MCHB ALL GRANTEE MEETING

MCHB ALL GRANTEES MEETING

MCHB History, Vision, Mission , Strategic Plan, and MCHB Partnership Investment

October 4-7, 2004

PETER VAN DYCK: Well, good afternoon. Can you hear all right in the back? It sounds good. I have to be careful not to grimace; I see I’m live on camera here--not to bite my lip, not to look peeved, not to sigh. Well, I have the pleasure of greeting you initially, and taking some time on the program to help you understand history and some of the inner workings of the Bureau, which I’m sure you’re dying to hear. But we will try to make it interesting, and it is an opportunity for us to share with you a lot of the inner workings of the Bureau--the recent information. First, I wouldn’t be doing you a favor by not telling you a story. So last night, as we were setting up here, I was in the bar, but you didn’t hear it here, and there was a group sitting next to me. And it was a meeting of major CEO’s of beer companies, as I kind of figured out. And the guy from Corona sat down, and the waiter came over and he said, “Senor, what would you like?” Well, what do you think? “I want a Corona .” So the bartender went and got a Corona , and came back and asked the second guy, “What do you want?” Well, he was from Budweiser, and he said, “Hey, I want the best beer in the world. Give me the King of Beers, a Budweiser.” Bartender went and came back, served it.

Third guy was from Coors. He says, “What do you want?” He said, “Oh, I want the only beer made with Rocky Mountain spring water. Give me a Coors.” So the waiter went back and got it, came back and asked the fourth guy at the table--you can imagine we’re all ears by this time. He happened to be from Guinness, and he said, “What do you want?” The waiter said, “What do you want?” He said, “I think I’ll have a Coke.” And the other CEO’s looked at him and said, “We’re all having beer. What’s the problem with you? Aren’t you drinking tonight?” He’s like, “Hey, if you guys aren’t going to have beer, I’m not going to have one either.” That was last night here in the bar. You know, the fiscal year has just begun, 2005. What’s today? October 3 rd. So it just began Friday. Two of the budget experts that helped us with our budget were on a fishing trip, and they had to rent all the equipment, because they do budget all day and really aren’t outdoors type of people. So they had to rent the reels and the rods and the boots and the boat, and they drove up to the main woods to go on a fishing trip.

Basically, they spent a small fortune doing this. And they drove eight hours to Maine from Washington --actually it’s probably closer to 12 hours. Long weekend, first day: No fish. Very disappointed, didn’t catch a thing. Went out the second day all full of expectations, not a thing. Didn’t catch a thing. This went on the third day, too. But finally on the third day, before they had to leave, one of them caught a beautiful, nice, eighteen-inch, four-pound fish. But they still were depressed. And as they were driving home, one of them said to the other, “I mean, do you realize that this one lousy fish cost us $1,500?” And the other said, “Boy, wow. It’s a good thing we didn’t catch anymore.” If I can have my slides up. Well, again, welcome. It’s really a pleasure to have you here. We really look forward to the next day. We structured this meeting around the power of partnership. Meeting today’s MCH challenges through partnership. And it’s to meet three goals: To communicate a shared vision and to present new and critical information relevant to performance measurement policy program and administrative changes; to generate MCH partners through increased awareness; to provide opportunities for working together that compliment and build upon partner activities within, as well as across a broad range of programs; and to identify critical issues facing the MCH population and opportunities for collaborative effort that can move effectively to meet the needs of the MCH population. And I assure you we’re going to have fun when we’re doing this.

Today, Sunday, we’re going to do a roadmap to MCHB and HRSA. You’ll have the opportunity to be updated about the Bureau’s programs, grant applications, grant reviews, site visit monitoring, TA as well as other information on MCHB performance measurement. Then Monday through Wednesday, in addition to some really great speakers and panels and exhibits, you’ll have the opportunity to partner together to discuss critical MCH challenges for the future. There are three ways you’re going to be mixed up together: One, in your states and in your regions so you get to know people from different grant families within your particular geographic area; in grantee meetings on Tuesday, and some on Wednesday and even Thursday afternoon, you’ll meet other groups of grantees, many of them ones that you’ve asked to meet with; and three, you’re going to be assigned to six different groups--workgroups, based on the IOM action areas in the future of public health report. And the idea here is discuss critical issues and strategies for the future of MCH. Then on Wednesday morning, we’ll have a report out from these workgroups and Dennis Williams, who is the Deputy Associate Administrator of HRSA and myself, will be listening to this, and in a town hall format, we’ll discuss these recommendations and findings before we leave on Wednesday.

