COUNCIL OF THE CITY OF PHILADELPHIA PUBLIC HEARING BEFORE COUNCIL COMMITTEE ON PUBLIC HEALTH AND HUMAN SERVICES - - - Room 400, City Hall Philadelphia, Pennsylvania Wednesday, May 24, 2000 11:25 a.m. - - - RESOLUTION NO. 000042 - Authorizing the City Council Committee on Health and Human Services to hold public hearings in order to review and analyze the proposals of Pennsylvania Governor Tom Ridge, Pennsylvania State Senator Vincent Hughes, State House Democrats, State Senate Democrats, and all other legislative proposals under consideration for the expenditure and investment and, in general, the use of the Commonwealth's estimated $11.3 billion settlement with the tobacco companies; and further authorizing the Committee to solicit comments and suggestions from, but not limited to, health care advocates, youth advocates, health-care industry experts, financial experts, academia, State Legislative and Executive Branch officials, as well as Governor Tom Ridge, and State Senator Vincent Hughes regarding these and other proposals regarding the use of the tobacco settlement funds PRESENT: COUNCILWOMAN MARIAN B. TASCO, Chair COUNCILMAN ANGEL L. ORTIZ COUNCILWOMAN BLONDELL REYNOLDS-BROWN COUNCILMAN FRANK RIZZO - - - VINCENT VARALLO ASSOCIATES, INC. Registered Professional Reporters Eleven Penn Center, Suite 600 Philadelphia, PA 19103 (215) 561-2220 2 5/24/00 PUBLIC HEALTH - RES. 000042 I N D E X Niles Schore (for State Senator Hughes). . . . Minority Staff Director, State Senate 5 Public Health and Welfare Committee 6 * Dr. Walter Tsou, Phila. Health Commissioner 23 7 * Andrew Wigglesworth, President . . . . . . . 46 Delaware Valley Healthcare Council 8 * Sharmain Matlock-Turner, President . . . . . 67 9 Greater Philadelphia Urban Affairs Coalition 10 * Henry Nicholas, President, . . . . . . . . . 80 District Council 1199c Dr. Catherine Balsley, Director. . . . . . . . 91 Curriculum Support, Philadelphia School District * Rachael Milenbach, Director. . . . . . . . . 101 Tobacco-Free Education and Action Coalition For Health * Jeffrey Barg, Chairman, TEACH. . . . . . . . 118 * Dr. Lawrence Frame, American Heart Assoc. 123 * Evonne Tisdale, Assistant Director . . . . . 128 Philadelphia Unemployment Project Consumer Health Coalition Richard Weishaupt, Consumer Health Coalition 136 * Stepheni Trott-Batipps . . . . . . . . . . . 141 Philadelphia Unemployment Project Consumer Health Coalition * Marcia Hinnershitz, President. . . . . . . . 145 Coalition for SmokeFree Pennsylvania * Joseph Minott, Director. . . . . . . . . . . 150 Philadelphia Clean Air Council * Shelah Harper, Chairwoman. . . . . . . . . . 153 Board of Citizens, Public Health Center No. 9 3 5/24/00 PUBLIC HEALTH - RES. 000042 (Index, cont'd.) Mental Assoc. of Southeastern Pennsylvania Holly Bennett. . . . . . . . . . . . . . . . . 158 * Patricia Romano, Friends Connection. . . . . 159 * Donna Preston, Peer Advocate . . . . . . . . 162 * Richard Askew, III . . . . . . . . . . . . . 166 * Frenzell Campbell, Friends Connection. . . . 170 William Dunn, Throat Cancer Victim . . . . . . 174 Bill Godshall, Founder, Executive Director . . 176 SmokeFree Pennsylvania Dr. Robert Sklaroff. . . . . . . . . . . . . . 178 Federation of Physicians and Dentists (* - Also provided attached written testimony.) Other Attached Attachments: - From Senator Vincent Hughes - "Call to Action" - Written Testimony, C. Weiss, 21st Century League 4 5/24/00 PUBLIC HEALTH - RES. 000042 P R O C E E D I N G S
Good morning. I'm asking the members of the Public Health and Human Services Committee to come to the Council chambers, please.
Good morning. I'd like to call the Committee on Health and Human Services to order. I'd like to say that we have quorum in the presence much Councilman Frank Rizzo, Councilwoman Blondell Reynolds Brown, Councilman Angel Ortiz. I'm Councilwoman Marian Tasco, the Chair of this committee. We'd like to have the clerk read the resolution, please.
