STATEMENT FOR THE RECORD

FOR THE

U.S. HOUSE OF REPRESENTATIVES

COMMITTEE ON APPROPRIATIONS

SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES AND EDUCATION

FY 2005

ON BEHALF OF
THE AMERICAN ACADEMY OF PEDIATRICS

April 23, 2004

This statement is also endorsed by:

Ambulatory Pediatric Association
and
Society for Adolescent Medicine

This statement is submitted on behalf of the American Academy of Pediatrics (AAP) and the endorsing organizations, the Society for Adolescent Medicine (SAM) and the Ambulatory Pediatric Association (APA).

America's children are generally healthier now than they were only half a generation ago. National infant mortality and child death rates have dropped significantly over the last decade, today the number of two-year-olds who have received the recommended series of immunizations is at an all time high and teen pregnancy rates have declined over the last several years. However, despite these significant improvements, more than 9 million children and adolescents through age 18 remain uninsured. Moreover, racial and ethnic health disparities for many children and adolescents continue to exist. And threats to our national security have considerably stretched already financially tight national, state, and local health care programs, and have raised concerns about the physical and emotional impact of terrorism on children and adolescents. Clearly, we have much work to do. As clinicians we must not only diagnose and treat our patients but also promote strong preventive interventions to improve the overall health and well-being of all infants, children, adolescents and young adults. Likewise as policy-makers, you have an integral role to play in improving the health of the next generation through adequate and sustained funding of vital federal programs.

The AAP, SAM and APA identify five key priorities that are at the heart of improving the health and well-being of America's children and adolescents: access to health care, physician payment, quality of health care, immunizations, and terrorism and emergency preparedness. Our statement focuses on those issues that most immediately fall under this Committee's jurisdiction - access, quality, immunizations, and terrorism and emergency preparedness.

ACCESS
We believe that all children and adolescents should have full access to health care. From the ability to receive primary care from a pediatrician trained in the unique needs of children to timely access to pediatric medical subspecialists and pediatric surgical specialists, America's children and adolescents deserve access to quality pediatric care.

Maternal and Child Health Block Grant: The Maternal and Child Health (MCH) Block Grant Program at the Health Resources and Services Administration (HRSA) is the only federal program exclusively dedicated to improving the health of all mothers and children. The MCH Block Grant Program provides preventive and primary care services to almost 27 million women, infants, children, adolescents and children with special health care needs nationwide. In addition, the MCH Block Grant Program supports community programs around the country in their efforts to reduce infant mortality, prevent injury and violence, expand access to oral health care, and address racial and ethnic health disparities. Moreover, the MCH Block Grant Program includes efforts dedicated to addressing interdisciplinary adolescent training and services and research for adolescents' physical and mental health care needs. HRSA also supports adolescent health programs for vulnerable populations, including health care initiatives for incarcerated and minority group adolescents, and violence and suicide prevention. It also plays an important role in the implementation of the State Children's Health Insurance Program (SCHIP), which is critically important at a time when states are continuing to suffer from massive deficits and shifting costs. One of the many successful MCH Block Grant programs is the Healthy Tomorrows Partnership for Children Program, a public/private collaboration between the MCH Bureau and the American Academy of Pediatrics. Established in 1989, Healthy Tomorrows supports family-centered, community-based initiatives in over 145 communities, including Ohio, Wisconsin, Texas, California, Kentucky, and Maryland, that work to address such issues as access to care including oral and mental health, preventive health care and comprehensive service coordination. To continue to foster these and other community-based solutions for local health problems, in FY 2005 we strongly support an increase in funding for the MCH Block Grant Program to $800 million.

Family Planning Services: The family planning program, Title X of the Public Health Services Act, ensures that all teens have confidential access to valuable family planning resources. The consequence of adolescent pregnancy, sexually transmitted diseases (STDs), and HIV/AIDS demands that adolescents be able to make informed, responsible sexual decisions. Title X - which does not provide funding for abortion services - supports teens in making those decisions. According to a January 2003 report from the Henry J. Kaiser Family Foundation, the percentage of high school students who report ever having had sexual intercourse has declined over the past decade. However, research also indicates that those teens that are engaging in sexual activity are inconsistently using contraception and therefore still at great risk of unintended pregnancy. Responsible sexual decision-making, beginning with abstinence, is the surest way to protect against sexually transmitted diseases and pregnancy. However, for adolescent patients who are already sexually active, confidential contraceptive services, screening and prevention strategies should be available. We therefore support a funding level in FY 2005 of $350 million for Title X of the Public Health Service Act.