It really does provide a wonderful opportunity for me to hear from you, and for us to hear from one another, for you to meet folks in the Bureau and to really have an exchange of ideas. It’s tough with so many people, but there’s also a certain richness we can gain by having this many bright minds together in one place. So good news is, it is a big success in the number of people coming. We have probably 1,200 people range here and several hundred more who wanted to come and we just didn’t have the facility to manage it. So you’re going to have to bear with us a little bit; you’re going to have to help us move from room to room and move on. We don’t want to hinder discussion, but it is going to be hard because of the numbers of people to move between. Now, today, I have the pleasure of being able to share with you some history, some of vision and mission, and an overview of key partnerships and some of our investments. All of the proceedings are being taped; all of the presentations will be online, so you’ll be able to get presentations. We purposely did not provide write-ups of all the speeches and things because it’s just too much paper.

So the MCHB strategic plan mission: To provide national leadership and to work in partnership with states, communities, public/private partners and families to strengthen the MCH infrastructure, assure availability in use of medical homes, build the knowledge and human resources in order to assure continued improvement in the health safety and wellbeing of the MCH population. The MCH population is not just moms and kids, perhaps like it used to be, but women, infants, children, adolescents and their families, including women of reproductive age, fathers, and children with special healthcare needs. And it’s all of America ’s children and families, not just vulnerable or poor mothers and children. These statements are all contained in the MCHB strategic plan; it is on our website. It might be a plan you might want to get and pull down, because there is a lot of good prose in there, very thoughtful prose which you might be able to use in some of your speeches or even in your own strategic plans. The vision statement, you’ve been reading as I’ve been talking here, we really do believe in a future American in which the right to grow to one’s full potential is universally assured.

The Bureau seeks a nation where there is equal access for all to quality healthcare and a supportive, culturally competent family and community setting. And we have value statements in there, as well. To achieve our mission, we rely on personal population-based systems and resource-building approaches to promote the health safety and wellbeing of the nation’s MCH population. We believe that affordable and accessible high-quality healthcare for all is of high value. There should be accountable, regularly monitored and evaluated evidence-based quality care. There should be preventive, protective healthcare that address individuals physical, psychological, as well as social needs. Comprehensive coordinated care in medical homes that includes direct and enabling services; consumer-oriented, family-oriented and culturally competent care linked to community services; and continually improving healthcare based on research, evaluation, training, education, TA and the dissemination of up to date information. We have four over-arching Maternal and Child Health strategic plan goals: We believe strongly and were urged to put in this goal from our communities about national leadership for maternal and child health by together, the Bureau and you folks, creating a shared vision and goals for MCH, informing the public about the needs and issues, modeling new approaches to strengthen MCH, strong collaborative partnerships--the theme of this meeting, and fostering a respectful environment that supports creativity, action and accountability for MCH issues.

The second goal is to eliminate health disparities, clearly economic, social and cultural barriers, as well as geographic; to assure highest quality of care through the development of practice guidance data and evaluation tools, evidence-based research and a well-trained, culturally diverse workforce. And the last, to facilitate access to care through the development and improvement of the MCH health infrastructure and systems of care, to enhance the provision of a necessary coordinated quality healthcare. We like to think of--and I know some of you in the room can recite this as well as I, and that feels good to me; but there are also many of you who maybe haven’t heard me say this, so bear with me for a minute. When we’re asked or when I was asked in the past to describe MCH services, one of the great strengths of MCH is its flexibility and its broadness and its scope of coverage; but one of the great weaknesses of MCH is its broad range of services, its flexibility and its scope of coverage, because it’s hard to succinctly in five minutes give somebody like a legislator or a staff person the essence of MCH. Well, we do all this infrastructure and partnering and enabling and, you know, it doesn’t sell. So we developed this pyramid, which is a way for us to help describe MCH services. The top of the pyramid is direct healthcare services--regular, basic, clinical kinds of services.

