Focusing on Children's Health: Community Approaches to Addressing Health Disparities: Workshop Summary (2009)

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4 From Policy to Practice: How Policy Changes Can Affect Children’s Lives T his set of presentations describes some of the practical issues affect- ing the implementation of policies designed to have a positive impact on child health. The first presentation focuses on policies at the state level, while the second describes a program at the local level. The implementation of health policy can have far-reaching effects, beyond the health of an individual child stretching to the overall well-being of families and communities, and beyond health, to education, economic welfare, and other aspects of a child’s life. Christine Ferguson of the George Washington University spoke about the practical issues of implementing health policy and provided data from several successful programs. Yvonne Sanders-Butler of Browns Mill Elementary and Magnet School for High Achievers discussed the innovative health initiatives she has implemented in her school. Changing Health Policy, Impacting Lives “There is no question, from my perspective, that policy intervention has an impact on outcomes,” said Ferguson, who went on to cite several examples. A study by Szilagyi et al. (2006) followed a group of new enroll- ees in the State Children’s Health Insurance Program (SCHIP) in New York State. Upon initial interview, 11 percent had a recent asthma-related hos- pitalization. One year later, the asthma-related hospitalization rate of the same group was 3 percent. While most would agree that this is a positive health outcome, it has other potential implications, such as a parent missing less work, or the child being absent less from school, and other effects on 27 

28 FOCUSING ON CHILDREN’S HEALTH the family that one might not ordinarily consider. Obviously, the asthma- related hospitalization data does not prove that quality of life is improved. But, Ferguson said, in the absence of that specific data, we need to be able to make some inferences from the health data. It is clear that when you intervene and provide health coverage, there are better outcomes. Another study showed that children’s average school performance also increased within the year after enrolling in SCHIP as measured by ability to pay attention in class and to keep up with assignments (Managed Risk Medical Insurance Board, 2002). More of this type of data is needed, Ferguson said, to aid the policy-making process and to help make the case that health care interventions have a very wide-ranging impact on a child’s life. Another study found that areas with greater Medicaid coverage expe- rienced lower rates of preventable hospitalizations for children than areas with less Medicaid coverage. Children covered by Medicaid or SCHIP were equally as likely as children covered by private insurance to have had one or more visits to the doctor or health professional in the previous year, while uninsured children were 25 percent less likely. And approximately 3 percent of children with Medicaid/SCHIP delayed seeking medical care due to costs, only slightly higher than the 2 percent of children in private insurance. In comparison, 17 percent of uninsured children delayed medical care due to cost (Ku et al., 2007). A fourth study Ferguson highlighted showed that children who had private insurance for either part of or the full year had about one more visit to the doctor each year than did uninsured children. Medicaid eligibility increased the probability of having at least one physician visit each year by about 10 percent. Compared to uninsured children, children covered with private insurance have more primary care visits, more preventive care visits, and more sick care visits each year; these visits translate into statistically significant improvements in immunization rates and an increased percent- age of children screened for anemia, lead, and hearing and vision problems (Buchmueller et al., 2005). Rhode Island RIte Care From a commonsense perspective, Ferguson said, one of the best ways to ensure that pregnant women on Medicaid receive good prenatal care is to make sure that they have the same level of access to obstetrical/ gynecological (OB/GYN) services that privately insured women have. This type of access was one of the quality improvements that were built into RIte Care, the Medicaid managed care program in Rhode Island implemented in the early 1990s, during the time Ferguson led the Department of Human Services (DHS) there. Within a year and a half of implementation of the RIte Care program in 

