New Starts and future trends for New Starts and Small Starts.

TEACHER QUALITY: Approaches, Implementation, and Evaluation of Key Federal Efforts GAO-07-861T (pdf, 17pp/224kB), May 17, 2007

Title II of both the 1998 amendments to the Higher Education Act (HEA) and the No Child Left Behind Act (NCLBA) provided funds for professional development and recruitment. This testimony discusses activities under the two acts, how the Dept. of Education (Education) supports these activities, and how funds are being used.

Doc, tell me something I don't already know

The Commonwealth Fund, a private foundation promoting "a high performing health care system that achieves better access, improved quality, and greater efficiency," published a study today on America's poor but expensive healthcare system:

Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries.

America ranked last or next to last compared with Australia, Canada, Germany, New Zealand, the United Kingdom in the five areas Commonwealth considers important to high performance health care: quality, access, efficiency, equity, and healthy lives.

The U.S. is the only country in the study without universal health insurance coverage, partly accounting for its poor performance on access, equity, and health outcomes. The inclusion of physician survey data also shows the U.S. lagging in adoption of information technology and use of nurses to improve care coordination for the chronically ill.

...the U.S. scores particularly poorly on its ability to promote healthy lives, and on the provision of care that is safe and coordinated, as well as accessible, efficient, and equitable.

Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care
(May 2007, pdf, 40pp/522kB)

Executive Summary (html)

Children's health insurance

The Congressional Budget Office (CBO) has published a report on the State Children's Health Insurance Program (SCHIP), as Congress considers its reauthorization this year. SCHIP was established by the Balanced Budget Act of 1997, P.L. 105-33 (pdf), Title IV, Subtitle J, chap. 1 (111 Stat. 552 et seq.), which provided funding for SCHIP from 1998 to 2007.

According to the report, SCHIP provides medical coverage to children in families with income that is low but too high for Medicaid. It is federally and state funded and administered by the states within federal guidelines. In 2006, SCHIP covered 6.7 million children, at a cost of $4.8 billion in federal funds.

CBO lists possible changes to SCHIP for Congress to consider in reauthorizing the program:

• Intensifying efforts to enroll uninsured, eligible children
• Redefining the target population
• Changing the allocation formula for state funding
• Modifying the rules for redistribution of unspent funds
• Changing state matching rates
• Modifying benefits states are required to provide

The State Children's Health Insurance Program (pdf, 31pp/1.9MB), May 2007

Continuing barriers define disability

The future of disability in America will depend on how well this country prepares for and manages the demographic, fiscal, and technological developments that will unfold during the next two to three decades.

So described The National Academies Press (NAP) their newly released prepublication evaluating "principles and scientific evidence for disability policies and services." Authored by the Board on Health Sciences Policy (HSP) and the Institute of Medicine (IOM), the almost 700 page report analyzes the barriers restricting "the independence, productivity, and participation in community life of people with disabilities."

Finding some progress has been made since earlier reports, the book states:

This progress includes a growing understanding that disability is not an inherent attribute of individuals. Rather, it results from interaction between individuals and their physical and social environments...advances in mainstream electronic and information technologies - combined with regulatory requirements for accessibility features - have been liberating for many people with disabilities.

However, little progress has been made in adopting earlier public policy and practical recommendations. The American with Disabilities Act (ADA), though adopted in 1990 and still helping to increase awareness of the concerns, has been disappointedly enforced and implemented.

This report argues that concerted action - taken sooner than later - is essential for this nation to avoid a future of harm and inequity.

The Future of Disability in America
(Uncorrected Copy - Prepublication Available, 2007, 680 pp/Open Book, NAP)

Report Brief - April 2007 (pdf, 4 pp)
Executive Summary (pdf, 31 pp)

Medicare Advantage

The Congressional Budget Office (CBO) has published testimony on the Medicare Advantage program presented by its Director in the U.S. House.

According to the testimony, Medicare Advantage (MA) is a departure from the traditional Medicare fee-for-service (FFS) program by allowing private plans such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and private fee-for-service plans (PFFS) to participate in Medicare.