The next step, enabling services, wraparound services, you know them: transportation, translation, case management, care coordination, getting into WIC, Medicaid. Third level: Population based services; newborn screening, a hot topic nowadays; lead screen; immunizations; sudden infant death, things that are delivered population-wide, educational services, nutrition for example, outreach. And the last and at the bottom, or not the last and at the bottom are infrastructure, building services, the base of the pyramid, the piece that holds the pyramid up, the piece that helps the rest of the pyramid work and not fall apart: needs assessment, evaluation, planning, policy development, coordination. Can you read from back there these smaller words? Okay. Quality of care, data. And what we like to say is, when we show the pyramid is that the MCH program, be it at the federal level, the state level or community level, city level, is the only federal or local program that deliberately and intentionally provides services at all levels of this pyramid. If we look at, say, community health centers as an example, they provide wonderful direct healthcare enabling services, some population based services like immunization, for example. But it’s for an area; it’s for a described area; it’s for a census tract or two census tracts; it’s not broad based, population based delivery of healthcare.

If we look at the Medicaid side and look at the children’s part of Medicaid, EPSDT, or we look at SCHIP or the CHIP program, wonderful programs providing reasonably good direct healthcare enabling services and some population-based services, like immunization, some care coordination, case management, but not on a universal, all children, all families method. And I’ve drawn those lines dotted because there are gaps even in the healthcare delivery--direct healthcare delivery that those programs provide. So this made it much easier for me to talk to Hillstaff and to talk to others about what MCH was. And in two or three minutes, I can help them capture the essence of how we’re different. Accountability. I’m going to go through these quickly, so read with me; I’m not going to read everything here. But there are some real important strengths in the MCH program that other major federal and state programs don’t have. This is a real partnership, not a partnership between the federal government and one city or the federal government and one university or the federal government and one NGO or one non-profit, or one city; it’s really a genuine partnership between federal governments, states and communities. And I’m using the word communities broadly here. Universities, families. Our statements of priorities, our performance measures and our accountability are consistent with national goals. And in the state part of the program, there’s certainly a commitment to a match as there are in a couple of the other programs.

There’s assessment and planning; there’s a framework that targets state expenditures or city expenditures to the entire population; there’s flexibility for states and cities, and many of you as individual grantees to tailor your programs within a broad structure or framework; and there’s a real commitment by all of us at the federal level and our partners to work together with other major programs. Idea, WIC, Medicaid and SCHIP, et cetera. There’s SPRANS and CISS, and I’m going to talk about them a little more in just a minute. SPRANS stands for Special Projects of Regional National Significance, and CISS stands for Community Integrated Service Systems. We’ll talk about those in a minute. And we have this overall Bureau performance measurement system. Now again, some of you have seen this before, some of you have not. But Cassie mentioned we have a national system for performance measurement in the Block Grant, and beginning October 1, two days ago, the system is now up for all grantees to apply online and to enter into the performance based system. And so all your guidance’s from now forward, you will have to measure yourself against a small set of performance measures; you’ll be able to apply live online; and you’ll be judged by how you match performance measures; you’ll have to collect some data on performance measures.

Here’s how that works, and there will be live demonstrations in one of the rooms somewhere during the meeting where you can go in and see the system. A system begins, whether it’s a state, a community, a university, city, whatever, by the grantee doing an assessment or the MCH Bureau doing assessment. And you assess your state indicators or national indicators; you look at national goals; you have legislative priorities; you have city or the mayor has priorities; and you get partnership inputs from others around you. And you need to do a needs assessment. You look at data. You do a needs assessment about what is needed in your particular program area, the same was we do. And then you set priorities and goals. And these three just happen to be three of our four national goals, but you set a series of goals. And then, once that’s done, you create a program or you create an answer to an RFP or you apply for money; you get resources. You attempt to get resources. And again, in the Block Grant, we try to explain or describe those resources or programmatic efforts by layers of this pyramid to help us better understand. And in some way, some of you will begin doing some of this. And then, we try to measure what we did. We try to measure what our programmatic effort was and if our resource allocations were correct. And we do that with performance measures.

And now, there are performance measures for the state Block Grant and for Healthy Start, and there now will be performance measures for all SPRANS, for emergency medical services for children, for dramatic brain injury, basically for all of our grantee programs. And they are an attempt not to measure all the activity, but to measure key pieces of the activities that we all set up in our programmatic plans. And hopefully it changes outcomes--infant, neonatal, maternal, perinatal mortality. Now, in the discretionary grant, which is everything that’s not the Block Grant, performance data, there is a standardized set of about 35 national performance measures. They’re a set that’s standardizes similar to those in the Block Grant, and the data collection forms that you will see if you’re not a state applying, will look almost exactly the same as the state sees when they apply. So it’s an integrated, common kind of system. And yes, you as an individual grantee--or no, you as an individual grantee are not going to have to report on 35 performance measures, just 25. No. You’re going to have to report on a set that’s tailored to meet your particular needs; there may be three, there may be five; in some cases, there may be six or seven. But generally, it will be a small set that relate directly or importantly to your programmatic activities.