Mental Health: It is estimated that one in five children and adolescents have a mental health problem such as, depression, ADHD, and eating disorders, and for as many as six million this may be significant enough to disturb school attendance, home and social conditions. Despite these startling statistics, the National Institute of Mental Health (NIMH) estimates that fewer than one in five of these children receives treatment, due in part to stigma and the lack of affordability of care and availability of specialists. One key point of access for helping these children receive the mental health care they need is the inclusion of mental health services - provided by qualified counselors, psychologists, and social workers - in this nation's schools. Grants through the Children's Mental Health Services program have been instrumental in achieving decreased utilization of inpatient services, improvement in school attendance and lower law enforcement contact for children and adolescents. To ensure the continued and growing success of this program and others focusing on children and adolescents suffering from mental health problems, the AAP and the endorsing organizations recommend that $113 million be allocated in FY 2005 for the Mental Health Services for Children program.

Health Professions Education and Training: Critical to building a pediatric workforce to care for tomorrow's children and adolescents are the Training Grants in Primary Care Medicine and Dentistry, found in Title VII of the Public Health Service Act. These grants are the only federal support targeted to the training of primary care professionals. They provide funding for innovative pediatric residency training, faculty development and post-doctoral programs throughout the country. For example, at the Cincinnati Children's Hospital, Title VII health professions programs have funded critically important programs in pediatric medical education. The Residency Training in Primary Care grant is designed to train physicians for a career in primary care pediatrics. This training program features a strong emphasis on behavioral and developmental pediatrics, pediatrics in a community setting, and care for under-represented minorities and medically underserved populations. The community settings in which the primary care training takes place - and, often, ultimately where the physicians chose to practice - are federally designated HPSAs with diverse populations. This program is now an integral part of the Cincinnati Children's residency program, and widely sought after by physicians entering training at Children's.

Through the enduring support of this subcommittee and Congress, the Title VII program has continued to finance exciting educational opportunities in a variety of settings to educate and train tomorrow's generalist pediatricians to be culturally competent and to meet the health care needs of their communities. We recommend FY 2005 funding of at least $40 million for General Internal Medicine/General Pediatrics. We also join with the Health Professions and Nursing Education Coalition in supporting an appropriation of at least $550 million in total funding for Titles VII and VIII. We further recommend and support the Administration's increase in funds in FY 2005 for the National Health Service Corps, a key component to ensuring an adequate distribution of health care providers across the country, but emphasize the need for continued support of training and education opportunities for health care professionals who will work in these areas.

Independent Children's Teaching Hospitals: Equally important to the future of pediatric education and research is the dilemma faced by independent children's teaching hospitals. Children's hospitals across the country are critical to the care of the nation's children and play a significant role in research and training tomorrow's pediatricians and pediatric subspecialists. This is especially important at a time when pediatric pulmonologists, neurologists and many other specialists for children are in short supply nationally. The children's hospitals have the critical mass of patients, physicians, and services needed to train these specialists, and their ability to sustain their teaching programs contributes to their ability to maintain these services. However, these hospitals qualify for very limited Medicare support, the primary source of funding for graduate medical education in other inpatient environments. As a bipartisan Congress has recognized in the past few years, equitable funding for Children's Hospitals Graduate Medical Education is needed to continue the education and research programs in these child- and adolescent-centered settings. We therefore join with the National Association of Children's Hospitals to support the President's FY 2005 recommendation of $303 million for the CHGME program. The support for independent children's hospitals should not come, however, at the expense of valuable Title VII and VIII programs, including grant support for primary care training.

QUALITY
Access to health care is only the first step in protecting the health of all children and adolescents. We must ensure that the care provided is of the highest quality. Robust federal support for the wide array of quality improvement initiatives is needed if this goal is to be achieved.

