Trends | February 2015



Calling the Shots

'Tis the season when flu, colds and other illnesses keep kids home from school, and while many illnesses are routine and unavoidable, others are serious and often preventable. 

For states, they’re also costly.

 In 2012, for example, 414 Colorado children, most of them under age 4, were hospitalized with vaccine-preventable diseases, such as pertussis and varicella, resulting in estimated hospital charges of $26.6 million and other related costs, including missed work days for parents.

In Colorado and other states, lawmakers have debated vaccine laws for schoolchildren in an effort to reduce the number of avoidable hospitalizations and limit disease outbreaks and suffering, while also respecting parents’ rights to make heath care choices for their children.

All states require kids to have certain shots to enroll in school so that preventable diseases don’t spread, but they do grant exceptions for medical reasons, such as a weak immune system. Additionally, most states allow exemptions based on religious grounds, and at least 20 states allow parents to refuse vaccinations for their children for personal or philosophical reasons. Some parents believe vaccines don’t help, or that shots can make their kids sick or cause certain disorders. Others consider mandatory vaccinations government overreach.

It’s a tough conversation for legislatures because it involves competing rights and values and deciding whether government or parents have the final say. “Exemptions to school immunization requirements continue to be an issue for discussion and debate in many state legislatures,” say authors of a 2014 study published in the Journal of the American Medical Association. 

Between 2009 and 2012, lawmakers in 18 states introduced 36 bills involving vaccine exemptions, 31 of which would have made opting out of shots easier. None of the 31 passed, largely because of strong evidence that withholding vaccinations leads to outbreaks of measles, whooping cough and other diseases. States with easier exemption policies were “associated with a 90 percent higher incidence of whooping cough in 2011,” according to a 2013 Institute of Medicine report.

Children who are vaccinated against preventable diseases such as influenza and whooping cough also have fewer doctors’ visits, hospitalizations and premature deaths, say the Centers for Disease Control and Prevention.

California, Vermont and Washington now require parents who want exemptions to get a doctor’s signature. In Oregon, parents must get a doctor’s signature or watch a video about the risks and benefits of vaccines. In Colorado, where whooping cough cases have topped a 60-year high, lawmakers passed HB 1288 in 2013 requiring schools to collect and make publicly available information about their vaccination and exemption rates. 

—Kristine Goodwin

On Track With Trains

The federal government created Amtrak in 1971 to resurrect passenger rail service—once the nation’s primary mode of long-distance travel. Although Amtrak has yet to turn an annual profit and has required continual federal subsidies, the government and many states continue to find value in passenger rail transportation. 

To help Amtrak financially, the Passenger Rail Investment and Improvement Act of 2008 (PRIIA) required states to share costs for intercity routes of less than 750 miles, which 19 states now do.

Congress and the states are grappling with how to balance funding popular passenger rail service in high-density areas while supporting long-distance routes that are not as cost-effective. Last year, Amtrak’s ridership grew 0.2 percent to 30.92 million riders and revenue rose 4 percent to a record $2.19 billion. In the Northeast, ridership grew 3.3 percent to a record 11.6 million passengers and revenue was up 8.2 percent. In 2013, the Northeast was responsible for almost 38 percent of total Amtrak ridership and 54 percent of its revenue.

On the flip side, its national long-distance network saw a 4.5 percent decline in riders and a 2.9 percent decline in revenue.

 Given PRIIA’s expectation that states will help fund and maintain passenger rail, legislatures and transportation departments are using a variety of approaches to ensure a high-quality passenger rail service. New York, for example, has agreed to pay the $22 million difference between revenues and costs for four Amtrak lines that cross the state.

In the Pacific Northwest, Amtrak’s Cascades carried more than 800,000 passengers in 2013 on a route linking Portland, Ore., Seattle, Wash., and Vancouver, British Columbia. The Washington Legislature appropriated $40 million for 2013-2015 to operate it, and the state has received almost $800 million in federal support for capital improvements. Oregon’s legislature provided nearly $30 million for 2013-2015 and received about $20 million in federal funding. Ticket revenues cover 60 percent of operating costs.

Colorado, Kansas and New Mexico are working together to provide capital investments in Amtrak’s Southwest Chief, which runs from Chicago to Los Angeles over tracks primarily owned by BNSF Railway. Some states are creating their own systems. In the early 2000s, New Mexico started funding and operating passenger rail service between Albuquerque and Santa Fe. In Florida, a private consortium is set to unveil high-speed rail between Orlando and Miami in late 2016. Also, construction on California’s controversial Los Angeles to San Francisco high-speed rail line is finally getting under way. It will be funded by a voter-approved ballot measure, federal grants and 25 percent of the state’s carbon cap and trade revenues.

 The U.S. House Transportation and Infrastructure Committee in September approved the Passenger Rail Reform and Investment Act of 2014 (PRRIA) to pay for Amtrak operations for four years, but at 40 percent less than current levels. The reauthorization would also continue a state capital grant program at $300 million annually and include provisions to boost private-sector involvement, such as development near train stations.

