Introduction and Welcome

Peter Van Dyck: Thank you, Cassie. Good morning. Good morning. They always give me the fun part on the agenda; I get to talk about history, the law, all the things you don’t want to hear about very much. So I always have second doubts when I get up and think about having to talk about this, although I do like to talk about it and share, and I think it’s something we all need to know. I swear to you, as I reading the paper this morning before I came, I looked at my horoscope and my horoscope says, “You may have second thoughts about an agenda. Have no fear. You’re ready for action and must go forward. A lucky connection is made by holding onto the truth.” That’s my horoscope for today.

Carrie Lauver: Which sign is that?

Peter Van Dyck: That’s Sagittarius. So I have no fear in moving ahead with this agenda. I’ve been preparing some speeches lately on leadership--you’re probably going to hear one eventually--and I was looking at some quotes and I’m just going to read you a couple quotes that I didn’t accept, but which, when you do a search on the web, came up. Napoleon said, “Never interrupt your enemy while he is making a mistake.” Erma Bombeck, “Never go to a doctor whose office plants have died.” This one from Lily Tomlin I’ve heard before, but I like it: “I always wanted to be somebody, but I should have been more specific.” Mark Twain, “You can’t depend on your eyes when your imagination is out of focus.” That one maybe I should keep, huh? Homer Simpson, “I made a deal with myself 10 years ago. I sure got ripped off.” James Bryant Conant, “Behold the turtle. He makes progress only when he sticks his neck out.” And the old Chinese proverb, you’ve heard it before, but it is an old Chinese proverb, “Do not use a hatchet to remove a fly from your friends forehead.” My daughter sent me an email a little bit ago. She graduated a while ago, but was a creative writing major, and she’s been working at a school reading themes as part of her job for the last year, and she sent me an email and said the kids had just read “The Lord of the Flies,” and she was reviewing some of the themes that they turned in, or these one page summaries of the story that they turned in, and she sent me a few of these quotes because she knows I like this kind of stuff. “I don’t believe that Simon is a Christ figure because he dies. Why would he die if he were so important?” “So in conclusion, the symbolism of “The Lord of the Flies” is large and in charge.” “The Lord of the Flies” is a classic example of the human psyche. To remove this book from schools would be like denying what the race really is.” “Also knowing that this book is an all time favorite should not only be used in schools that are located here and there, but in schools located in a vast area for use.” “All in all, Jack is one bad and possessed little boy.” You remember “Lord of the Flies” when you had to read it a while ago? “They did have a civilization that did work together, but clay, paint, and fun turned them on each other.” “If there were two different genders in the world, things could be less chaotic.” These are real. These are high school kids. So those are some of the fun ones. There’re also some very bright kids as we all know, and we should celebrate them. Well, I have the wonderful task of sharing with you some things about the Bureau. There is a handout that you got. You can follow through my slides. At the back of those slides there’s some large ones for some of the pieces that may be too small to read. And I’m going to go through these fairly quick. If there are questions, raise your hand because I am going to go quickly, and I’m going to talk about leadership first, and I’m going to talk about the Maternal and Child Health Strategic Plan. You do have a copy of the Strategic Plan. I think it’s really a good document. Everybody that you’re going to hear from today and others have worked hard on it over a period of a couple of years. There is a lot of material in it. It is labeled “draft.” Don’t worry about that. That just means that we have the right to change it if we find something funny it. But it is a document from which we really do make decisions. We do issue RFPs based on it. We do make budget decisions on it. We really do use it and we would appreciate your suggestions and ideas, particularly after you get together at a meeting like this and hear what everybody has to say and hear from all of us. Our mission is to provide national leadership and to work in partnership with states, communities, and public/private providers and families to strengthen the MCH infrastructure, assure the availability and use of medical homes, build the knowledge in human resources in order to ensure continued improvement in the health, safety, and well being of the MCH population, and that MCH population is bigger than we might traditionally think. People you talk to may say mothers and kids, but it’s really mothers, women, infants, children, adolescents, women of reproductive age, fathers, and children with special health care needs, and if you think about the programs you’re responsible for, or we’re responsible for, certainly includes all of these folks. We need to provide national leadership is the first goal for Maternal and Child Health by creating a shared vision and goals for MCH: informing the public about the issues, modeling new approaches to strengthening MCH, forging collaborative partnerships, and fostering a respectful environment that supports creativity and action and accountability for MCH issues. The second goal: eliminate health disparities. The third goal: to assure the highest quality of care. Again, practice guidance, data monitoring, evaluation tools, using evidence based research, and well trained in a culturally diverse workforce. And the fourth goal, the last goal: to facilitate access to care through the development improvement of the infrastructure and systems of care, which you know we talk about so often. So these are the four goals and I’m not going to go into more detail, but in the Strategic Plan itself there’s a lot more detail about all of those issues. Something about performance: leadership performance and accountability we like to talk