Thank you. Resolution No. 000042, authorizing the City Council Committee on Health and Human Services to hold public hearings in order to review and analyze the proposals of Pennsylvania Governor Tom Ridge, Pennsylvania State Senator Vincent Hughes, State House Democrats, State 5 5/24/00 PUBLIC HEALTH - RES. 000042 Senate Democrats, and all other legislative proposals under consideration for the expenditure and investment and, in general, the use of the Commonwealth's estimated $11.3 billion settlement with the tobacco companies; and further authorizing the Committee to solicit comments and suggestions from, but not limited to, health care advocates, youth advocates, health-care industry experts, financial experts, academia, State Legislative and Executive Branch officials, as well as Governor Tom Ridge, and State Senator Vincent Hughes regarding these and other proposals regarding the use of the tobacco settlement funds. Thank you.
Thank you very much. This resolution was introduced by my colleague Councilwoman Blondell Reynolds Brown, and her staff has prepared the witness list. If there is anyone who has not initially signed up to testify today, they should come forward and sign up with Miss Frazier. This resolution affords us an opportunity, as a city, to influence the approach 6 5/24/00 PUBLIC HEALTH - RES. 000042 that the Governor and the legislature will take in allocating Pennsylvania's tobacco settlement fund. Right now I'd like to recognize Councilwoman Blondell Reynolds Brown, who will make a statement at this point.
Good morning, good morning. Let me first thank the Chair of our committee, Councilwoman Marian Tasco, for allowing us the chance to register our interests on this very, very important issue at a very, very important time. Let me thank you all for coming out and putting us in your demanding schedule to attend today's hearing on the tobacco settlement. As we all know, the state government is currently deliberating on how to spend approximately $11.3 billion over the next years as its portion of 19 the tobacco settlement. 20 An integral part of the word "hearing" 21 is the word "hear." The purpose of today's 22 hearing is for this committee to hear from you, 23 the citizens of our city and the surrounding 24 areas, what you view to be the best ways to spend 25 the dollars that will be coming through in this 7 5/24/00 PUBLIC HEALTH - RES. 000042 settlement. In addition to the members of the committee, we have the newly appointed health commissioner, Dr. Walter Tsou, with us today, and as the Street Administration's top official on health issues, we're happy that you have joined with us. We may have individuals from the State House of Representatives, the State Senate. We already know that we have a representative from State Senator Vincent Hughes' office, and the Ridge Administration coming in to listen today as well. Being that they play the major role in how the tobacco monies are ultimately allocated, it is important that they know what you, the testifiers', opinions are on this issue. To that end we will deliver copies of today's transcript, written testimony, as well as recommendations to the decision-makers in Harrisburg. The decisions that are being made in Harrisburg will have a long-term effect on all Philadelphians and Pennsylvanians, and the Greater Philadelphia Urban Affairs Council stated it more specifically, and I quote, "Smoking is on the rise 8 5/24/00 PUBLIC HEALTH - RES. 000042 amongst groups that are hard to reach: the young, the poor, high school dropouts, and racial minorities." In short, those whose health status is most at risk. We are studying the settlement and, again, we will recommend that intense efforts be made to reach these special communities. We all know that the best use of this money is to help Pennsylvanians live healthier lives. Striking this important balance of what should be spent on which health initiatives is the challenge: Should there be greater dollars given to low-cost health insurance? What about dollars spent on smoking cessation programs, or Philadelphia health clinics? What amounts should be set aside for increasing children's health insurance? What can be done to ensure that those who are traditionally underserved have their needs met? Sitting here today, I will admit that I do not know the ideal formula. I do know that many people in this room have had time to study 9 5/24/00 PUBLIC HEALTH - RES. 000042 the Governor's proposal and do have strong feelings on the issue. We do look forward to hearing your educated and, I'm sure, well-informed comments. We will shape our opinion, which I intend to make known to those, as I said, who will be making the bottom-line decisions. In closing, this is a unique opportunity for us to participate in the dialog that will help shape a comprehensive strategy for reducing the use of tobacco and in promoting improved health among all of our citizens. Thank you for your presence, your participation, and for helping us do what I call "seize the moment." Thank you, Madam Chair.