Now, some of you in different programs will report on some of the same individual performance measures. So we’ll be able to add or aggregate those performance measures from different sets of grantees. We’ll be able to know how many people you serve. We’ll be able to know the budgets on your kinds of programs. So there’s a minimal data set for each grantee--no. So that’s the standard set of performance measures. Then, there will be another page that asks you for some data specific to your programmatic effort. So if your Healthy Start grants or your Emergency Medical Services for Children grants or your LEND grantees or whatever, there will be a small set of individual data points that we will collect specific to your program. Then some of you who are in large groups of grantees, where there may be 15 or 20 or 30 or 35, or in the case of states, 50, grantees that make up a family of grantees. In Healthy Start, there’s 100. EMSC, there may be 50 to 60. LEND, there may be 35. There are families of grantees. We have given you the ability to develop a small set of your own performance measures that you as a group work on yourself, decide yourself, approved by the Bureau, but that we work on together, that you think are important to you beyond those that the Bureau is imposing on you.

And we will put those into the system; they will be part of the electronic system just the same as the federal ones are, and be collected in the same system. Then there may be a few other administrative or leadership data things that we will ask--a few other data points that will not be owners. This has all been approved by OMB and it went into effect Friday, October 1. All of the guidances and all of the forms are standardizes across all grantees. If you apply for more than one grant, which I know you do--how many in the room, just for a show of hands, apply for more than one grant? Yeah, so that’s a pretty sizeable number, maybe one-third of you--one-quarter to one-third of you. The grant forms you see will be the same now for every grant you apply for, except for the difference in a couple of data points or the difference in the performance measures you may have to meet. All the other forms will be the same, so you really gain some advantage in filling out these forms. So now, we have a discretionary performance measurement system, but it’s the same. And I don’t want to belabor this, but you do a needs assessment, you have a set of goals, you fill out things related to the pyramid.

We have a sane set of outcome measures, but these SPRANS performance measures are really geared more to the divisions or the programmatic aspects of your program, not to a broad overview of the programs. Can you read that? That looks faint on my screen. This is a number of people served in the MCH Block Grant program. The second column from the left shows the number served in 1997; the third program is those served in 2003, which is this last year of data. And the last column is the percent served in 2003 as a percentage of all the category in the United States . And for those of you that can’t read it, the first line across says pregnant women. We served 2,460,000--we collectively served 2,460,000 pregnant women in 2003, which was 62 percent of all pregnant women in the United States . And that’s just the State Block grant. That doesn’t describe the whole program, does it? Because we’ve got a whole set of grantees at this meeting that serve pregnant women. We don’t know; those numbers aren’t added here. When you add those in, we’re going to serve far more. Infants, we served basically 3.9, almost four million infants, which is the number born in the United States . Seventeen or eighteen million kids, which was 22 percent of all children in the United States . Over 1,100,000 children with special healthcare needs, which we now know is about 12 percent of the kids with special healthcare needs in the country.

And we served three million others, which is largely women and largely in family planning kinds of programs. So in the state Block Grant alone, we serve over 28 million people each year in our programs and as partnerships. Now, we’ll be able to add in, in a period of a year or two, the additional folks served by all of you who represent the discretionary grantee pool, as well. But not will we only be able to look at the numbers you serve, we’ll be able to look at the additional dollars that are contributed to the MCH program, the additional effort, the number of students trained. I mean, you can just go on and on in the additional information we will have that we’ve not had before. We can tell our story so much better having the programmatic numbers for everything we do. So we’re really excited about this, hope you are, too. And we’ve tried to make it as easy on you as possible. I think it will actually be easier than filling out the new forms than what it is now. Budget: We have--the budget is composed of authorizations, and an authorization is a law, which says there is such a program; such a program exists and what the parameters of that program are, and in some cases, what the maximum amount of money that program can get.