The Director's main points:

• Unexpectedly strong growth in MA enrollment in 2006-early 2007 led CBO to increase its projections for MA enrollment and spending
• Medicare's payments for MA beneficiares are higher than for FFS beneficiaries, increasing net Medicare spending
• Increase in enrollment and cost differential with traditional FFS are especially large in PFFS plans, which are largely in rural and some suburban areas
• Reducing the payment differential betweeen MA and FFS would result in savings to Medicare but would also reduce the supplemental benefits and cash rebates.

Testimony on the Medicare Advantage Program: Trends and Options (pdf, 20pp/116kB), March 21, 2007

See related FR post, Premium support in Medicare, Dec. 12, 2006

Health costs - seniors not the main driver

A recent report from the Congressional Research Service (CRS) concludes that the increase in health care costs comes from demand from all age groups, not just the elderly. The report notes:

...population aging is itself a relatively minor factor in the growth of national spending for health care. Other factors, including rising per capita income, the availability of new health care products and services, health insurance coverage, and characteristics of the health care system, play a much bigger role.

However, even if aging has a minor impact on national health spending, it will have a larger impact on federal spending because of growth in costs and enrollment in Medicare.

Health Care Spending and the Aging of the Population, CRS Report RS22619 (pdf, 6pp/80kB, from Open CRS), March 13, 2007

A risky age

Operating under the National Research Council (NRC) and the Institute of Medicine of the National Academies, the Board on Children, Youth, and Families (BOCYF),

addresses a variety of policy-relevant issues related to the health and development of children, youth, and families. It does so by convening experts to weigh in on matters from the perspective of the behavioral, social, and health sciences.

BOCYF recently published their workshop report dealing with reducing teen-driver crashes.

Calling teen crashes "a critical public health problem," the workshop found teen-driver crashes to be the leading cause of death in the 16 to 20 year age group, and that two thirds of all deaths in such crashes are other than teens. "Knowledge about how and why teen motor vehicle crashes happen is the key to developing countermeasures to reduce their number."

The panel explored three areas addressing this issue:

1. How do theories and evidence from the behavioral, cognitive, social, health, and biological sciences inform understanding of both the risk factors that increase and the protective factors that reduce such crashes?
2. How can theories and evidence inform prevention, program, and policy interventions to reduce risky teen driving?
3. What research and interventions are most likely to advance teen motor vehicle safety over the short and the long term?

Preventing Teen Motor Crashes: Contributions from the Behavioral and Social Sciences: Workshop Report
(2007, Open Book, 76pp)

The May 15-16, 2006 Workshop is also available as both audio webcast and pdf presentations from BOCYF.

Genetic testing - some background

In a recent report, the Congressional Research Service (CRS) noted that several bills relating to genetic and genomic technology and testing were introduced in the 109th Congress. Although none passed, "they signal the growing importance of the public policy issues surrounding the clinical and public health implications of new genetic technology." In its report, CRS summarizes fundamental concepts in genetics and provides an overview of genetic tests and key policy issues.

The Food and Drug Administration (FDA) and Centers for Medicare and Medicaid Services (CMS) regulate genetic tests through the Clinical Laboratory Improvement Amendments (CLIA) of 1988 (P.L. 100-578). CRS emphasizes that CLIA regulates the analytical validity of genetic tests but not their clinical validity and thus is subject to criticism that it "does not go far enough to assure the accuracy of genetic tests."

Genetic Testing: Scientific Background for Policymakers, CRS Report RL33832 (pdf, 13pp/108kB, from Open CRS), January 26, 2007

A system in need of change

The newest installment in the recently published Pathways to Quality Health Care series by the National Academies Press (NAP) bluntly states:

The overall quality of healthcare delivered to Americans is worse than it should be. While many quality improvement efforts have been undertaken, their success has been limited by current payment systems. The existing systems do not reflect the relative value of health care services in important aspects of quality...

Rewarding Provider Performance: Aligning Incentives in Medicare (Pathways to Quality Health Care Series)
(2007, Open Book, NAP, 227pp)

How medical care is organized, financed and delivered is a current concern of The American College of Physicians (ACP) as reported in a Monday Reuters story and voiced in ACP's State of the Nation's Health Care 2007: ACP Releases Comprehensive Reforms to Move towards Patient-Centered Care.

Video watch

The National Institute on Media and the Family issued its 11th annual video game report card at the end of November. The Institute stated:

For the past ten years, we have used this annual report card to challenge the video game industry to improve its record of attending to the welfare of younger players. More recently, we urged retailers to step up to their reponsbility to keep adult games out of the hands of children and youth. This year we acknowledge the strides taken by both sectors of the industry.