—Ben Husch and Douglas Shinkle

Painkillers Are Killing Us

States are on the front lines of a drug overdose epidemic that kills an estimated 113 Americans every day—more than die from motor vehicle crashes, according to the Centers for Disease Control and Prevention.

As legislators and health experts discuss in a new NCSL video, “Prescription Drug Overdoses: An American Epidemic,” the crisis is devastating families and costing states millions of dollars in health care, lost productivity and law enforcement.

Drug overdose deaths in the United States have tripled since 1990, primarily due to increasing rates of prescription opioid painkiller abuse and accidental misuse, the CDC says. The agency is helping states fight the epidemic with grants designed to beef up states’ prescription drug monitoring programs and evaluate policies.

Kentucky, Oklahoma, Tennessee, Utah and West Virginia recently were awarded “Prescription Drug Overdose: Prevention Boost” grants by the CDC. Over the next three years, the agency will provide more than $6 million to health departments in these states, all of which have high overdose rates and have plans in place to reduce them.

—Melissa K. Hansen

Florida Tops New York

Florida has overtaken New York as the third most populous state, thanks in part to brutal winters up north and an improving jobs market in the Sunshine State. California and Texas maintained their first and second places. Other Sun Belt states also felt the love: Census data show the 10 fastest-growing states were in the South or West, with the exception of oil-rich North Dakota. 

19.9 million
Florida’s 2014 population. New York’s was 19.7 million.

Average number of residents Florida added daily.

No. 1
California’s rank by population—38.8 million—followed by Texas at 27 million.

Population increase in North Dakota, the fastest-growing state. The next-biggest booms were in Nevada and Texas, which both saw 1.7 percent growth.

Number of people Texas gained, the largest numeric increase of any state, followed by California, Florida, Georgia, Arizona, North Carolina, Washington, Colorado, South Carolina and Virginia.

1 million 
Immigrants who arrived in America last year.

318.9 million
U.S. population last year, an annual increase of roughly 2.4 million, or 0.75 percent, the slowest growth rate since 1937.

States that lost population, including Alaska, Connecticut, Illinois, New Mexico, Vermont and West Virginia.

Sources: U.S. Census Bureau data, July 1, 2013 to July 1, 2014, released Dec. 23, 2014; USA Today, Dec. 23

Three Ways to a Healthy Start

Gone are the days when kids came home from the pediatrician’s office with only a wild pink Band-Aid as a badge of honor. In all 50 states, in more than 5,000 Reach Out and Read program sites, doctors’ offices are handing out children’s books to patients and their parents—and talking about the importance of early reading.

Reach Out and Read, a nonprofit organization of medical providers that promotes early literacy and school readiness, focuses mostly on low-income families, giving children 6 months to 5 years of age a new book to take home as part of their well-child visit. In its more than 25 years of existence, Reach Out and Read serves an estimated 4.2 million children annually and distributes more than 6 million books each year. Fourteen states currently invest state and federal funds to support local Reach Out and Read. 

Another 23 states are duplicating a Connecticut program in which doctors and medical workers are on the alert for developmental and behavioral problems in children so they can direct their parents to community resources. “Help Me Grow” (HMG) connects at-risk children with existing early childhood health services, helping to control unnecessary health care costs. The program, started by a Connecticut physician and later funded by that state’s legislature in 2002, includes four components: 

  • A call center to connect families to services and to give professionals—including child health care providers, child care providers and teachers—information, help and referrals for children;
  • Outreach to pediatricians and other child health care providers to encourage them to conduct child developmental screenings and to use the call center;
  • Community outreach to promote use of the program;
  • Data collection by the call centers on caller demographics, how callers heard about the service, what help is needed and outcomes so the service can improve.

The initiative has connected thousands of families to community resources and has saved states millions of dollars in expensive, sometimes unnecessary, medical services. According to its 2013 annual report, Connecticut’s Help Me Grow Infoline helped more than 18,300 parents, doctors and child care providers with support and referrals to services such as parent education, programs for children with developmental disabilities and mental health services.

Across the nation, several states use the American Academy of Pediatrics’ Bright Futures guidelines as the official standard of care for physicians who care for children enrolled in Medicaid. 

The guidelines offer physicians checklists and questionnaires to use with their patients from infancy to late adolescents to help them talk about nutrition, safety and mental health risks, among other things. Launched in 1990, Bright Futures provides families and health care workers with educational materials and practical tools, including oral health pocket guides and mental health risk assessments.

All three programs are advancing what research is showing to be the importance of positive early childhood experiences on health and well-being throughout a child’s life. Working together to address all the various needs of a child “is critical to building a foundation of lifelong health,” according to a new report by the Robert Wood Johnson Foundation. Moreover, the Foundation finds that early childhood experiences are tied to health, brain development and long-term social issues such as academic performance, teen pregnancy, income level and criminal behavior.

—Kristine Goodwin, Julie Poppe, Robyn Lipkowitz

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