An authorizing legislation does not fund anything; it’s not a budget. It’s just a permission to have a program and to say in some cases what the limit might be. So these are authorizing legislative authorities for the Bureau. One is the Block Grant, which contains SPRANS and CISS; one is a traumatic brain injury program. You can see Title V of the Social Security Act is a Block Grant. Traumatic brain injury is a section in the Public Health Service Act. Healthy Start is part of the Public Health Service Act. Newborn hearing screening is part of the Public Health Service Act. Poison control is a Poison Control Center Enhancement and Awareness Act. Abstinence is Title V. And Emergency Medical Services for Children Program is a Public Health Service Act. I only put that up there to separate authorization from appropriation, or permission from budget, and to let you know that it’s not the programs the Bureau has responsibility for are not all Title V of the Social Security Act or just Social Security Act. Now, what is this SPRANS and CISS stuff? Whenever the total appropriation for Title V of the Social Security Act exceeds $600 million, the amount over $600 million, 12.75 percent, is taken of that and that’s what funds CISS. That’s the amount of money we get for CISS. 12.75 percent of the appropriation over $600 million.

Then, the remainder that’s left is divided 85 percent to the states and 15 percent to SPRANS. So you know where--many of you who are funded by SPRANS, some by CISS, you may not know the difference because it may not be transparent to you. That’s how the funding runs. So additionally, however, the amount the states get, that 85 percent, there is a floor for every state. In 1983, the Block Grant had $422 million. Each state had a proportion of that. That forms a base. The state always gets that much. Now, in addition to the $422 million, that amount is distributed at the proportion that low-income children in the state represent to all low-income children. So if California has five percent of all low-income children, they get five percent of the 85 percent above $422 million. Okay. That’s how the formula works. So let’s look at the Block Grant. Now, we’ve got columns across the top: Fiscal Year 2004, last year; Fiscal Year 2005, which began Friday, October 1, this year; PB means the President’s Budget--that’s what the president turned in; Fiscal Year 2005H, which is the House mark--the House has a mark right now, although we’re on a continuing resolution, the House has marked up the bill and proposed amounts to appropriate; and then 2005 Senate; the Senate also has a mark that’s called appropriation--proposed appropriation. And the House and Senate will get together at some point in the year and give us a budget for this year.

As you know, we’re on a continuing resolution until November 20. We expect Congress to come back before November 20 and pass another continuing resolution, probably until the end of January, or in February. Continuing resolution means we can only spend exactly what we got last year and for the same purposes. We can’t create new programs. We can’t fund new programs. So from now until there is not a continuing resolution, or from now until there’s a real budget, we will be spending at the same level as last year. We go on with our program announcements; you go on writing grants. We just can’t increase them or we can’t write new--we can’t ask for new types of grants. So you can see the budget line for the Maternal and Child Health Block. The House has 730, and the Senate has an increase of five million dollars. Now, you know that anytime there’s an increase in the overall Maternal and Child Health Block Grant, SPRANS gets increased and CISS gets increased some, as well. So you can see the appropriate amounts for SPRANS and CISS. $597 million gets divided to the states by that low-income children formula; $105 million is for SPRANS, and that’s the grants many of you are funded by, as well as CISS; and then there’s something called earmarks.

Earmarks are when Congress says to us, “You will spend three million dollars on epilepsy in Fiscal year 2004,” which they did say to us. And so we devise a program that would be funded for one year, because that’s the only way an earmark can come, for one year, for three million dollars. So it’s a different kind of program than if you’re doing something for three or four years. I’ll show you the marks for 2005-the earmarks in just a second. So those are earmarks. And in some cases, we get extra money for earmarks, but because earmarks come within the SPRANS authority usually, they occasionally say, “You’ve got $105 million for SPRANS,” if we look at the Senate for 2005 as an example. “Fund some of those earmarks out of that already existing money,” which means that we than can’t fund something else because the earmarks the requirement. So it’s a mix of these things. So just to give you an idea of how that budget works. I don’t want to go too much into it. Now that you’ve seen the budget and you see that there’s $730 million in the Block Grant, now you can look at this again and say, “$730 million minus $600 million is $130 million.” So you take 12.75 percent of that $130 million and you get the amount of money in CISS. You take the remainder then and divide it 85/15. So I don’t want to prolong that.