FROM POLICY TO PRACTICE 29 Rhode Island, the interbirth interval for women with low incomes became nearly the same as that of women with middle incomes (taking the source of insurance as a proxy for income) (Griffin, 2002). From a health perspective, the significant decrease in the percent of women on Medicaid with short interbirth intervals (less than 18 months between deliveries) is a positive health outcome. But beyond that, delaying having the second child can also mean the family is better equipped economically to support the growing family as a whole, so there is the potential for a positive effect on income- support programs. There is also likely a positive effect on education costs since families that have children with short interbirth intervals are more likely to access special education programs, Ferguson noted. As part of the original proposal to the Centers for Medicare and Med- icaid Services (CMS, which was the Health Care Finance Administration, HCFA, at the time), Ferguson said she requested that CMS require Rhode Island DHS to conduct a study on the impact and health outcomes of RIte Care on children and their families. Because such a study was then required by the agency, Ferguson had the justification to spend the money to do the research. Otherwise, it may not have been done. New England has many very old houses, and another example of a policy intervention involves lead paint, known to cause numerous ill effects in children, including learning disabilities. One of the primary sources of lead in the home is the dust created when windows in casings painted with lead paint are raised and lowered. Many of the low-income housing land- lords either are not willing or lack the money to invest in replacing all of the windows in a house. So it was decided that when a child was identified as having elevated lead levels, Rhode Island DHS would use Medicaid dollars to replace the windows and to conduct lead abatement in the house where the child lived. This program, unfortunately, was eliminated by CMS when the new administration came in. But the novel use of health care dollars in a way that supplements or supports the education system (by reducing lead- related learning disabilities), and the demonstration of how those health and education outcomes are linked, was very important. Ferguson noted that it is hard to sustain those kinds of interventions because we can’t show what the impact is on the schools, or other parts of the system, in terms of making those investments. Challenges A particular challenge at the state government level in Rhode Island is that the state budget must be balanced at the end of the year, and it becomes a question of trade-offs and long-term versus short-term goals. Savings that result from an intervention must be demonstrated, and return on invest- ment needs to be shown in the same year the investment is made, which is 

30 FOCUSING ON CHILDREN’S HEALTH very unlikely, Ferguson said. One difficulty with health care and education initiatives is that the investments don’t necessarily accrue rewards to the people who make the decisions to invest. A leader makes an investment and has perhaps eight years in office to see it through. Some programs can accrue returns within eight years, but others might not accrue for another 10 years. In the research world, data can confirm that something has been a good investment. But administrators often have to overcome barriers of prejudice or bias when implementing new programs. That, Ferguson said, is why we still have disparities. Fundamentally, underneath all of the data and information are a series of deeply held core beliefs that trump data. And what we do not do well is either figure out how to present the data in a way that appeals to the bias (because it may be morally reprehensible to so many of us) or find a way to change perceptions about the fundamental bias. As researchers, we tend to think that the data are so clear, it should speak for itself. That is a significant challenge going forward. Next Steps Ferguson offered several suggestions for going forward. Using smoking as an example, she noted that we have to be more clear what the effect of an intervention is on other people, whether it is an economic effect or a personal effect. With smoking, of course, the tipping point was the data showing how smoking in public places affected other people. We have to be willing to take risks in how we use data, and we have to have some sympathy for those who are trying to apply the data in policy development. We must understand the need to spin data in a particular direction to get the job done. We need ways to connect the policy makers, decision makers, and leaders with the researchers, and we need people who can translate between the two groups. We need to provide leaders with support when they inevitably come up against resistance because they are pushing the envelope on a sensitive issue. We must enable leaders to take risks and to allow some of these difficult conversations to take place. We need to do a better job of creating networks. We need to keep key people rotating through different leadership roles. For example, a school principal who institutes change may at some point be relieved by the school board who thinks he or she has pushed too far. The same thing happens with state government leaders; so shifting those people around, and putting them in different roles exposes new people to their ideas. 

