View from Washington


The Promise and Peril of the Economic Recovery Act’s Health Provisions

By Brent Ewig, MHA
Director of Public Policy & Government Affairs, AMCHP

As an English major, I was taught to assiduously avoid clichés – but I can’t resist: these very well may be the best of times and the worst of times. To extend the Tale of Two Cities reference, consider this: as state capitals across the nation are facing dire budget crises and being forced to make horrendous budget cuts, our nation’s capital is engaged in a spending spree the likes of which we have never seen.

Just last week Congress reauthorized a $32 billion expansion and reauthorization of the State Children’s Health Insurance Program (SCHIP) and began debate on Economic Recovery legislation with an $825 billion price tag. These developments along with rapidly exploding federal deficit have huge implications for the future of public health and the Title V MCH Block Grant. As we prepare to gather for the 2009 AMCHP Annual Conference, I do not think it is an understatement to say that the Title V MCH program is approaching a critical crossroads.

The SCHIP reauthorization is largely good news and while there are some dissenting viewpoints, many see this as a building block for health reform and a step towards assuring that all children in America have affordable health insurance. The implications of the unfinished stimulus bill are not as clear, but may also be considered a step towards health reform. AMCHP has compiled an initial comparison of the health provisions included in the House and Senate proposals for Economic Recovery available here.

The Senate and House proposals both include substantial new funds for prevention — $3 billion in the House and $5.8 billion in the Senate — but they take different approaches in how it would be allocated. Most striking, you will note that billions of dollars are proposed for maternal and child health issues — tens of billions when you consider that the $87 billion for Medicaid will maintain coverage for many women and children that would otherwise be forced from the roles. However, to our great disappointment neither proposal specifically includes funds for the Title V MCH Block Grant.

At this point the House has passed their bill, and the Senate is expected to begin debate on their version on February 2. An important caveat is that we do not yet know what form the final package will take so we do not know the totals and ultimate mechanisms HHS will use to get money to state and local levels. The stimulus proposals are important however because particularly in the Senate bill, they are framed as a “down payment” on the preventive measures that could be included in a health reform package to emerge later. In this sense, the exclusion of the MCH Block Grant in the House proposal is deeply troubling. However, with the Senate approach, many health programs are not specifically mentioned and instead great discretion is delegated to the HHS Secretary to allocate about $2 billion in funding. If Congress chooses this route, we think we can continue to make the case that the MCH Block Grant is an efficient and accountable funding mechanism. 

A larger concern is that the huge and rapidly expanding deficit will make it impossible to sustain these investments and instead many health programs, including Title V, could be put up on the chopping block in the near future. This is something we will watch carefully, but considering what is currently included in the proposals, we see two dramatically different visions of what could happen in the near future.

Under the first scenario, the public health community could coalesce in a way previously unseen to take advantage of opportunities never before possible to extend and expand public health services. At the end of the funding cycle we could collectively say: despite the most dire economic crisis in recent history we worked together to finally fully immunize an entire cohort of children; we began to put preconception care concepts into action by screening tens of thousands of people for HIV and STD, and millions more for chronic disease risk factors; we linked millions of people to preventive care either by helping them enroll in SCHIP or Medicaid, and helped those who remain uninsured to access care in new community health centers; we improved birth outcomes and health status by helping tens of thousands of smokers to quit, and counseled millions more to never start; we finally began work in earnest to prevent injuries — the leading cause of death in children; we created health communities to address the obesity epidemic; and we began to strengthen our infrastructure through the investments in the public health workforce and health professions. 

We need to recognize that under current proposals, State MCH Programs might not be the sole lead on any of these efforts. However, if we seize the opportunities before us, and work to forge partnerships with partners both in and out of government we can make tremendous progress in improving the health of the women, children, and families we serve. In this sense, we are presented with the chance to test the old maxim, “It’s amazing what we can accomplish if we don’t care who gets the credit.”  

In the second scenario, our history could be written for us and will say when the prevention money was on the table, the public health community engaged in a months long food fight arguing over who would control what. Epidemiology and public health science were thrown out the window when the programs with the best lobbyists got the most money. Fundamental state health department roles were by-passed when most funding allocations were made with no consideration of existing needs assessments or ability of grantees to link to broader public health systems. Worst of all, a lack of vision, leadership and creativity prevented us from spending the money quickly and wisely, with hundreds of millions of dollars left unspent and few results to show. Under this scenario, damaging perceptions could be created that our public health system is slow, inefficient, and ineffective. At this critical time in our nation’s history, with the health of our economy and future generations inextricably linked, the stakes are too high for us to allow this scenario to prevail. 

With your help, support, and ideas, AMCHP is engaging now in a dialogue with leaders across the political and public health spectrum to assure that the collective experience, capacity, and mission of state MCH programs can be put to work to make sure that this proposed investment in prevention succeeds.