Thank you very much. We'd like to welcome all of you today, whether you're here as visitors or here to participate in this hearing. I notice that we have some students who have come into the room. We'd like to welcome them to City Council, and we are having a hearing today on the -- how to spend the tobacco money that the State will receive from 10 5/24/00 PUBLIC HEALTH - RES. 000042 the tobacco settlement. Thank you for coming. State Senator Vincent Hughes has been very, very instrumental in the State in addressing this issue in the Senate. He was here yesterday, a day early, and probably had a conflict today, and he is not here this morning, but we do call on Niles Schore, who is from his staff, who will present Senator Vincent Hughes's testimony. (Witness comes forward. )
Thank you. My name is Niles Schore, and I'm the Minority Staff Director for the Public Health and Welfare Committee in the Senate. The Senator would like to commend your timing in particular. Just this week, it was announced that there will not be closure on this issue until the fall now, so that the Senator's particularly eager to hear your recommendations and those of your witnesses both as to the percentage allocations and, most importantly, to details of the programs. That is, indeed, what is the tie-up in Harrisburg is, there is not agreement on the details. I would like to very briefly give you 11 5/24/00 PUBLIC HEALTH - RES. 000042 some background, give you some of the major issues that the Senator has identified, both as differences between his program and the Governor's, and some issues to be concerned about to make sure that we do it properly. I'll begin by saying that the tobacco settlement agreement is between 46 states and most, but not all, cigarette companies. In Pennsylvania, it's about 99.some-odd percent. You've heard the figure, $11.3 billion over 12 years. In fact, this agreement goes on forever. 13 The Master Settlement Agreement really outlined 14 for the first 25 years, and they are no more than 15 guidelines. That is, we may end up with more than 16 $11.3 billion, we may end up with less. 17 To give you an idea, to date, we were 18 scheduled to have received $226 million. We have 19 actually received about 198 million. The reason 20 for that is, fewer people are smoking. One of the 21 adjustments made to the annual payments was called 22 "the volume adjustment." That is, if fewer 23 people smoke, we get less money. Obviously, that 24 is a good thing, but we need to keep in mind that 25 that $11 billion will be changing over the years. 12 5/24/00 PUBLIC HEALTH - RES. 000042
So that if we eliminate smoking totally, we'll get zero.
We will get zero, but I think we would all stand up and applaud if we were able to do that. We'd have an awful lot fewer sick people to worry about their health care. Right now, there has been several bills introduced. The Governor's proposal, which has not yet been introduced, proposes to do the following. It will set up an endowment fund of 5 percent. It will take 40 percent of the annual proceeds and put them into adult health insurance programs -- there are two different programs, and I'll tell you briefly about those in a few moments. There will be money set aside -- 15 percent for senior citizens for home and community-based services, money set aside for cessation or prevention programs, research, and for the first three years of the program, a venture capital fund. The Senate Democratic proposal covers the same areas, but the percentages are somewhat different. One area that they both also have in common, obviously, is uncompensated care for 13 5/24/00 PUBLIC HEALTH - RES. 000042 hospitals. It's important to recognize that hospitals will benefit in two different ways by both the Governor's proposal and the Senator's proposal. One, there will be direct payment, known as "uncompensated care": And, secondly, to the extent people will become ensured who are not now insured, obviously, there will be less uncompensated care to be concerned about. 2 percent thereafter, and create an adult health insurance program and other programs designed to benefit both children, seniors, a wide variety. The one that has gotten the most press and would take the largest amount of the money are the two major adult programs. One would be an expansion of the Medicaid program to 100 percent of the poverty level, and it would create a CHIP-like program. It's important to focus on the services being provided by the Senator's proposal and by the Governor's proposal. You'll hear the phrase "an adult CHIP-like program" describing both. But remember, the Governor's program does not 14 5/24/00 PUBLIC HEALTH - RES. 000042 provide pharmaceuticals, the Governor's program does not provide behavioral health services. The Governor's program does include a $30-per-month deductible copayment. And the Governor's program would take any lapsed money and put it into the endowment. The Senator's program would retain it within the health insurance program. One of the major concerns that one needs to have about any of these health insurance programs: number one, are they comprehensive? and, number two, are they affordable? I expect the testimony you will be receiving today will focus greatly on those problems. There's a secondary issue that I think particularly the City Council will be interested in because it has to do with welfare to work, interestingly enough. The Governor proposes that 15 percent of this money go for home and community-based services for seniors. You may be aware that there's an enormous issue going on in this state about the salaries of direct-care workers and whether we will, indeed, have sufficient direct-care workers to get these programs up and running. 15 5/24/00 PUBLIC HEALTH - RES. 000042 Right now, there is no particular language in the Governor's proposal -- at least that's been shared with the Democratic caucus -- that would tend to address this problem. And the concern will be to the extent either that the salaries are not funded appropriately, will these services even be up and running at all? But, secondarily, if these services are funded appropriately -- the salaries -- but other programs are not, what will this do to the basic MHMR system in this city and in this state? what will it do to the child care system? what will it do to the existing long-term care system? If all that it will do is take people who now work in the system and move them elsewhere, what will happen to these existing services? I think that's one of the most serious issues that has not really been getting a lot of discussion to date.