about. When I first came and congressional staff wanted to hear about MCH, I started talking and I had a long agenda, and I quickly noticed that in five minutes, or eight minutes, or 10 minutes, peoples eyes began to glaze over and I was just getting started. I mean I was excited, enthusiastic, and I was just getting started. But they had 10 minutes or 12 minutes, and that’s as long as I could get their attention. So we developed a way of helping people understand what our story really was, and this pyramid, although it may take me longer than 10 minutes to explain it, a graphic representation of this in a discussion of MCH can really speed along understanding, I think, of what we are about. The top of they pyramid is direct health care services. Something we all know about and most of you are familiar with this. Enabling services, transportation, translation, care coordination, case management, family support services, all those things that are important to making direct health care really work. The third level are population based services: immunization, lead screening services--there is a big one of these at the back of your presentation--oral health, injury prevention, nutrition, outreach, those things that we offer on a population basis, population wide, (inaudible) death counseling, all these kinds of things. And at the bottom of the pyramid, forming the base, forming the basis, forming the foundation are infrastructure services: needs assessment, evaluation, monitoring, data, quality, standards, legislation, systems development. Without this strong foundation, none of this stuff above really works, and we know we have a problem in this country making the health system work. Now, that’s a description of the overall health system. Where does MCH fit in? Well, MCH is the only program either at the state level or the city level or the federal level that really deliberately and intentionally provide services at all levels of this pyramid. We encourage infrastructure development services and you provide many of those on a statewide basis. You also provide population based services enabling and direct healthcare, and we can tell from you block grant applications that you spend about half of your money on direct healthcare. You spend about 10 or 12 percent on infrastructure and about 10 or 12 percent on population based, and we know there’s this tension between trying to provide more infrastructure services and perhaps less direct care services because when we develop infrastructure, we think our money goes farther, but there’s this tension between, the movement between, the top and the bottom of the pyramid. But when I explain this to people on the hill, they really have a much better idea of where we fit in. If we look at community health centers, they provide direct care enabling, some population based services. They provide wonderful services, but really not on a statewide or citywide or countywide or district wide or region wide level. If we look at the Medicaid side with early periodic screening diagnosis and treatment or the SCHIP program, kind of the same, they really don’t provide infrastructure services nationwide, statewide, region wide. They do provide some wonderful direct care and enabling and some population based services like immunization. I’ve also drawn those lines dotted because they cover less well, perhaps, children with special health care need or some others. There are holes in the coverage, but they do provide wonderful services. So showing this pyramid and then talking about what you want to talk about for MCH, I think will really benefit the people you’re trying to explain your program to. Accountability. There’s another big one at the end of this. Some of these just take a few minutes, but I think it helps us get our arms around, get our hands around, our psyche around, what we’re about and how we think and how we try to create a structure for ourselves within which we can make progress and record our progress and document our progress. If we think about how we, or should, perhaps, develop our programmatic efforts, all of us, federal level, state level, city level, we start with a needs assessment of some kind. We either have health status indicators, or we have Healthy People 2010 indicators, or we have state goals and priorities from the Governor or the Legislature. We have partnership inputs or we have family inputs. We arrive at a whole series of data points that help us understand what the needs are in our state. From those needs, then, we develop a set of goals, and I read you four goals for the Bureau. We have another set objectives. We have a whole set of performance measures. But these priorities flow from the needs assessment. In our case: decreased disparities, increased quality, improve infrastructure. Three of the goals and we added a fourth goal in this last strategic plan, which was to provide national leadership. Then we allocate resources, or in our case, we issue RFPs, to get the work done and we think, sometimes, not always, but sometimes about allocating those resources towards direct healthcare or towards infrastructure services or towards a media campaign or towards sudden infant death counseling, which is a population based services. I mean we really think about this in some creative way, generally. And then to measure what those programmatic efforts due and allocation of resources do, we have sets of performance measures at our level, for the state block grant and now for SPRANS, Healthy Start, and all of our programs, which I’ll describe in a minute, and attempt not to measure very single piece of what we do, but an attempt to measure at least significant things or the bulk of what we do so that we can be accountable to the people that give us the money, and we hope that this improves outcomes, and those outcomes, which OMB basically prescribed to us several years ago, are things related to infant and perinatal mortality and to the infant death disparity between white and black infants. So this is the scheme and we can draw one of these schemes for every one of our programs. Budget: first, to give you an idea that the Bureau’s programs, and as you probably already are aware of, your