MCHB 2006 Federal/State Partnership Meeting

Legacy, Leadership and a Vision for the Nation’s Children

October 15-18, 2006

RENEE JENKINS: Thank you very much for inviting me. I looked at the program. The only regret I have is I wasn't able to be here for some of it earlier. I saw a number of people I worked with over the years, Bob Blum and the president elect of APHA and I also see a lot of people I already know already.

I have a history of working with MCHB as the chair of the academy's committee on community health services for the Healthy Tomorrow's partnership when that first started and reviewed grants for that.

And for those of you who know about the MCHB research arm, I survived Tan Lamberti, for about four years, for those who know him. Definitely a wonderful guy but an interesting person to work with but taught me a lot about research review.

I'm very much a product of working really closely with MCHB and I'm happy to have a chance to talk with you in this new role. You have to understand I'm still in training here.

I saw some of the slides that talked about how the MCHB is working with the academy. I have to still learn some of that as I'm going forward. And that's why it takes so long. But I'm certainly much of what I'm going to say resonates with what the speakers before me said in terms of the national issue and also collaboration.

All right. So let me get started. First of all, I think the title was just awesome that Pam gave me. Legacy leadership and a vision for the nation's children. It took me about two weeks to be able to even think about being able to sort of put something together that sort of met the challenge of that title.

But first of all, when I thought about legacy, ended up thinking about what our legacy is, I think leadership has to think about what will our legacy be.

What are we looking at now in terms of what could be our legacy? This is Ian. Ian is a four‑year‑old preschooler, one of three children of a mom working one full time and one part‑time job. She makes too much to qualify for her state SCHIP program, but she has subsidized child care for Ian but not for his 12‑year‑old brother. Ian is in the 45th percentile, which is good, but his brother who is a latchkey kid, helps himself to the household food and snacks and is greater than 95th percentile BMI for his age. Ian is just starting to learn to read but he doesn't have many books at home.

And he watches four to five hours of TV before we goes to bed. Now, how can I talk about that being our legacy? Let me just go forward. First of all, as I go through the presentation, we're going to talk, I'm going to talk about what the good news is, what the not so good news is, what I think national level leadership approaches are using the American Academy of Pediatrics as a model. Then to talk about some of the state level leadership approaches that I became familiar with on the campaign trail when I was running for president‑elect, and then talk about what I think the vision may be for us in terms of the future for our nation's children.

Here's the good news. The good news is that some of the rates we're concerned about are going down. For example, infant mortality, even though it's plateauing out, it certainly has made progress over the years.

And that's due to lay programs, including programs at MCHB.

The rate of serious violent crime victimization has gone down dramatically. I work especially in the area of teen pregnancy prevention. And as many of you know, we're down at rates that we've never seen before. They really are low. Now, we don't want to talk about comparing them to other industrialized nations but we only want to look at least of the progress we've been making.

And these are those birth rates. What's the not so good news? The not so good news, I think, is not a surprise to any of us. This is the chart for the percentage of children who are overweight by gender. And we see that in the past four years this has gone up dramatically.

This is a significant problem in terms of what it means to our adults and what it means to work force, what it means to chronic diseases.

The other not so good news is access issues and health insurance and how many families are really covered by health insurance. What we see here, and I don't have a pointer, but when you look at the government health insurance line, you see that going up. And I think that's a reflection, obviously, of SCHIP funding.

But what you also see is private health coverage coming down, which is not a good trade‑off. So when we look at this I think we've got to take the larger picture into consideration.

And what that means is we're really pretty stagnant in terms of access, because we've done these trade‑offs, and I think that's going to be important as we talk about what our visions are for universal coverage for children.

The other not so good news is the percentage of children living in poverty. And as we can see here, those lines went down some but are now starting to creep up a little bit.

And so, again, something that impacts significantly on children's health and well‑being.

Now from a national perspective, what is one organization's response to this? And obviously this is my new mantra for the next year and a half, which is sort of talking about how the academy is approaching some of these challenges that are going on in child health.

Many of you have worked with the academy. You've probably seen some of these slides, heard of this. Just relax, some of the people haven't. So let's just try to go through it.

First of all the academy's mission as you see here has to do with the broad aspects of child health and well‑being, not just with the medical perspective.

So it really takes on the WHO approach to what it means for good health for children. And in terms of its core values, the academy stands for the inherent worth of all children; that children are our legacy, they deserve optimal health and high quality care.

Obviously the academy believes that pediatricians are best qualified to provide child healthcare. And we advance this organization and do a lot of advocacy around child health and well‑being. Many of you are familiar with that role of the academy.