I would entertain any questions on the back end of this point because I think you have so much testimony that's valuable to be heard that to have me drone on about all of the different proposals, you can get that information in many place places, including -- our office would be 16 5/24/00 PUBLIC HEALTH - RES. 000042 more than happy to provide any background that you need. But this is a large proposal, lots of different options. The thing that I would ask in your recommendations mostly to remember is that we only have 100 percent of the money to spend.
100 percent of the money to spend. I can tell you, the Senate Committee held a hearing -- held three hearings around the State, and by the end of it, we had proposals for about 175 percent of the money to be spent. So to the extent that you would like to see some piece increase, please remember that somebody is going to lose.
Can you go -- what are the differences -- Senator Hughes has a proposal, a bill. What are the basic differences between the proposal that Senator Hughes has and what is perceived is going to be Governor Ridge's proposal? 17 5/24/00 PUBLIC HEALTH - RES. 000042
Number one, Senator Hughes would expand the existing medical assistance program to go to 100 percent of the poverty level. That will mean, number one, we will get twice as many people covered because we will be getting federal funds.
What is the amount of money that that will take -- what portion of the money of the tobacco settlement would then go to that?
His proposal altogether would take in excess of 200 million of the 400 million annually. The medical assistance piece -- it's 53,000 people that we're talking about. So the arithmetic would probably be about $50-plus million dollars of tobacco money. And that would be matched by an equal amount of federal money. Obviously, the medical assistance program is comprehensive. The copays are nominal, there's no insurance deductible copayment that goes along with it.
The Governor has one adult 18 5/24/00 PUBLIC HEALTH - RES. 000042 health insurance program that does not include pharmaceuticals, does not include behavioral health services, requires everyone in the program -- that is, every adult in the program -- to pay $30 per month, plus we assume, but do not know at this point, that there will also be a service copayments. So that is to get into the program, you'll pay $30 a month each, each adult, toward the insurance, the monthly insurance premium. And then when you actually go to the doctor or wherever you're going, you'll have to pay some amount. That amount has not yet been released. The other biggest difference is, Senator Hughes understands that the tobacco settlement alone will not solve the problem of the uninsured in Pennsylvania, and has proposed in Senate Bill 1408 that the cigarette tax be increased. Pennsylvania is about number 30 on the list of our cigarette tax, at 31 cents a pack. New Jersey is at 80, New York just went to $1.11. That would raise in the vicinity of 500-plus million dollars. Pennsylvania is one of only seven states in America that does not tax non-cigarette 19 5/24/00 PUBLIC HEALTH - RES. 000042 tobacco products. We would propose doing that. That won't raise an enormous amount of money, but it will raise about $20 million. And I think for some of the proposals that you will hear today, $20 million would be more than enough to fund them. By doing all of that, we'd be talking about a billion-dollar program for the uninsured rather than a $140 million, which is roughly the Governor's proposal, or about 200-plus million dollars, which is the Senator's proposal, if you only use the tobacco settlement. The difference is between covering about 100,000 people and covering 60 or 700,000 people.
The services that are provided are different, where we get the money from is different, and how much money we're talking about -- which pretty much is the whole -- everything. What is similar is roughly the percentage of the tobacco settlement, but a key point on all of this is given the 1.2 million 20 5/24/00 PUBLIC HEALTH - RES. 000042 uninsured in Pennsylvania, if you rely only on tobacco settlement, you're not really making the dent. I mean, this really is a historic opportunity to go forward. The cigarette tax is one that I think most people recognize would be appropriate to raise. New Jersey did raise theirs for this very purpose, in line with the tobacco settlement, as did New York. Now is the perfect time to do it.
What are the other interests -- who has -- well, who are the other interests in this legislation?