Now, there are other programs run by the Bureau--Healthy Start, hearing, EMSC, poison control, abstinence education and TBI, and I’ll let you scan that kind of quickly across. There is a significant increase for Healthy Start in the Senate mark, about seven million dollar increase. You can see for hearing screening, in the President’s budget, he proposed nothing, but in the previous years, the House and Senate have both increased it to $10 million, and this year they proposed the same. And you can see the differences in abstinence funding. And then here are the earmarks. The earmarks only come from Congress, they don’t come from the President. They don’t come from the administration. So you can see the earmarks for 2004; that’s what we currently had up until Friday. Five million for oral health; four million for sickle cell; three million for epilepsy; two million for genetics; and 1.6 million for mental health. And you can see that in the House and the Senate, those earmarks have been proposed to continue at some level. And again, you can see the levels are consistent until you get down to mental health, and there’s been about a doubling of the earmark for mental health. So these aren’t real numbers to hang your hat on yet, but it’s sure a hell of a lot better having a number there than having a zero there. And we have great expectations that some of these will be funded. And it allows us then to continue the activity for another year, if we perform well--if you perform well. And if we can report on what we do well, these things often have legs, and that’s good for all of us. So that’s kind of how the budget works.

History: This is kind of fun. 1912, the Children’s Bureau was created to investigate and report on the status of children, and on their common as well as special needs. I visited Hull House in Chicago three or four months ago, and this is where the women worked who were the creators of the Children’s Bureau. And it was really interesting to be there and be in a place and see the plaques and the pictures on the wall of these women, and it really brought home for me how far ahead of the times these women were--Julia Lathrop, Grace Abbott and others--in promoting children’s health by creating this Children’s Bureau in 1912. The greatest selling book in the history of the federal government is “Prenatal Care”. It was first published in 1913. “Infant Care” was published in 1914. We have a version--I have a version on my desk--I have the copy of the original publication. And we are thinking about perhaps putting out that--we’re reprinting it and putting it out as it was then. It is wonderful to read. I mean, you just can’t believe some of the suggestions in that. We’ve come a long way in some things, and we’ve not come so far in some other things. In 1921, Shepard Towner Act was passed. And the Shepard Towner Act was passed and was administered by the Children’s Bureau for as long as it existed, which was 1921 to 1929.

And it was based on the Department of Agriculture legislation, but it was the first federal grant and aid program of states for health, establishing the principle of public responsibility for child health, to promote the welfare and hygiene of maternity and infancy, but it was very controversial and was labeled radical and socialistic by its critics. And listen to this: The American Medical Association, the Catholic Church and the Public Health Service together, partnering were instrumental in having it repealed eight years after its enactment. But because of that disagreement within the AMA, there was an off-shoot formed by the AMA at that time, which was then called the American Academy of Pediatrics, and that’s how the American Academy of Pediatrics was first formed. In 1935, Title V of the Social Security Act was passed. That’s the authority, you now know, under which we operate because we saw that authorizing legislation. It authorized grants and aid to states for MCH programs, including services for crippled children and for child welfare. And the MCH program represented an enhancement and broadening of the educational and preventive element of the Shepard Towner Act.

In contrast, the Crippled Children Services Program, CCS as it was called, was the first program of medical care in United States history that was based on the principle of continuing federal grants and aid to the states. CCS became a model of coordination and comprehensiveness, for example, and included case finding and aftercare in its services. 1943, autism was first officially described. 1950, disposable diapers were invented. Long time ago, wasn’t it? I bet you didn’t realize it was that long ago. 1957, mental retardation programs were first authorized, and Congress earmarked one million for a demonstration program for children with mental retardation. ’62, St. Jude’s was founded by Danny Thomas. For some of you, young like me still, you remember 1960s having the Maternal and Infant Care Program and the CNY Programs. I know some of you in the room remember these programs. In addition to three other new grant programs: the Newborn Intensive Care Unit Program, Family Planning and Dental Care. So there was this family of five programs that were fist funded. ’68, electronic fetal monitoring was first used. 1969, administration of the Children’s Bureau was transferred to the Public Health Service. And in 1981, I think you heard Casey say I was president of MCHIP, ’78 to ’80. And in the meeting where I was leaving as president and the next person was coming in--I think it was Judd Force, as I remember, from Baltimore --we heard for the first time at our meeting as the program began, that it was going to be completely reorganized into a Block Grant.