The academy's vision, again, is optimal health and well‑being, but also, as a membership organization, it is committed to professional satisfaction and personal well‑being for pediatricians. This is something I think we put in there relative to, and we think about it in terms of pediatric practice, but I can tell you this year was really dramatic in terms of thinking about it for pediatrician well‑being. Many of our pediatricians in the >Louisiana and >Mississippi areas lost their practices. And the organization had to really chip in to be supportive financially as well as with resources and consultation, because these pediatricians lost, essentially, everything.

So I think we need to think about organizations in terms of what the member's needs are from those respects, from a personal level, but I think this year many of us learned that we do have that responsibility as an organization also.

Now, obviously I've pointed out a number of issues that face our challenges for us now. An organization like the academy doesn't have unended resources. It has very good resources. I come from sort of an organization that does not have lots and lots of resources and it's been sort of encouraging and stimulating to really work in the academy where we have a lot of smart people and people that look along the continuum of issues for children.

But in order to determine where the resources are going to go in a priority fashion, we have to put together a strategic plan. I think as you heard earlier about how MCHIB put together its strategic plan.

What the academy basically does is it has this diagram that it basically adjusts every year based on what the priorities are going to be.

And what you see there are children with special healthcare needs, oral health, disaster preparedness, mental health, obesity and immunizations, as our priority issues.

What I want to point out, though, that does not change by year, is what the universal principles are for the academy. And those are healthcare equity, the medical home, which I think we've probably snatched from Title V and really expanded it to all children, so we have to own up to that, and also the professionalism of pediatrics. So those are our principles.

What we mean by those principles is that these must be advanced at a high level, and anything that we bring on at priorities cannot be counter to these universal principles.

In addition, that drawing has what we call enduring pillars, which are fundamental to our needs, to our existence and the needs of children.

And primary and constant, until we have some changes in what's going to happen around insurance and providers is the issue of access. And I think that's our primary goal as we go forward.

But obviously with access you want to ensure that the access that the healthcare children have access to is high quality healthcare. And clearly that means that the people who are providing that healthcare have to have some guaranteed way to be financed.

Now, when we get these child health priorities, what do we do with them? First of all, there's a planning phase where we very often organize task forces, individuals not only from the academy but on, for example, the mental health task force, members of MCHB. They're members of the Association of Pediatric and Adolescent Psychiatrists, and there are also consumers. We have on that task force family members. When we use the task force methodology, we try to cut across what we think are stakeholders for those types of issues.

Then we go into an implementation phase, and when we determine what our child health priorities are, we look for the national prominent issues, which I showed you the slides earlier.

We also want to have priorities that are clearly ethical, desirable, feasible and that are doable. That's really clear, because I think there are a lot of challenges out there that we very often get stuck on in terms of whether we really can do something about it.

I think poverty very often is one of those kinds of issues. We also look at what we're likely to have an impact on with the stakeholders that are prominent in these issues. And that we have the competencies to fulfill these priorities and they are priorities that are consistent with the rest of the organization.

So in the drawing I showed you, the priorities that are now in the planning phase are the foster care priorities, the oral health priorities and the disaster preparedness priorities.

Those that are in the implementation phase are already the mental health obesity and immunizations.

Now, for access, our implementation plan has first of all been about keeping access issues on the public agenda, keeping it out there in front of us.

One of the access issues, for example, that we're facing is what the implications, as someone talked about earlier, of the Deficit Reduction Act, and I'm sure you heard, I saw in the program you heard a lot about that during this week, and I think some of those changes obviously are occurring at the state level, and they really, really have to be monitored. There have been some almost hostile kinds of things that are being done to children and families as a result of the DRA. I really do think it's up to people who work with and care about children and families to be at the kits in their states around the changes.

Within the academy we try to encourage all of our chapters to really work with health plans around quality issues so that things are being monitored and there are no disparities occurring that people are not watching and being able to intervene on.

We also have taken a road which some of our members are not really happy about in terms of implementing steps. That means we're really advocating for access for children.

We have a model bill called Medikids where we're saying children are not expensive to cover. Why don't we as a nation at least cover our children?

We have members who think universal coverage or nothing. But I think there are those of us who try to balance what we want as an ideal and what we think is doable in terms of medical coverage from birth for children.

We also want to make sure that harmful legislation and guidelines are not being promulgated in states. And, again, I'm sure you heard about some of that this week already.

We want our members to step up to the part of the regulatory process not just to be reactive around some of these issues, but to really be in the line where you can be proactive.

We also have some states that actually have filed lawsuits against Medicaid in their states, for example, Oklahoma, >Michigan has lawsuits, and these are progressing, but as you know lawsuits, you think legislation takes a long time.