There are those people who say that none of the proposals does enough for children, and some people talk in terms of further expansion of the CHIP Program, some talk in terms of expending school programs. There are those who say that seniors don't get enough out of this program. The Governor's does have 15 percent of 21 5/24/00 PUBLIC HEALTH - RES. 000042 the money going for a senior program, but there are any number of problems with that program and we have reason to believe that he'll ever spend the percent. 6 The people who are supporting cessation 7 and prevention programs, it's my understanding 8 that they will tell you that they believe that the 9 percentage allocated to them is insufficient; that 10 is, it's significantly less than what the Centers 11 for Disease Control are proposing -- about half, 12 to my recollection. 13 The cancer institutes and other medical 14 research facilities will tell you that most of the 15 programs do not -- most of the proposals do not provide them sufficient funding. And I will tell you, probably the one that gets closest is the Senate Democratic Caucus one, which does provide percent. The Governor provides 10 percent, and 20 that really is a terribly broad range of 21 possibilities that could be used. 22 Then there are those who would like to 23 see the insurance money go to subsidized employers 24 rather than employees. 25
Are there 22 5/24/00 PUBLIC HEALTH - RES. 000042 advocates or are they lobbyists, or are they representatives, elected officials?
So far, there have been some elected officials on the House side and some lobbyists. Part of what's going on here, I think, is --
What would be the advantage of monies going to the employer?
Well, I'll give you an example. There are some circumstance where it would make sense. An example would be, let us suppose that you had somebody who was working and the spousal coverage was $50 a month, but the person couldn't afford to pay the $50 a month. It might make sense to have this health insurance program pay the $50 rather than pay the complete premium for the spouse. So there would be some times when it actually would make sense. We do that in the medical assistance program, and Senator Hughes' bill certainly does suggest -- probably if the bill ever moved, we would amend it to it make it clear that that is one of the expectations: that when it is more 23 5/24/00 PUBLIC HEALTH - RES. 000042 affordable to subsidize an employee through their employer-based program, we ought to do that.
Are there any other questions? (No further questions.)
Thank you very much for your testimony. Next would be Dr. Walter Tsou, our new health commissioner. (Witness comes forward.)
Councilwoman Tasco and members of the City Council Committee on Public Health, my name is Dr. Walter Tsou, and I am the newly appointed Public Health Commissioner of Philadelphia, and I am grateful for the opportunity to speak.
This is my first testimony at City Council, and I look forward to working with members of City Council on public-health issues of common interest in the years ahead. I speak to you today on the issue of tobacco settlement funds for Philadelphia. In 24 5/24/00 PUBLIC HEALTH - RES. 000042 1998, Pennsylvania entered into an agreement with the attorney generals of 46 other states in what has been called "the Master Settlement Agreement," with all the major tobacco companies in America. This settlement created an unprecedented pool of funds to compensate the states for costs associated with tobacco use. In Pennsylvania, this has been estimated to result in revenues over and above current expenditures of around $400 million annually for the next years. It's 12 estimated, though, that these funds will decrease 13 as smoking prevalence also decreases. " Many public hearings throughout 18 the State were conducted to help create this 19 plan. In general, there's been bipartisan support 20 from Pennsylvania legislators to use the funds for 21 health. 22 The Governor has outlined general 23 guidelines on how the funds will be spent, which I 24 won't enumerate for you because Niles Schore has 25 done a nice job of doing that for you, but you've 25 5/24/00 PUBLIC HEALTH - RES. 000042 heard the basic percentages that he's stated, and I have it in my testimony written here. In general, I believe we should support much of what the Governor has put forward, and in particular, using the funds to support health programs. Since it is likely that any final legislation will reflect these general categories, I will structure my comments around how the Governor's proposal could benefit Philadelphia and specifically our Health Department. Number one, support of the Health Department. First, we would request dedicated funding for public health departments from the tobacco settlement for several reasons. The Governor's plan -- I would support these funds that come from the venture capital or insurance pool. Local health departments are in the best position to understand what local resources are available and those who would best benefit from tobacco education or uncompensated care funds. Further our health department can best coordinate resources without duplication within the City. Most significantly, public health is the foundation upon which we build a health care 5/24/00 PUBLIC HEALTH - RES. 000042 system. A weak public health foundation leaves major holes in our safety net, seriously weakens our ability to respond to public health outbreaks and emergencies. I believe -- in thinking about how to best implement the tobacco settlement funds, I urge City Council to use our health department as your conduit. I would like to propose two simple mechanisms to strengthen public health infrastructure and which would allow a more logical approach to implementing the tobacco settlement. And I should tell you that in all the public debates, no one has suggested this with the Governor, so this is somewhat novel. First, local health departments are created and supported by the County Health Act 315 of Pennsylvania. Since its passage, despite inflation, the cap on the funds has not increased in 17 years. Currently set at $6 per capita, it is woefully inadequate in comparison to the annual per capita health care costs of $4,800 nationwide. Raise the cap to $12 per capita. Still quite small in comparison, but it would dramatically improve funding for local health departments. 27 5/24/00 PUBLIC HEALTH - RES. 45 million to Philadelphia and could dramatically help fund a variety of public health programs, including our district health centers. 50 per capita to $3 per capita. This would support hiring staff so that we can address the many and growing environmental issues faced by our City. Since both acts would need to be simply amended, it would be easier than to recreate new legislation.