own state programs do not only get money from the Title V of the Social Security Act. The MCH services block grant does get money from Title V of the Social Security Act. The Social Security Act also has Title XVIII Medicare, Title XVIIII Medicaid, Title XX, which are some welfare services, and all the titles in between. That’s Title V of the Social Security Act. A traumatic brain injury program and many of our other programs are authorized in the Public Health Service Act, a completely different Act, and I won’t belabor these things, but just so you have a feeling that many of the things we do, we talk about Title V program, we talk about an MCH program, but it really is multifaceted and comes from many different sources of funding. The Poison Control Center Act comes from neither of those two; it comes from the Poison Control Center Enhancement and Awareness Act. But this gives you a list of the programs and the types of authorities that we work under and because they are different types of authorities, they have different laws and the announcements look a little different and the requirements are a little bit different. Now SPRANS and CISS, how do we figure out the money? Whenever the total appropriation exceeds $600 million, this is in Title V of the Social Security Act, and right now it’s at $700 and what, $31 million, $730, $731 million. So we exceed $600 million. So the way the formula works: 12.75 percent of the amount over $600 million is used to fund CISS, Community Integrated Service Systems Set Aside Program, and I’ll describe that in a minute. Once you take that off of the difference between, in this case, 600 and 731, so it’d be $131 million, about 13 percent of $131 million, take that off, then the rest is allocated in a formula: 85 percent to the states and 15 percent to SPRANS. Now the amount that the states get, you get a base in every state, which comes from $422 million, which is a basis on an amount awarded in 1983, and above that base in your state, the rest of the formula’s allocated on the number of low income kids in your state under 18 as a percent of all poor kids in the nation. So sounds a lot more complicated than you thought, doesn’t it? CISS comes off the top, then it’s split 85/15 for SPRANS in the formula, but it’s not all given to you by the formula. You get a basic amount of what the distribution was in 1983. It adds up as a total of $422 million, and then the amount above that in each state is allocated by the formula. Now to give you an idea of the budget for last year, now fiscal year 2003, and these numbers are the President’s budge, that’s what the PB stands for for 2004. Again, you can see these amounts: the $730 million. The President’s budget had $751. The Senate and the House marks are lower than that. The state block grant proportion of that you can see: $600 million and $622. The SPRANS amount, the 15 percent set aside, you can see what that is. CISS: 15.9 and 19.3, and we always get earmarks that say from Congress, “We’ll give you $5 million for an oral health program. We’ll give you $5 million for a special program to some hospital. We’ll give you $5 million to provide sickle cell training across the United States,” or something like that. And just to scan these other authorities that we have in the programmatic efforts we have, you can quickly see what some of these are for the Bureau. Now history. Any questions on the budget or that formula? I don’t want to make it harder than it is, but you should have a basis for understanding how that formula works, what our strategic plan is, how we allocate money, those kinds of things. We have a long and a very rich history, and I think you should be aware of this, and I think the more we get busy with contemporary issues, the more we forget our history and the purpose for why we were created, and it really goes back to 1912. Title V is the oldest public health service program in the nation. I think we should be proud of that, going back to 1935, but the Children’s Bureau was formed in 1912 and it was to promote the welfare of the child population. It was created to investigate and report on the status of children and on their common as well as special needs, and the Bureau, the Children’s Bureau, interpreted its mandate to mean the establishment of facts for the purpose of stimulating action for children. Then in 1913, 1914, two publications were published by the Children’s Bureau, which were two or have been two of the biggest selling government books every published. They are out of date now and old. We are even thinking about perhaps reissuing these perhaps in a historical version as well as an up-to-date version, which really might be interesting to contrast the two. In 1921 then, the Sheppard Towner Act was passed and was administered by the Children’s Bureau. This was really an important Act and you’ll hear about it from time to time. People talk about the Sheppard Towner Act. It was in existence from 1921 to 1929. It was based on Department of Agriculture legislation, and it was the first grant and aid program to states for health and established the principle of public responsibility for child health, to promote the welfare and hygiene of maternity and infancy care. It was really a first, and because of that, it was controversial and was labeled radical and socialistic by its critics. This was in 1921. The American Medical Association, get this, the American Medical Association, the Catholic Church, and the Public Health Service, were instrumental in having it repealed eight years after its enactment. Can you imagine a more interesting partnership? And because of a disagreement within AMA over the opposition to the legislation, the American Acad of Pediatrics was formed in 1930. So the American Academy of Pediatrics split from the AMA over the repeal of this legislation because they thought it was good even though it was radical and socialistic at the time. Title V of the Social Security Act then was formed in 1935, was passed in 1935, and it was really as a result of the Great Depression the few years early because it demonstrated the Depression, how tragically dependent children were upon the government for some services and for some