Lawsuits are like you do it by decades. I think >Michigan is like is on the 15th year of their lawsuit. It's not a quick process but it's a persistent process. And I think what we've all learned by being in whatever institutional environment we're in that persistence is an important characteristic, that rapidity is not going to be part of what our experience is.

But we also, lastly, want to make sure pediatricians initiate and sustain community programs that are very often safety net programs. We have funding source in the academy called the Catch Programs, community activity programs that pediatricians apply for within their communities that very often provide free care to uninsured people in their communities. And so we still have to, until our universal access issues are resolved, support pediatricians who do work to provide these safety nets in their communities.

Now, around quality issues, our current president, Jay Berkelhammer from Atlanta is pretty much going to be known as our quality president, and he underscores a number of these issues in terms of what quality does to enhance our ability to look at outcomes for our patients, not just what we're doing, but are we making a difference in those respects.

Also, innovation. What can we do in terms of quality, what kind of creative innovative things can we do especially that may be unique to our state levels to assure that we're reaching all populations that are in need and that we're monitoring and measuring what's happening and that we're using sometimes sort of models that are not the standard models for how we deliver care.

For example, home visitation models, models that use lay persons as extenders within a community. Especially when the language issues are prominent and different in communities. Very often you have to use different methodologies to get to patients in those areas.

And we see these really as quality issues. How can you measure that you've made a difference in some of these populations unless you begin to use creative methods to reach individuals.

In terms of mental health, our mental health task force is about six months from ending its work. But it has so far offered these objectives in terms of its implementation, that we should be doing mental health screening. The pediatrician should be in the office based each time a child comes for a health maintenance visit. That pediatricians need to be educated on the resources available.

In some communities there aren't a lot of resources. We have to face up to that.

I think we also have to look at more creative ways to use the limited resources that we have. And there are some offices that are now, Dr. Dave Talo, on our board from North Carolina, brings a mental health consultant into his office on a weekly basis so rather than trying to get a kid set up to go to a mental health, they actually bring the mental health to their kids.

And North Carolina Blues also pay in a way that doesn't make you have a DSM‑IV diagnosis before they'll allow a youngster to be seen for mental health reasons.

So there are a lot of issues that I think create obstacles to bring mental health services to children, but I think we cannot deny that one of the key mental health issues is we don't have enough providers of mental health services in most of our communities.

We also are trying to work and do work with the >American >Academy of Child and Adolescent Psychiatry. We are looking again for funding to continue some creative initiatives in how mental health services can be brought to people.

And we will be able to publish when the task force is finished its work continuing interventions as well as having a home within the academy where mental health issues are going to be consistently addressed, even when their work is finished.

Now, this is one of the toughest areas, obesity. And I don't think there's anybody that's worked in nutrition and obesity that won't admit that this is really tough business.

And when you talk about persistence and not giving up, this is one of the areas where I think it's really, really important.

Obviously we're now measuring BMIs in the office. We're not just doing our little growth charts of height and weight, but really using the sort of red, yellow and green markings to try to make it simple to make the point with parents about BMI and the importance of keeping your child below the 95th percentile for BMI.

We also are trying to help our colleagues create interventions that can be useful to them in the office. Motivational interviewing, for example, is a strategy many of us are using as a way to engage parents that does not, that's not judgmental and that tries to say, okay, how can I relate to what the motivating forces are for you to make a change as opposed to my perception on what you ought to do to make a change.

I think, again, in terms of getting people to move forward, empowering them, helping them really talk about what issues are important to them is really the key to whether people are going to be compliant or go along with recommendations or whether they're not going to be.

There's a lot of work to do still in medical schools and residency programs about education around nutrition. They always say go ask your doctor. Those of you know when you've gone to doctors they ask them about nutrition, we are not the best resources, okay.

We are still trying to get our arms around it, and good nutritionist is worth, I can't say their weight in gold, that doesn't sound good for obesity. They are very valuable. In terms of really helping the docs make some reasonable recommendations.

So we've got a lot to do still in terms of education and medical school and residency around intervening with families around obesity issues.

And then obviously active, being active is important. And it's a challenge especially when you work in, with low income patients that are in intercity areas about what activities they can do that are safe.

And I think that really is going to, you're going to see how when I talk about what we can do as implementation, that means that what we do is not just a medical approach, that there is an environmental, there's a well‑being approach that we really need to sort of get on board with if we're going to make a difference, especially in the area of obesity.

Now, going from the national level, which, the example of the academy serves, I think clearly a lot more activity is going on now at the state level and one thing that I became familiar with again when I was on the campaign trail was this move by some states that's been going on around in some states around Children's Cabinets. And I think this is beginning to sound like a way that we need to go if we're really concerned about child well‑being on the larger scale.