And because we would be supporting local health departments throughout the Commonwealth, I believe we should be able to garner bipartisan support across geopolitical boundaries. Second, uncompensated care pool should include federally qualified and federally qualified-like health centers, such as our district health centers. In Philadelphia, we run the largest ambulatory care program in the State, and we have over $13 million in uncompensated care, which we 28 5/24/00 PUBLIC HEALTH - RES. 000042 must contribute through City dollars, and I have some graphs that I have attached. Our ambulatory care program alone sees over 110,000 patients annually; and most significantly, our uninsured percentages have dramatically increased from 42 percent in 1993 to 62 percent so far this year. While many hospitals will lobby hard for the uncompensated dollars, the Philadelphia district health centers are seeing dramatic increases in the number of uninsured without any relief. Even hospitals have referred uninsured patients to our health centers since we are truly the place of last resort for them. So to be clear, passed without changes, the uncompensated health pool will bypass our health centers and go directly to hospitals and health systems, which should continue to lobby for a share of the uncompensated health pool. Third, tobacco prevention, education and cessation should be administered by local health departments, if present. The Pennsylvania Health Department has stated that the tobacco prevention and cessation monies will be distributed through an RFP process. The City, 29 5/24/00 PUBLIC HEALTH - RES. 000042 through its health department, will respond to this RFP. 5 million, and its implementation, we, in turn, can subcontract with many of Philadelphia's based nonprofit voluntary health agencies, the Philadelphia School District, community-based advocacy groups, hospitals, and other health providers to promote tobacco prevention awareness and enforcement based on the CDC Best Practices model. Coordination to prevent duplication is one of the unique advantages of using our own local Health Department. Fourth, expand the availability and benefits of the insurance for the uninsured. And in this way, I should say that we should support Senator Vincent Hughes's bill. I support many of the comments of the Pennsylvania Consumer Coalition, who will be speaking later, and I won't enumerate in great detail, but in short, there are at least five areas that they have stated: One is, the insurance premium of $30 per month should be phased out for those at 200 percent at poverty or below; We need to simplify the administration 30 5/24/00 PUBLIC HEALTH - RES. 000042 of CHIP and adult CHIP Programs so that they look the same; 3. We should maximize the federal match in Medicaid dollars by using the tobacco settlement dollars to draw down the federal match; 4. 3 million people uninsured in Pennsylvania and growing, we should use the tobacco settlement money to expand and not replace the Medicaid dollars; and 5. As stated earlier, the benefit package should include both physical and behavioral health, including substance abuse, which, I should mention, nicotine is a highly addictive drug, and it should cover basic prescription drugs. This is very important to offset the rising cost of pharmaceuticals. And the fifth and last point I want to make is that we should limit the size of the endowment fund to 5 percent. If we have the money, let's spend it on health care needs now, not in some distant future. So, in summary, there are important uses of the tobacco money that will greatly enhance the ability to reduce duplication of 31 5/24/00 PUBLIC HEALTH - RES. 000042 services and enhance local programs. Number one, let's support local health departments in Pennsylvania in enhancing Act 315 and Act 12. Both have not had any increases in the past years.
7 Second, use the uncompensated care pool 8 to include district health centers and federally 9 qualified health centers to serve the majority of 10 outpatient visits for the uninsured. 11 Third, let's administer the tobacco 12 education and cessation programs through our 13 health department. 14 Fourth, expand and improve the benefits 15 and availability of insurance for the uninsured, 16 including mental health and drug abuse treatment. 17 And, finally, let's spend the money on health and not on a rainy day fund. Thank you for your consideration, and on behalf of our department, I appreciate the opportunity to comment on this bill, and I would be pleased to answer any questions at this time.