kind of protection against economic hazards. Title V authorized grants and aid to states for MCH programs, including services for crippled children and child welfare services. The MCH program represented an enhancement and broadening of the Sheppard Towner Act. In contrast, the Crippled Children’s Services Program was the first program of medical care in U.S. history that was based on the principle of continuing federal grants and aids to states. CCS was a model of coordination and comprehensiveness because it included case finding and aftercare in its services. Just to give you a feeling for some other historical moments: 1943, autism was first officially described by Dr. Leo Kanner; 1950, disposable diapers were first invented by Marion Donovan. What’s that? Fifty years ago now; 53 years ago. In 1957 then, mental retardation programs were first passed, and as the MCH program matured, project specific grant authority began to appear, like mental health, and Congress increased the appropriation and earmarked $1 million for demonstration clinical programs for children with mental retardation, and these funds were used for discretionary projects to educate the public and professions and to sponsor development and evaluation clinics. In 1963 then, John F. Kennedy gave a presidential message relative to mental illness and mental retardation and Congress increased the MCH and CCS appropriation, earmarking part for special projects to clinical programs for mentally retarded children. Also, the MIC, the Maternal and Infant Care programs, and the Children and Youth programs were developed between 1963 and ’65, and three new grants in addition, and collectively they became known as the Program of Projects. Newborn intensive care units were first funded, family planning was first funded, and dental care was first funded through the MCH programs. So that was around 1965, 1967. Nineteen sixty-eight, electronic fetal monitoring was first used, and in 1969, administration was transferred to the Public Health Service, the administration of the Maternal and Child Health activities. I shouldn’t say this since that’s a long time ago; I was President of the Association in 1981. That’s when this program was converted to a block grant by combining seven categorical programs: the traditional MCH Children’s Special Healthcare Needs Program, SSI, lead screening, genetics, SIDS counseling, hemophilia treatment centers, and the Adolescent Program grant. And I can remember we were meeting, we had our national meeting in March or so and I think we were in San Diego, and this was imminent, this block granting, but within two or three hours of that meeting beginning, we heard that President Regan had signed this, and we had an emergency meeting in a session like this with 250 to 300 people, and we completely decided to scrap the agenda we had developed and we spent the whole meeting discussing block granting, what it meant, how we were going to deal with it, who were we going to write letters to. I mean I can remember that so well. I can remember that was back in the days of the singing telegram and we were all bemoaning the fact that someone was going to come knocking at our door and we were going to open it and somebody in this little (inaudible) says, “(Inaudible) MCH is dead.” Well, anyway. Anyway, it had a big impact on me, as you can tell, because the idea of converting to a block grant was to save money and because you could administer these programs more efficiently when they were linked together, you could save 15 to 20 percent. So budgets were cut, programs were linked. There is some advantage to a block grant. There are some bright points to a block grant. I think we have made the best of a block grant and turned it around and then made good of it, but it was a challenging time and it’s something that is an important piece of our history. This is when the 85/15 percent came in, the SPRANS allocation. In 1982, the first prenatal test for sickle cell. In 1984, Emergency Medical Services for Children was enacted. That’s still run for the Bureau. And in 1989, OBRA-89--you saw OBRA-81 there too. OBRA stands for Omnibus Budget Reconciliation Act. That’s when Congress gets together and lumps a bunch of things together. It’s really a congressional term, but you hear it all the time. So just so you know what it is. “O” is Omnibus, “B,” Budget, Reconciliation Act. It’s getting all the pieces together and reconciling them, and put together in a piece of legislation, which makes them all get funded. Nineteen eighty-nine there were major changes, which you now are familiar with, that were introduced, and they were introduced for the first time in ’89. An application which included a needs assessment and a set of priorities, measurable objectives. Not performance measures. Those have come since, but there were measurable objectives that each state had to have. Budget accountability, documentation of match, the three for four match, and the maintenance of effort first came into effect in 1989. So these were really sweeping amendments to the block grant. It made the block grant more accountable. In 1981, things were blocked, but there was no accountability built in, and we in states thought that would be good. You know, we didn’t have to answer to all these objectives and answer for all this money. But you know what? Over the period of the next several years, we wished it were there, and we began as a group in our MCHIP meetings beginning to think we need to develop some accountability on our own because we can’t tell Congress or people funding us what we are doing. So on our own we began to say we want more accountability, we need more accountability, we need more consistent accountability across states, and so it was a self-realization that this was an important piece and a lot of that was built into 1989. The CISS funding, the 12.75 percent for CISS, first came into account in the 1999 OBRA amendments. Nineteen ninety-one Healthy Start Program, the federal Healthy Start program, in 1996, Abstinence Education Program, the state program began, and in 2000 we introduced performance measures, the Children’s Special Healthcare Needs Survey, the website for the data, newborn