Because these Children's Cabinets are pulling together leaders not just from health but leaders from housing. Leaders from juvenile justice. Leaders from a number of aspects that touch on children and families within a state. And they're actually coming together and trying to talk to each other.

Whenever I hear about these sort of multi‑disciplinary issues, most of us have worked in a multi‑disciplinary ‑‑ it takes a while just to be able to talk to each other. So the fact that people are meeting together, even though very often there's some frustration about what and how quickly we get to outcomes, I think the beginning is that we're all sitting around the same table and beginning to communicate about what we're all doing for children and families.

Now, there are 16, there were at least by 2004 that had these children's cabinets. I came across this actual governor's guide, the National Association of Governors, about what Children's Cabinets are about. These are some of the reasons that people formed these Children's Cabinets. The shared vision agencies come together. It is really support for governor around policy making issues for this to be really the center of the sounding board around child health policy. In the states in which they're effective it is visible that this is a long‑term commitment to children and families.

The visibility piece of it, I think, you put it down on paper. You've really at least made the step that children and families are important in this state.

The kind of things that the cabinets are doing have to do with strategic planning, goal setting, funding and policy recommendations, and really tracking what the outcomes are for their population of children and adolescents.

And some of the measurable outcomes, and some of you may recognize some of these outcomes from the sort of key indicator data that comes out from the Annie Casey Foundation where we get a book each year about what the child health measures are.

These are some of the things that some states are using as their sort of outcome analysis of whether coming together with these children's cabinets are making a difference for our children.

I think this is not mixed. I think some states have other kinds of issues that they would want to put on the screen for outcomes. But I do think we cannot get away from the fact that we do have to look at whether the policies that we're having are really making a change within our states.

Now, this is the kind of change I would love to see us make. Many of you, are there people here from Illinois? All right. Pam. Okay. You identify with >Illinois.

>Illinois as many of you know now has initiated this month I think it's a sign‑up month, for healthcare insurance for all children. And it's not all free. Families who are middle income, I think, 40,000 to 59,000 for a family of four, do pay a fee for being covered, but it is really a very reasonable fee based on what we understand most people pay for employer‑type insurance, even when it's subsidized.

I don't know how many of you have ever been exposed to the COBRA, how much that costs. You know, it's a heck of a lot less. It's about a tenth of the cost of COBRA. I have a daughter who outgrew my insurance. And when the benefits people told me how much COBRA was, I thought, oh my God, I hope she doesn't get sick, because it was really so incredibly expensive, $400 or something a month. She's 25 years old. We're talking about a state that's saying, okay, we will subsidize insurance for you and your families and they are at very decent rates. And there are some small co‑pays that are a part of it. But it's at least a state that took the stand and said: Children must be insured and we are going to put in place a program to do that.

I think it's important for the states to watch what the costs are with it but also what the outcomes are in terms of improvements in child health.

Now, what's the point of going over the children's cabinets? Because what we really need is a national Children's Cabinet. And we don't have that. We have collaboration, I think, now, that's occurring and clearly this is just the logo for the national Children's Cabinets. We really want agencies to come together and really work for the benefit across agencies for children's issues.

And I know there have been collaboratives at different times, but we don't see something that is long lasting that is there and a commitment over time at the federal level to organizing our issues around children in that way.

The academy has now reformulated its plan, its strategic plan to look at a national children's agenda. It has obviously worked with a number of organizations but has now through our immediate past president Eileen Willett, who is a lawyer, addressed some of these issues to the business community, because clearly a healthy, well educated population means we're going to have a healthy well educated work force.

And you know if that's the way we need to get to our win‑win situation for investment, then I think we need to get to that win‑win situation.

But at this point I think when we stand back and look at some of our policies that are occurring at the federal level, they are not only child neutral, some of them are actually child hostile. And I think we need to stand up as people that work for children and families for and advocate for them to really do our part to really change that climate so that, again, children and families are highly valued.

So in terms of my vision for Ian, I see Ian at 12 years old. Unlike his brother, he has a communicated‑based after school program activities near his home. He's in the 50th percentile for BMI. He reads at eighth grade level. He has a guaranteed health insurance that he's had for the past eight years and maybe he might even want to be a healthcare professional.

So I have a vision that I hope we can all work together to accomplish, because as Margaret Mead has said never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.

I think we don't look like a small group but we certainly are a committed group. We need to bring in our consumers and parents as you all beautifully outlined as part of that commitment that we want to wrap our arms around. Because I learned from my mom early on that if you are not part of the solution, you're part of the problem. And I know that this audience is not part of the problem. Thank you.