In October, the Institute and Iowa State University sponsored the first National Summit on Video Games, Youth and Public Policy at which academics, public health officials, child health advocates and video game industry representatives convened. There the Entertainment Software Rating Board (ESRB) pledged additional funding for ratings education for parents. ESRB ratings include E (Everyone) and E10+ (Everyone 10+).

The report noted:

...some video game makers are focusing on kid-friendly games and technologies. The Nintendo DS, for example, has gained a reputation as a "clean console" because of the vast number of E-rated games it supports, and Microsoft is said to be investing heavily in E and E10+ games.

According to its website, the Institute is "the world's leading and most respected research-based organization on the positive and harmful effects of media on children and youth."

11th Annual Video Game Report Card (pdf, 13pp/84kB), November 28, 2006

See related FR post, Minors and violent, sexual video games, Jan. 06

Ready or not yet?

Half the states are definitely not, and most others need improvement. Oklahoma scored the highest in a report on American health emergencies readiness and disaster preparedness, achieving 10 of the 10 possible indicators. Virginia had 8. The Trust for America's Health (TFAH) released a 2006 report card on America's disaster readiness as it had in 2005, noted in the FR post in January '06, which had rated Hawaii as one of 16 states to receive only 5 out of the ten indicators. This year's report found Hawaii to achieve 7 out of the ten indicators for preparedness.

The report mentions several key findings:

• Forty states face a shortage of nurses.
• Rates for vaccinating seniors for the seasonal flu decreased in 13 states.
• Eleven states and D.C. lack sufficient capabilities to test for biological threats.
• Four states do not test year-round for the flu, which is necessary to monitor for a pandemic outbreak.
• Six states cut their public health budgets from fiscal year (FY) 2005 to 2006.

Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism, 2006
(2006, pdf, 84pp/1MB)

Summary and individual state reports available in HTML.

Premium support in Medicare

One of the strategies proposed to control escalating Medicare costs is converting Medicare to a premium support system, whereby the federal government would give beneficiaries an amount to purchase regular Medicare fee-for-service coverage or to enroll in a private plan. Formulating such a system is the subject of a recent 66-page report from the Congressional Budget Office (CBO).

According to the report, about 17 percent of Medicare beneficiaries are enrolled in private Medicare Advantage plans that provide Medicare benefits. For each private enrollee, the government sets a maximum payment called the benchmark, which is set at the county level. In a premium support system, CBO proposes that the government's contribution could be established by competitive bidding by private plans or be a set amount. In a bid approach, benchmarks could be determined by the bids rather than by statutory rules as currently done.

In its analysis, CBO notes a number of uncertainties in the effects of such a system, from costs and premiums to whether a benefits package should be standardized. Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, P.L. 108-173 (pdf, 416pp/1MB), the government is to conduct a six-year, six-city demonstration of premium support beginning in 2010.

Designing a Premium Support System for Medicare (pdf, 66pp/608kB), December 2006

Rating the examiners

Reported in the New York Times (NYT), the consumer advocacy organization founded by Ralph Nader, Public Citizen, publishes online a report evaluating state medical boards web sites.

The report, based on a survey conducted by Public Citizen's Health Research Group, graded state medical board Web sites for all 50 states and the District of Columbia. In 14 states where the licenses of medical doctors and doctors of osteopathy are overseen by different boards, Public Citizen evaluated each board separately, resulting in a total of 65 boards. Outside experts in the field of physician discipline helped devise a weighting scale for the different elements.

Public Citizen found that since Massachusetts in 1996 became the first state to require information regarding their medical board and its actions against physician misconduct be available on the Internet, almost all states "now provide some form of information online." Quality of content and the degree of usability were used to rank the boards web sites. Public Citizen also found most sites "seriously deficient in providing this important information for patients."

The findings are published in a searchable database. The database can generate individual profiles of state boards or comparison reports of all states by ranking factors (e.g., rank and score, types of physician-identifying information, disciplinary actions taken by hospitals, etc.).

The Hawaii Board of Medical Examiners offers information through the Hawaii Department of Commerce and Consumer Affairs' (DCCA) Professional and Vocational Licensing Search. Out of the 65 boards evaluated, Hawaii ranked a low 45, with a score of 38.7 out of 100, providing no information on hospital disciplinary actions, malpractice information, federal disciplinary actions, or conviction information.