And this was 1981. And it was converted to a Block Grant as part of the Omnibus Budget Reconciliation Act; that’s what OBRA stands for, Omnibus Budget Reconciliation Act. So when Congress doesn’t get their act together very well and pass an individual budget for everybody and they just pass one great big budget with everything in a big basket. Categorical programs consolidated under the MCH services Block Grant include those you see there. And the theory in this was each of these individual programs required separate administration in a state. Wouldn’t it be wonderful to combine them and save all those extra administrative dollars in a Block Grant where you could have a common administration? And so as I remember, and I can’t remember the numbers exactly, 10, 15 percent of the overall MCH program was cut because that’s the amount that could be saved by combining these individual programs into a Block Grant. That was 1981. And that’s when the 15 percent and 85 percent became much more clear, although SPRANS had been in effect before that. This is when it really got consolidated. ’82, prenatal tests for sickle cell disease. ’84, EMSC, Emergency Medical Services for Children, and in ’89, was really the last major change to the Block Grant. And as you can see, that’s when the needs assessment for states and the priorities was put into the law.

That’s when measurable objectives were required. That’s when budget accountability was required. That’s when the documentation of MCH, maintenance of effort. And this was really a swing of pendulum from 1981, because in 1981, by Block Granting everything, authority went to the states with the Block Grant, away from the federal government. Ronald Reagan had just come in as president, and there was this movement to move things from federal government to states. And it took from 1981 to 1989 for, I think, the Congress to recognize that they wanted to know more about where the money was going and this kind of lax relationship between the federal government and the states; and so they strengthened the reporting requirements in 1989 for the Block Grant. And this has been, I think, most of us in MCH feel, has been a great improvement from 1989 on. Healthy Start was enacted in ’91, abstinence in ’96. Performance measurements, the Children’s Special Healthcare Needs Survey, newborn screening began to get to attention because of the inequity among states with the early advancement of technology in 2000. Abstinence, clearly. Poison control was strengthened and bioterrorism money started to become available in 2000, 2001. And then in 2004, performance measures, Children With Special Healthcare Needs Survey; you’ll get the chart book at this meeting.

Child Health Survey is ready to be released in the next several months. Anti-bullying campaign, emphasis on early childhood. Newborn screening is really hot now. Women’s health, discretionary grants, reporting system, which we talked about. Data and evaluation emphasis. There’s a training strategic plan which will be discussed about at this meeting and many others. I’ve just listed a few. And I hope we haven’t come too far. "I’m worried that healthcare has become too impersonal, Doc." “Hey, just relax, lay back on the barcode scanner.” Okay. The law. And I’m going to go through this fairly quickly. I recognize this is not like looking at a data presentation of some kind. This would be kind of pedantic, but let me run through the law, because there’s a lot of interesting points that people who even have been in MCH a long time forget are in the law. And the law is a strength of the MCH program. First, there’s five or six extremely important provisions. Title V authorizes appropriations to states to improve the health of all mothers and children. It is law. All mothers and children. And again, these PowerPoint’s will be on the website after the meeting; you can pull any of them down.

To provide and assure mothers and children access to quality maternal and child health services. You can see the dots; I’ve just highlighted these provisions. To reduce infant mortality, preventable diseases and handicapping conditions of children; increase the number of immunized children. This is the formation--beginning the formation of this broad mandate, this really broad mandate we have, which is so important. To increase low-income children receiving health assessments and diagnosis and treatment services. To promote health by providing prenatal, delivery and postpartum care. To promote health of children by providing preventive and primary care services. And if you’re trying to develop a program in your state, you can find the authority to do that almost under any of the provisions. Then to provide rehabilitation services for blind and disabled individuals under 16. Receiving benefits under Title XVI to the extent it is not provided under Title XVIV. So this is kids on SSI that you serve in your children with special healthcare needs services. And then the last: To provide and promote family-centered, community based coordinated care for children with special healthcare needs and to facilitate community based systems of services for such children and their families. This is the beginning of the law. This is now it begins. It gives us this broad mandate and authority to have a tremendously flexible program developed to serve all mothers and children.