screening; major newborn screening programs were funded for the first time from the federal government from MCH. Abstinence, as I mentioned before. Poison Control services were first funded at the federal level, and bioterrorism began to be funded, and since then, all those other wonderful things that have happened to MCH. Now, organization: there is an organization chart, a large one as well, and I’m not going to go through this. It’s at the back of your handout. But on that chart, you can see we have five divisions. You’re going to hear from those divisions today. We have several offices; you’re going to hear from those offices, and you’ll see the people that you’re hearing speak, so it helps you put them together. And I do want to introduce somebody to you that’s not speaking today because he’s new, but is the new Deputy Associate Administrator for Maternal and Child Health and that’s Steve Pelovitz. Steve, here in the front of the room, let people know who you are, and Steve will be around during the meeting. He began a month or six weeks ago, and I went away for two weeks or more to Afghanistan and Steve went away to somewhere sunnier and shinier to England and Italy and Austria, and so we’re just getting back to regroup. Steve provides senior leadership and policy direction for the Bureau as the Deputy, basically, and prior to assuming this position, was the Director of Survey and Certification in the Centers for Medicare Medical Services. He was responsible for the oversight of major operations activity such as the development, interpretation, application of specific laws, regulations, and national policies that directly govern the operations and management of the agency. During HCFA’s reorganization effort, he was the Chief Operating Officer of HCFA, the Health Care Financing Administration. He’s testified before Congress many times and represented HCFA, which is now CMS, interests to the Secretary of Health and Human Services and OMB. So Steve brings years of experience, administrative experience, in a major, really the major Health and Human Services Agency, and is already been used for many questions related to Medicaid and other issues that we deal with with CMS. So welcome Steve. Come up and say hi to him, let him know who you are, give him a feeling for what you’re doing in states. He’s had a chance to meet with all our folks in the Bureau, but has really not met with state folks yet, so this gives him an opportunity to hear what some of you do. Welcome, Steve. The law. Okay, how I’m I doing here? I know this is a lot of stuff, but I think it’s important stuff. So the law: this is Title V of the Social Security Act. The law’s surprising. It gives us this wonderful flexibility and I’ll tell you we use it all the time, but at the same time it gives us flexibility, it has a lot of the right words in it. It really allows us to develop our priorities, to set our goals and objectives, and find a legal means within which to operate. Title V authorizes appropriations to states to improve the health of all mothers and children. Not just poor kids. Not just disadvantaged. Those under underlines our mind, but it’s the health of all mothers and children. Very important. To provide and ensure mothers and children access to quality maternal and child health services. Obviously these are all abbreviated and they’re longer in the law. You have a copy of the law in your book. To reduce infant mortality, preventable diseases, and handicapping conditions among kids; increase the number of immunized children; to increase low income children receiving health assessments, diagnosis and treatment services; to promote health by providing prenatal delivery and postpartum care; to promote health in children by providing preventive and primary care. Children with special healthcare needs are also mentioned. SSI is in the law, which is what Title XVI is, and 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 children and their families. So clearly, fit within this, most of our activities. In fact, all of our activities can be found within this really broad stroke of the law. Now SPRANS. SPRANS again stands for Special Projects of Regional and National Significance, in case some of you are so new you don’t know that. Special Projects of Regional and National Significance, and that’s the 15 percent set aside and that represents $115, $120 million of money that we RFP to states, communities, organizations for special projects of regional and national significance. They can provide research. They can provide training, genetic disease testing. You’ve read ahead of me now. Hemophilia, screening of newborns, other genetics, follow up services. These are quotes from the law, but it allows us to really stay on top of what federal or state priorities, what our own priorities are, and to fund towards those things. CISS stands for Community Integrated Service System. Community Integrated Service System, that’s right. To provide for maternal and infant health home visiting programs, to increase participation of OB’s and pediatricians under Title V and Title XVIIII. So even programs where we try to facilitate getting care by OB’s and pediatricians are covered. Develop integrated MCH delivery systems and use the model application form. A model application form, when this law was passed, was an attempt to create a single application form across state health or health and welfare programs, and many states have made good progress there. To develop MCH centers which provide prenatal delivery/postpartum care for pregnant women, and preventative and primary care services for infants up to one year of age, bringing these services together. To develop MCH projects to serve rural populations and to develop outpatient and community based service programs for kids with special healthcare needs. So CISS has a broad, again, a broad, but yet defined, and fairly well defined, set of legal requirements, and to you, when you see RFPs from us, you may not even recognize the difference between a CISS and a SPRANS grant, and I’m not sure you have to because we’ve taken the responsibility of making sure that that announcement fits the legal requirements for either SPRANS or CISS, but