Thank you very much. In your Item A, first support public 32 5/24/00 PUBLIC HEALTH - RES. 000042 health departments, you talk about amending the Act 315 and Act 12, and by -- in doing this by working with other health departments throughout the Commonwealth, what action is our department taking to initiate this statewide support to amend these acts?
Well, that's a very important question. I have discussed this with directors of virtually all of the health departments, and there are 9 out of the 67 counties in Pennsylvania. I think there's a recognition by all of us that we would like to enhance our County Health Act dollars. We don't have the political and lobbying power that many of the larger providers have in this state. And, so, although I think there was verbal strong consensus that we need to do this, we have not had the organizational ability to enact it. And one of my roles, I think, as health commissioner, is to help use my bully pulpit to advance this way of providing directed support to local health departments.
Are these other directors of -- county health department 33 5/24/00 PUBLIC HEALTH - RES. 000042 directors, are they lobbying their local state legislators?
I believe that if there was an effort on our part, an agreement on our part in Philadelphia that we would do this, that they would join us in lobbying their state legislators. And I say that to you as someone who came from Montgomery County and the suburban counties around us, where I can tell you, Bucks, Chester, and Montgomery Counties, their health departments would definitely lobby on this issue with us.
So it's important too to enlist support from your counterparts in the western part of the state and probably in the middle part of the state.
To show the need. You state that there has been a dramatic increase in your ambulatory patients. Could you give me a reason for the dramatic increase from 42 percent to 62 percent?
I think there are several factors on why we have a rising number of 34 5/24/00 PUBLIC HEALTH - RES. 000042 uninsured in our health centers, and I should point out that no entity, no matter how sufficient it can try to be, can sustain those type of percentages of nonpayment for services. So it is putting a stress on the City dollars. I think, first off, that there is a rise in the number of uninsured that has happened. As you recall, one of the changes in the Welfare Act was to actually cut 220,000 people off the rolls of Medicaid who were considered able-bodied and single individuals. Many of those people happen to be residents of Philadelphia and are coming to our health centers. We see an increasing part of that culture diversity of our city is -- we have a lot of people who may be immigrants from other countries, may not understand how the health care system works, and they often come to our health centers for care as their first entree into medical care. We also have many people, with the changes of welfare to work, who do not understand that they could still qualify for health benefits and, as a result, assume that they are uninsured 35 5/24/00 PUBLIC HEALTH - RES. 000042 in the workforce. And then one of the efforts that we are doing as a health department is, we have insurance counselors now in each of our health centers, and we're working strongly to try to make sure that they are informed of their rights to get health insurance, but there's still a gap between the time that they come into our health centers and the time that they actually get health insurance, and that gap is reflected in some of the rise of the uninsured.
Some time ago we had an issue -- and this is sort of a side issue on this discussion -- about billing -- the Health Department billing the State for those patients who qualify for Medicaid, and we had not fully exercised our right to bill for the services that we provide. How is the billing going in the Health Department?
Well, the good news is that the billing is doing much better, and we are much more aggressive in asking about qualifying for insurance status, for Medicaid status, when people come to our health centers. 36 5/24/00 PUBLIC HEALTH - RES. 000042 We have insurance counselors, as I mentioned, in each of our health centers to help us with that, and we've hired a consultant who is a strong expert in the area of Medicaid to do some training with our benefit counselors to enhance that capability. So we think that we're moving in the right direction. But, still, the reality is that we have 1.3 million people without health insurance in Pennsylvania. Many of them, if not the bulk of them, disproportionately are right here in Philadelphia, and it does put an unusual burden on our system.
Doctor, I'd also like to also welcome you to city government. It was interesting. As you know, there's additional controversy going to be discussed today about banning -- the banning of smoking in businesses and in other areas in the City of Philadelphia. And one of the City employees approached me as I walked into the 37 5/24/00 PUBLIC HEALTH - RES. 000042 building and said it would be helpful if the insurance providers would give us some assistance, and I see you have listed by percent for tobacco cessation programs. Would the Health Department be ever in a position to -- what would be the -- has there been an analysis of -- do we do anything to try to help people that are uninsured stop smoking? Are there -- is there something that you could do, or the Administration could do, to have added to the insurance coverage of City employees that the patch and other programs be included in the benefits that they have? Again, I don't know if any company's insurance providers do offer that type of assistance, but I think it's a direction that we need to go. Obviously, a person that wants to quit will do it no matter whether they have the insurance or not, if they truly need to do it for health reasons, but I'm wondering if that added coverage would lead to some people saying, Look, it's there, I should take advantage of the program, and maybe with we'd get fewer people that smoke. 38 5/24/00 PUBLIC HEALTH - RES. 000042 So, again, I don't know where we are with that piece of the pie, but it's something that I think we really need to do to encourage more people to stop.