There’s an authority for SPRANS. What is says SPRANS is supposed to do is, SPRANS, research and training for MCH and CSHCH for genetic diseases; testing, counseling and information development and dissemination programs. For grants including hemophilia, relating the hemophilia without regard to age, for the screening of newborns for sickle cell and other genetic disorders and follow-up services. And then the CISS has six parts that it’s supposed to address: Maternal and infant home visiting programs--remember these are old--this is old law now; increase participation--let me go back. Increase participation of OB’s and pediatricians under Title V and under Medicaid; to develop integrated MCH delivery systems, and there was a big push on using a model application form a few years ago; develop centers which provide prenatal, delivery and postpartum care; develop MCH projects in rural areas; and to develop outpatient community based services including daycare for special kids whose medical services are provided primarily through inpatient institutional care.

Now, there are some restrictions to the Block Grant, and I’m going to list three or four or five of the most important restrictions, things you cannot do. You cannot pay for impatient services using Title V money, other than for services to children with special healthcare needs or to high-risk pregnant women and infants. You cannot make cash payments to intended recipients of health services. You cannot purchase or improve land, buildings or other major medical equipment without prior authorization from the federal government. You cannot use MCH federal dollars for satisfying the requirement of expenditure of non-federal funds. In other words, Medicaid requires a state match in your state. You can’t use MCH federal dollars to provide that match. You also can’t use state MCH matching dollars to match twice to Medicaid. We cannot pay for research or training other than to a public or non-profit private entity. So that’s not too bad for a set of restrictions. But there are some things we must do, as well. We shall do, must. We must establish a fair method for allocating funds among such individuals, areas and localities who need MCH services. That’s not only from the federal government, but it’s from the state government. There must be a publicized, public method for allocating those funds statewide.

We must apply guidelines for content of healthcare assessments and services and for assuring their quality. We develop guidelines. We may use Bright Futures guidelines, which is a product of the Bureau. You may develop guidelines for prenatal care. You may develop guidelines for health and safety and daycare, or childcare. If you apply charges, and certainly, many of you should, if imposed, they will be public, are not for low income mothers and children, and that’s under 100 percent of the poverty level, and will be adjusted to reflect income resources and family size. Many state clinics charge, some city clinics charge, some of our grantees charge. It must meet this requirement. And the state must provide for a toll-free hotline for use of parents to access information about providers for Title V and Title XVIV Medicaid and about relevant other healthcare providers. And again, as part of the performance measurement system and data collection on the web for the Block Grant, the number of calls received by each state toll-free number is on that data site. That data site, by the way, is mchdata.net. So if you want to see what the Block Grant data looks like--the money, the people served, the reporting on performance measures--you go to mchdata.net.

That will be what the site looks like for your discretionary grant requirements. I mean, you’ll have the same kind of site. It will look somewhat the same. You must coordinate activities with EPSDT including periodicity and content standards and ensure no duplication. We encourage state MCH programs to provide for EPSDT and Medicaid the appropriate standards for child and pregnant women care. There must be an agreement with the state. MCH and Title XVIV or Medicaid program for coordination between those two agencies, and it must be a public document. You must coordinate activities with other related federal programs, and you must provide for services to identify pregnant women and infants eligible for Medicaid and assist them in applying for assistance. And you have to make the application public. The state must make the application public to facilitate comment. And you know that any application you make to us as a grantee, if it’s approved and funded, becomes public. And importantly nowadays, our law says that the money has to come from the federal government for the state Block Grant to the state health department. And that must be the administrating agent for the MCH Block Grant.

Well, that wasn’t too painful, was it? A small advance everyday will eventually total much less than a big advance everyday, so I just like to say, “Let’s just make it a big advance everyday, right?” And certainly, this meeting, I think, is one way to make a big advance to get us all beginning to think about the same things, begin to understand one another, begin to meet one another and recognize the wonderful, wonderful things that each of our grantees does to give you a chance to know those folks better because we all have the same aspirations and desires for our population; for you to get to know the Bureau better. And I know you get disappointed sometimes. And I haven’t shown this for a long time, but I used to show it all the time. You know when you get disappointed? Remember. Doing a good job here is like wetting your pants in a dark suit; it gives you a nice, warm feeling, but nobody notices. Do you ever feel like that sometimes? Folks, I’ll be here at the whole meeting. I’ll be happy to talk to any of you at any time. I enjoy it when you come up and introduce yourselves. I know many, many, many of you from meeting with you over the last several years. I respect what you do. I applaud what you do. And it’s really an honor to be here, to be able to talk in front of you and to share a few thoughts about the history and the budgets of the Bureau. Thanks very much.