2006 Report on Doctor Disciplinary Information on State Web Sites
- a Survey and Ranking of State Medical and Osteopathic Board Web Sites.
(Oct. 17, 2006, online database, provided by Public Citizen)

Affordable health care for all Americans

The Medicare Prescription Drug, Improvement, and Modernization Act Of 2003 (Public Law 108-173) created the Citizens' Health Care Working Group (Sec. 1014) with a mission to, " Develop an action plan for Congress and the President to consider as they work to make health care that works for all Americans." The citizen's group announced the release of its Final Recommendations on September 25, 2006. President Bush has 45 days to comment on the recommendations and offer a report to Congress.

Also reported in a New York Times article Tuesday, the panel report's number one recommendation is that, "'It Should Be Public Policy that All Americans Have Affordable Health Care' and that all Americans have access to a set of affordable and appropriate core health care services by the year 2012." Further recommendations include:

• Guarantee Financial Protection Against Very High Health Care Costs
• Foster Innovative Integrated Community Health Networks
• Define Core Benefits and Services for All Americans
• Promote Efforts to Improve Quality of Care and Efficiency
• Fundamentally Restructure the Way End-of-Life Services Are Financed and Provided

The working group continues with three guiding principles financing new initiatives: fairness, incentives for economic efficiency, and sufficient funds.

Citizens' Health Care Working Group, Final Recommendations

Health Care That Works For All Americans (September 2006, pdf, 39pp/356kB)
Executive Summary (September 2006, pdf, 16pp/400kB)

Web site - CSG's Healthy States

A partnership of The Council of State Governments (CSG), the National Black Caucus of State Legislators (NBCSL) and the National Hispanic Caucus of State Legislators (NHCSL), Healthy States is an initiative which provides tools to effect successful strategies promoting wellness in society.

In public health, the goal is to prevent disease or injury in a whole population--a city, state or country, for example. That's different from the goal of health care, which is to care for individuals...This Web site is focused on the major public health issues facing states today.

Tackling such conditions as diabetes, cancer, obesity, infectious diseases, disabilities and birth defects, and more, Healthy States provides online publications, webcasts, conferences, and events for legislators, staff, and other policymakers

regarding population-based interventions to promote health and to prevent disease, injury, disability, and premature death, appropriate for use by communities and health care systems.

The next live webcast (Wednesday, Aug. 30, 2006 2:00 - 3:00 pm EDT) is, School Wellness Policies: Nutrition and Physical Activity, addressing the "growing epidemic of childhood obesity." Free to policymakers and staff (requires initial registration), this webcast is to examine "innovative policies and programs to improve childhood nutrition and physical activity."

Publications offered include, Healthy States e-Weekly and Healthy States Quarterly, both newsletters with national and state reports, links, and "information on emerging and priority public health issues, new and existing research in public health, and other news of interest to state policymakers."

A recently released online document is their, State Official's Guide to Wellness, (Spring 2006, pdf, 79 pages/2.1MB),

a snapshot of the current state of health in America...Most useful to state policymakers is information on how states have begun to use wellness initiatives to promote healthy behaviors.

CSG's Healthy States has as advisers the Association of State and Territorial Health Officers (ASTHO) and the American Public Health Association (APHA), and is funded by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC).

BRCA1 & BRCA2 - new study

In a news release yesterday, the National Institutes of Health (NIH) announced the publication of a study it funded on mutations in two breast cancer genes - BRCA1 & BRCA2.

Each year, approximately 200,000 women in the United States are diagnosed with breast cancer. The majority of breast cancer cases are caused by genetic changes that occur during a woman's lifetime and not by genetic mutations inherited from her parents. However, researchers estimate that inherited mutations play a role in anywhere from 5 to 27 percent of all breast cancer cases. In the mid 1990s, researchers found that mutations in the BRCA1 and BRCA2 genes are a major cause of the hereditary form of the disease.

The advantage of the new study was its inclusion of "under-studied" groups such as African American and older women. The study's findings appear in the article "Prevalence and Predictors of BRCA1 and BRCA2 Mutations in a Population-Based Study of Breast Cancer in White and Black Amer