Agency for Healthcare Research and Quality: Quality of care rests on quality research - for new detection methods, new treatments, new technology and new applications of science. As the lead federal agency on quality of care research, the Agency for Healthcare Research and Quality (AHRQ) provides the scientific basis to improve the quality of care, supports emerging critical issues in health care delivery and addresses the particular needs of priority populations, such as children. Substantial gaps still remain in what we know about health care needs for children and adolescents and how we can best address those needs. Children are often excluded from research that could address these issues. The AAP and endorsing organizations strongly support AHRQ's objective to encourage researchers to include children and adolescents as part of their research populations. We also support increasing AHRQ's efforts to build pediatric health services research capacity through career and faculty development awards and strong practice-based research networks. Additionally, AHRQ is focusing on initiatives in community and rural hospitals to reduce medical errors and to improve patient safety through innovative use of information technology - an initiative that we hope would include children's hospitals as well. Through its research and quality agenda, AHRQ continues to provide policymakers, health care providers, and patients with critical information needed to improve health care; therefore, we join with the Friends of AHRQ to recommend funding of $443 million for AHRQ in FY 2005.

National Institutes of Health: Since its inception, the National Institutes of Health (NIH) is an integral part of the public health continuum. NIH has served as a vital component in improving the nation's health through research, both on and off the NIH campus, and in the training of research investigators, including pediatric investigators. Over the years, NIH has made dramatic strides that directly impact the quality of life for infants, children and adolescents through biomedical and behavioral research. For example, NIH research has led to successfully decreasing infant death rates, increasing the survival rates from respiratory distress syndrome, and the transmission of HIV from infected mother to fetus and infant has dropped from 25 percent to just 2 percent. NIH is now preparing a comprehensive research initiative to address and explain the reasons for a major public health dilemma - the increasing number of obese and overweight adults and children in this country. Today U.S. teenagers are more overweight than young people in 14 other developed countries. There is also a need for ongoing and increased biomedical research and funding support to study pre-term delivery, etiology, prevention and treatment regimens. In 2002, more then 480,000 babies were born prematurely and the causes of nearly half pre-term births are unknown. The pediatric community applauds the commitment of Congress to maintain adequate funding for the NIH. To sustain the momentum of scientific discovery we support the recommendation of the Ad Hoc Group for Medical Research Funding to add 10% in FY 2005 to the previous year's budget. In addition, to ensure ongoing and adequate child and adolescent focused research, such as the National Children's Study conducted at the National Institute for Child Health and Human Development (NICHD), we join with the Friends of NICHD Coalition in requesting $1.3 billion in FY 2005.

We commend this committee's ongoing efforts to make pediatric research a priority at the highest level of the NIH. We urge continued federal support of NIH efforts to increase pediatric biomedical and behavioral research, including such proven programs as targeted training and education opportunities and loan repayment. We recommend continued interest in and support for the Pediatric Research Initiative in the Office of the NIH Director and sufficient funding to continue the pediatric training grant and pediatric loan repayment programs enacted in the Children's Health Act of 2000. This would ensure that we have adequately trained pediatric researchers in multiple disciplines that will not come at the expense of other important programs.

Finally, as clinicians, we know first-hand the considerable benefits for children and society in securing properly studied and dosed medications. The benefits of pediatric drug testing are undisputed. Proper pediatric safety and dosing information reduces medical errors and adverse events, ultimately improving children's health and reducing health care costs. In a very conservative estimate, the FDA projected savings from pediatric testing of over $228 million a year in reduced hospitalization expenses for just five diseases affecting children. But until now there has been little incentive for drug companies to study off-patent drugs - older drugs that are critically needed therapies for children. The Research Fund for the Study of Drugs, created as part of the Best Pharmaceuticals for Children Act of 2002, provides support for these critical pediatric testing needs, but unfortunately is currently funded at an amount sufficient to test only a fraction of the NIH and FDA-designated "priority" drugs. Therefore, we urge you to provide the NIH with sufficient funding - $100 million - to fund the study of generic (off-patent) and selected on-patent drugs for pediatric use.

We believe that these requests represent the best and most reliable estimates of the level of funding needed to sustain the high standard of scientific achievement embodied by the NIH. However, we encourage Congress to explore all possible options to identify additional sources of funding needed to support these increases if we are to reach these funding goals while not weakening any other valuable component of the Public Health Service.