for us it is a budgetary issue. Now there are some restrictions in Title V. Despite its broadness, and despite the fact that it gives us great flexibility in creating programs that respond to specific state needs, we cannot pay for inpatient services other than for services to children with special healthcare needs or to high risk pregnant women and infants. We cannot make cash payments to intended recipients of health services. We cannot purchase or improve land, buildings, or other major medical equipment. This is one is accepted in some cases of extreme dire need: cannot be used for satisfying the requirement for expenditure of nonfederal funds. You can’t use federal funds for match. You can’t use federal funds and call them anything else other than federal funds. They are federal funds. You cannot pay for research or training other than to a public or nonprofit private entity. There are some things you should do, you shall do, you will do. You must establish a fair method for allocating funds among such individuals, areas, and localities, who need MCH services. How do you allocate money to counties? How do you allocate money across children’s special healthcare needs to perinatal care to infant care to childcare? You have to have a publicly available fair method for allocating funds. If you have a sliding fee scale, it must be public and it must be fair. You must apply guidelines for content of healthcare assessments and services and for assuring their quality. You have to have some performance measure, a valuative assessment of the services you provide. You must assure that charges, if imposed, will be public, are not for low-income mothers and children, and will be adjusted to reflect income resources and family size. You may not charge for services in poor mothers and children, usually interpreted to mean below the poverty level, and if you charge those above the poverty level, you must reflect income resources and family size in that allocation. You must provide for a toll free hotline for use of parents to access information about providers for Title V and Medicaid, and about other relevant healthcare providers, and to our knowledge, every state does have a hotline, but you must keep that hotline up-to-date and it must be functional. You must coordinate activities with EPSDT, Early Periodic Screening Diagnosis and Treatment, which is the children’s part of Medicaid, including periodicity, how often visits occur, and what occurs at each of those visits, the content of each of those visits, which includes content standards, and ensure no duplication between the services you provide perhaps in well baby clinics or well child clinics or early development clinics or early childhood clinics or screening clinics, and what EPSDT or Medicaid provides, and usually that’s done through an agreement, a written agreement with Medicaid. You must have an agreement in writing with Medicaid that describes where you work together, the areas coordinate, the areas you decide not to coordinate, how you work with payments, who’s first payment, and those kinds of things. You must coordinate activities with other related federal programs: WIC, education, other health, developmental disability, and family planning. These aren’t my words, these are in the law. I mean these things we shall do are really wonderful. They sound like mandates. They are mandates, but the things we should do and often want to do, in fact, should want to do, but they give us an entrée into working with these other agencies. I mean you can take this law and go to education or go to the Development Disabilities Agency or go to Family Planning Agency or go to Title XVIIII Medicaid and say, “This says I have to come see you and we have to work together in some way. Can we sit down and discuss how we’re best going to work together?” This gives you an entrée to do that. You must provide for services to identify pregnant women and infants eligible for Medicaid and assist them in applying for assistance. So anyway that you can help Medicaid identify women and infants and get them into service, is an important adjunct to Medicaid that you are supposed to provide and which should be outlined in that agreement. Again, it gives you an entrée into working with Medicaid. You shall make the application public within the state to facilitate comment from any person during its development and after its development. I’m sure you all here, during your block grant reviews, how each of us could be better at doing that. And something that’s very important: the state health agency--the state health agency shall be responsible for the administration or supervision of the administration of programs carried out under this title, Title V, except those that could be grandfathered in prior to 1967, where children with special healthcare needs may be administered by another state agency. There are six to eight states where the Children with Special Healthcare Needs Program is in a university, a state university, therefore, it’s not under the state health agency. That’s okay if it was prior to 1967 and grandfathered in. This piece of the law has been very important in the last several years as states are thinking of reorganizing, downsizing, consolidating. The state cannot move Title V activities out from under the administration of a state health agency. They can’t move it to the welfare organization; they can’t move it to a human service organization or agency. It is against the law unless there is a written agreement signed by the Governor that such administration should happen. So this is an important piece of legislation at this point and time, put together as states are reorganizing, and if you think you’re running afoul of this, be sure to call Cassie and her group and let them know because this is an important struggle for us. A small advance every day will eventually total much less than a big advance every day, so let’s just make a big advance every day, right? Thank you very much. I know we covered a lot in a short time. I hope it was useful and I hope you come back to it. I hope you refer to the law and the other documents in your book; the Strategic Plan especially. Any burning questions? Yes?