FROM POLICY TO PRACTICE 31 Healthy Kids, Smart Kids Although many people call her “the sugar-free school principal,” Yvonne Sanders-Butler introduces herself as a “survivor” of childhood and adult obesity. She has firsthand experience about children, nutrition, and how nutrition affects learning, behavior, and socialization. The causes of obesity start at a very young age, and for Sanders-Butler, her habits and addictions with food started as early as 3 years old. She almost lost her life to a stroke in the mid-1990s, the result of a lifetime of overeating, eating foods that were very poor in nutrition or had little or no nutritional value, and leading a high-stress life. For 20 years or more, she had been dieting, was 50 pounds overweight, had become prediabetic, and became one of 60 million people who suffered from the diseases that were brought on by obesity, hypertension, high cholesterol, and depression. She had to make a behavioral change as prescribed by her physician to live. This was very dif- ficult after 30 years of poor eating habits and little or no exercise, but her research proved she was not alone. She joined a 12-step support group and for the first time realized she was addicted to certain foods that triggered certain behaviors. The support from her family, friends, and colleagues helped her to make a major, life-saving lifestyle change. As an educator and an elementary school principal, she saw that the children in her school were following the same pattern she had as an ado- lescent and adult. However, her children were on a fast track, with high levels of fast-food consumption and little and or no exercise. Many of these children could well lose their lives in their early 30s or late 20s due to obesity-related illnesses. With children, Sanders-Butler said, you have to deal with parents, and she didn’t know quite how to tell them but she believed only brutal honesty would get their attention—and it did. She informed parents that if they did not make a change in their children’s nutrition and in their physical activity, they would bury their children at a very young age. She shared with them research showing that this is the first generation of children who would die before their parents die. Sanders-Butler’s school, Browns Mill Elementary, is in the most affluent area of DeKalb County, Georgia. Parents influence school administration and not vice versa. But she felt she was brought to her school to make a difference, and before students can be educated, they have to be healthy. The pivotal moment for Sanders-Butler was one day when she was on lunchroom duty and observed a young overweight boy trading the last of his baseball card collection to another student for chocolate milk and fudge cookies. It was that day, she said, that she decided to create the first sugar-free school in the United States. This was the beginning of Browns Mill School’s wellness policy. 

32 FOCUSING ON CHILDREN’S HEALTH Sanders-Butler met with the parents of the Browns Mill Elementary students and shared with them that test scores were less than ideal, and although this was an affluent geographic area, their children were not per- forming any better than children attending Title 1 schools in impoverished communities. To get the parents’ attention, she compared schools and academics. The parents were eager to remedy the situation, but were less enthusiastic when Sanders-Butler proposed that the solution was a change to their diet, removing high-sugar, high-calorie foods. She emphasized that the 130 first graders, if they continued on the path they were on with poor diets and no physical activity, would probably be not only overweight and obese, but they would be hypertensive, and some could even have strokes as early as 18 to 22 years old. Finally garnering the parents’ support, she moved to get the students to buy into the program, knowing that they would be the ones who would actually sell the approach at home. The program, entitled “Healthy Kids, Smart Kids,” supports academics and fights childhood obesity by giving students the information they need to know about their health so that they will be empowered to make healthy decisions (Sanders-Butler, 2005). She enlisted the students’ support by identifying the student leaders and making them a part of the program. Although sugar was the primary focus, overall Browns Mill imple- mented healthier menus. They removed at least 85 percent of the processed sugar from the menu and also looked for items that were baked and not fried, and items that were lower in salt. For students who bring lunch from home, there is a preferred snack list, and parents have adopted the diet because children can only bring certain foods to school. Sanders-Butler visited 15 grocery stores in the community to ask them to provide foods that would support the families in meeting the goals of the program. Before the program began, there were many 5-year-olds coming into kindergarten already overweight. Now their younger siblings are starting school, and they have been on the same diet at home and are not overweight. The local churches where many students attend are also supportive. In the first year of implementing this program, discipline concerns dropped 28 percent. Sanders-Butler used to see a large number of students in her office for disciplinary issues immediately after breakfast, which used to include items such as pancakes with syrup and chocolate milk. But the real test, she said, was when the school saw a 15 percent gain in math and reading scores in the state-mandated standardized tests. When Sanders-Butler entered Browns Mill 10 years prior, 23 percent of students received free and reduced-price lunch. Research shows that when a school is largely filled with reduced-price lunch recipients, their standard- ized scores are correspondingly low. Demographic shifts in DeKalb County 