IMMUNIZATIONS
Immunization remains one of the greatest public health achievements of the 20th century and has saved millions of lives. Since the widespread use of vaccines, millions of children have avoided terrible diseases that can cause great suffering and in some cases, death. For example before immunization, polio paralyzed 10,000 - 25,000 children and adults, rubella (German measles) caused birth defects and mental retardation in as many as 20,000 newborns, and measles infected millions of children, killing 400 - 500 and leaving thousands with serious brain damage. Immunizations have reduced by more than 95 to 99 percent the vaccine-preventable infectious diseases in this country.

Pediatricians, working alongside public health professionals and other partners, have brought the United States its highest immunization coverage levels in history. As a result, disease levels are at, or near, record low levels. We attribute this, in part, to the Vaccines for Children (VFC) Program and encourage Congress to maintain its commitment to ensuring the program's viability. The VFC program combines the efforts of public health and private pediatricians and other health care professionals to accomplish and sustain vaccine coverage goals for both today's and tomorrow's vaccines. It removes vaccine cost as a barrier to immunization for some and reinforces the concept of vaccine delivery in a "medical home." However, we are concerned that the Administration's FY 2005 proposal to expand VFC while reducing funding for the Section 317 program may prove to be shortsighted. Additional funding is necessary to provide the pneumococcal conjugate vaccine (PCV-7), a vaccine that prevents an infection of the brain covering, blood infections and approximately seven million ear infections a year, to the 19 states that currently do not provide it. Also increased funding is needed to purchase the influenza vaccine. Beginning with the 2004-2005 influenza season, it is recommended that young children between the ages of six months and 23 months of age receive an annual influenza vaccine. This age cohort is increasingly susceptible to serious infection and the risk of hospitalization.

The public health infrastructure that now supports our national immunization efforts must not be jeopardized with insufficient funding. One of the conclusions of the 2000 Institute of Medicine report, Calling the Shots, was that unstable funding for state immunization programs threatens coverage levels for specific populations and age groups and vaccine safety. This continues to be true today. A strong and sufficient infrastructure is essential. For example, adolescents continue to be adversely affected by vaccine-preventable diseases (e.g., chicken pox, hepatitis B, measles and rubella). Comprehensive adolescent immunization activities at the national, state and local levels are needed to achieve national disease elimination goals. States and communities continue to be financially strapped and therefore, many continue to divert funds and health professionals from immunization clinics in order to accommodate anti-bioterrorism initiatives. Moreover, continued investment in the CDC's immunization activities must be made to avoid the recent childhood vaccine shortages by providing and adequately funding a national six month stockpile for all routine childhood vaccines - stockpiles of sufficient size to insure that significant and unexpected interruptions in manufacturing do not result in shortages for children.

While the ultimate goal of immunizations clearly is eradication of disease, the immediate goal must be prevention of disease in individuals or groups. To this end, we strongly believe that CDC's efforts must be sustained. In FY 2005, we recommend at least $824 million for CDC's immunization program and sufficient funding for CDC's global immunization initiatives - including funds for polio eradication and the elimination of measles and rubella.

TERRORISM AND EMERGENCY PREPAREDNESS
As with many other aspects of health care research and delivery, children's unique health and mental health needs require special consideration when it comes to terrorism and emergency preparedness. Children are not little adults - they require different equipment and supplies, as well as different drugs and drug dosages, if they are to survive a terrorist attack or other disaster.

One specific program that assists local communities in providing quality care to children in such situations is the Emergency Medical Services for Children (EMSC) grant program. While children currently account for up to 30% of all emergency department visits and 10% of ambulance runs annually, many facilities lack the specialized equipment needed to care for children. Moreover, many emergency personnel do not have the necessary education or training to provide optimal care to children. In order to assist local communities in providing the best emergency care to children, we urge that the EMSC program be maintained and funded at $27.5 million in FY 2005.

CONCLUSION
We appreciate the opportunity to provide our recommendations for the coming fiscal year. As this Subcommittee is once again faced with difficult choices and multiple priorities we know that as in the past years, you will not forget America's children and adolescents.

Other Recommendations for FY 2005

DEPARTMENT OF HEALTH AND HUMAN SERVICES