Unidentified Speaker: (Inaudible).

Peter Van Dyck: The question was: where’s the copy of the law and where’s this legal compendium, and I think it’s in the booklet that you will--did you not get that today? Okay, so it’s in that booklet. It’s not in that smaller packet of materials you got for today. And if it doesn’t happen to be there, let somebody know. But there’s a lot of material in your bigger book. Yes?

Murray: I want to ask you about the bottom of the pyramid, the infrastructure. States are having trouble now with budget and a lot of them are looking to cut government, which essentially (inaudible) the infrastructure. Is this bottom of the pyramid meant to be governmental infrastructure or in the--what defines what the government does and what the rest of the universe does?

Peter Van Dyck: I think it’s meant to be all the types of infrastructure with which we at MCH or the State Health Department would interact. So I look at it as infrastructure we create or develop or infrastructure which we facilitate or coordinate. We may not create all legislation, but we can certainly facilitate, add to, review, advocate for in some cases, legislation that would support an infrastructure. We may not write every standard for the state for child health, but we should certainly facilitate or encourage or add to or review or support child care standards from daycare or periodicity schedules for EPSDT, or supporting the local Academy of Pediatrics in writing child standards or injury prevention standards, or whatever. So I see it as us being a player in some way. Some things we do directly, others we facilitate and encourage and support.