FROM POLICY TO PRACTICE 33 show that Browns Mill is now at 50 percent free and reduced-price lunch, yet test scores are higher than ever before, confirming that nutrition and physical activity are connected to not only the health of students but to how they perform. Unfortunately, it was apparent early on that there was no funding avail- able for what Sanders-Butler set out to do. So she convinced her husband to mortgage their home, which was almost paid off. The funds were used to partly help assess the school environment, bring in subject matter experts such as nutritionists and fitness experts to provide staff training, help plan school initiatives and projects, and help plan activities for the school and the community. Outside experts also provided advice on how to create and implement a schoolwide curriculum across content areas. Finally, the funds were used to purchase a variety of vegetables, fruits, and beverages that were not offered in the school cafeteria. An investment she fully believed in has clearly paid off. There are 102 elementary schools in the district, and Browns Mill is the most requested school in DeKalb County. People move to the area because of the Healthy Kids, Smart Kids program. We have some very good data now, Sanders-Butler said. The school has been named a Georgia School of Excellence twice and was also named a National Blue Ribbon School. This would not have been possible had there not been an environment created that fostered excellence. Discussion In the discussion following the two presentations, one attendee asked whether the Browns Mill program changed diets in the students’ homes or in the broader community. Sanders-Butler noted that two-thirds of a child’s nutritional needs can be provided in the school setting, which is critical given the increase in students eligible for free and reduced-price lunch. She also worked with grocery stores to ensure that the appropriate foods were available to students and their families. Ferguson stated that schools also need to talk about what schools themselves can do to support families. Another participant asked if there was a role for community organi- zations in getting school districts to change their nutritional and physical activity policies. Ferguson noted that what is critical is identifying a couple of people in key leadership roles who are willing to take a risk and con- necting them with policy leaders. A Morehouse College student commented that eating healthy is expen- sive for a starving college student, and that it is easier and cheaper to eat   Although considered an affluent community, Sanders-Butler said, after 9/11 people were losing jobs at an alarming rate, and the economy has continued its downturn over the last 7 years, resulting in the increased need for subsidized meals. 

34 FOCUSING ON CHILDREN’S HEALTH unhealthy choices. Sanders-Butler said that buying food in bulk helps to not only reduce costs but allows for the preparation of several meals over a period of time. Although fast-food might appear to be less expensive, it is only eaten for one meal. The notion that healthy foods are more expensive is not necessarily true if one thinks about what it costs over time to eat unhealthy choices. References Buchmueller, T. C., K. Grumbach, R. Kronick, and J. G. Kahn. 2005. The effect of insurance on medical care utilization and implications for insurance expansion: A review of the literature. Medical Care Research and Review 62:3-30. Griffin, J. F. 2002. The impact of RIte Care on adequacy of prenatal care and the health of newborns: 2000 update. Barrington, RI: MCH Evaluation, Inc. Ku, L., M. Lin, and M. Broaddus. 2007. Improving children’s health: A chartbook about the roles of Medicaid and SCHIP. http://www.cbpp.org/schip-chartbook.pdf (accessed January 12, 2009). Managed Risk Medical Insurance Board, California Department of Health Services. 2002. Health status assessment report: First year report. Sacramento, CA: California Depart- ment of Health Services. Sanders-Butler, Y., and B. Alpert. 2005. Healthy Kids, Smart Kids: The principal-created, par- ent-tested, kid-approved nutrition plan for sound bodies and strong minds. New York: Perigee Books. Szilagyi, P. G., A. W. Dick, J. D. Klein, L. P. Shone, J. Zwanziger, A. Bajorska, and H. L. Yoos. 2006. Improved asthma care after enrollment in the state children’s health insurance program in New York. Pediatrics 117(2):486-496.