Murray: Is there anything that defines the set of activities that we do directly (inaudible). Like if we were going to peel down things and say, “Well, we coordinate with all these other (inaudible).” Is there anything that defines the core of what government does?

Peter Van Dyck: For the infrastructure piece?

Murray: For MCH infrastructure.

Peter Van Dyck: No, and we have decidedly not tried to create a defined definition for it because every state is a little different and we want preserve some of that flexibility. Now in the Strategic Plan there is some discussion around this, and I think you can get a sense if you read that Strategic Plan because there’s a session in there on mission, there’s a session on values, what we value in MCH, there’s a section on goals. I mean there is some backup material that help describe what our really core issues, values, and thoughts are, and I think that goes towards them in some way and give you general direction, but we stayed away from specific direction because we wanted to preserve flexibility among states and to give you the biggest advantage, not limit you in some way in states. Yes?

Unidentified Speaker: You said the Governor could write a letter or sign an agreement about the exception of having MCH (inaudible) state health service division or agency. Can you talk more about that?

Peter Van Dyck: The question was can I talk a little more about the administration of the program meeting to be under the health department, State Health Agency, and how does that get exempted, and I said something about the Governor having to sign something. If you think this is happening in your state, you need to contact us. Then we will help you negotiate what some agreement needs to look at. Now the one that comes to mind instantly to me is three or four years ago parts of the MCH program in Illinois were transferred to the state welfare agency, and the agreement was the Governor would right a letter acknowledging that transfer, acknowledging that the money was going to be transferred from health to welfare, and that he agreed with that transfer, and that the health department would still have some basic oversight of that program. I can’t remember the exact language, but this piece of the law, I mean, it is really there. It really says what it says, and we think it’s an important piece. We really think MCH programs should be administered by the state health department, state health agency. Yes?

Unidentified Speaker: Well, I agree with you (inaudible) and I hope that there was a lot of strength to support (inaudible). So how very broadly or narrowly can you find the health agency (inaudible)?

Peter Van Dyck: Well, it’s defined in each states own laws and it’s a fairly precise definition. I mean it will define who the state agency is. You know, how the state agency director gets appointed, whether it’s by a Board, or the Governor, or an outside group of citizens, or whatever. And in state statute, there will be a specific statute related to the creation of a state health agency, and it will say what that state health agency is responsible for. Yes?

Unidentified Speaker: Can you tell me what the expected relationship is between the State Title V Program and the hemophilia treatment centers?

Peter Van Dyck: The question was what is the expected relationship between the State Title V Program and the hemophilia treatment centers. Hemophilia treatment centers, there are 12 or 13--(inaudible) here yet? There are 12 or 13 or 14 scattered across the United States and each of those then have a series of clinics or contractees to come to a total of 110 or 120 service providers for hemophilia. Those monies go to those centers directly, however, a State Title V Agent should know about those, should coordinate with them, should make sure their a piece of the treatment system, certainly in children with special healthcare needs program. They should perform or an important adjunct of that program. So if that’s not occurring or you wonder where they are, I mean, and if we need to be better about getting you a list of those clinics, then we can certainly do that, but we expect that there is a relationship between them that goes both directions. Thank you very much, folks.