Right. Well, I thank you for that question. I think, in fairness, that, you know, historically, most people who do stop smoking do it on their own, for whatever reasons that motivate them. And one of the roles I think we could do with the tobacco money is to develop more education programs where we do counseling, individual counseling, to try to encourage them to do that. We certainly have people who come through our City health centers, where we talk to our patients that way. We have a medical evaluation unit, which does some employee help, where this is some psychological counseling that's given. But our funds are limited in terms of direct money directed specifically for tobacco education and cessation. And to your question about whether the patch is done, I don't think we actually purchase 39 5/24/00 PUBLIC HEALTH - RES. 000042 patches specifically for our employees. I see that only as an aid to the larger question of how to do counseling for smoking cessation. We see that there's a lot of expertise in the City of Philadelphia. I receive letters from some of the major medical centers about their smoking cessation programs. We know of very good programs that the American Lung Association, the American Cancer Society have put together, the American Heart Association have put together, and we would see, if we got these funds, to work really cooperatively to enhance many opportunities for smoking cessation for our City employees and also for residents of the City.
Doctor, you just mentioned something very interesting. Have we tried to join hands with any of those organizations and invite their participation at the health center level to bring their programs at no cost to the Health Department or to the City of Philadelphia? Would that be possibly a conduit for them to have access to more people? I mean, have we --
Well, I think you've -- this 40 5/24/00 PUBLIC HEALTH - RES. 000042 is part of the creativity of public health, and you've sort of touched on some of that, that we happen to see lots of patients, they have a program, and of course, they want to get paid to help do this program. And with some tobacco cessation funds like this, there could be a nice marriage where we could use the expertise of our academic medical centers and voluntary health organizations to work directly with our health centers to put together some special programs.
Great. Thank you, Doctor. I like the fact that you're willing to get out of that box and do some things that might not be what we normally do. So good luck.
Of those that you 41 5/24/00 PUBLIC HEALTH - RES. 000042 serve in the public health centers, can you guesstimate the approximate percentage of children and youth that are served at health centers, currently? A round number.
Yeah. I'm probably not the right -- I should probably turn to other people. (Commissioner Tsou consults off-mike with colleagues.)
My guess is that it's about 30 percent of the patients that come in are children.
My follow-up question, and the reason for asking is, in proposals for recommendations, I do always look to see where the most vulnerable among us fall, and they're further down on the list, so is that to suggest, then, that should consideration in a strong way be given to supporting the public health departments more substantially, that one 42 5/24/00 PUBLIC HEALTH - RES. 000042 by-product benefit would be that children would be better served as well. Is that --
Absolutely. Money that would be directed to our health department through Act 315, we have the discretion then to use it in the best way possible, and we certainly have a strong program for children in our health department.
Given the way the Governor has listed his guidelines, with 40 percent going for insurance for the uninsured, might there be an opportunity for us, as we move to carefully craft the special interest and then prioritize -- and when I say "us," I mean the Philadelphia set of recommendations that ultimately go forward -- will there be a need to recommend that of that 40 percent for insurance for the uninsured, a special consideration, special category, or whatever, be specifically targeted for children?
We certainly could expand the CHIP Program, which is the Children's Health Insurance Program in the State with some of these tobacco dollars. 43 5/24/00 PUBLIC HEALTH - RES. 000042
Part of the purpose, I think, in the Governor's proposal is to recognize that the parents of these children are often ignored in this debate, and there's been a lot of pressure of addressing an adultship, if you will, type of program. So we could certainly lobby and say, you know, we should expend more money to support CHIP. There was a lot of -- the biggest problem, apparently, in the CHIP Program is that there is money available, and a lot of people do not -- children aren't aware of how to get access to it and take advantage of what's available right now. So one of the hopes, I guess, is that to add an additional component by maybe including adults with this money, we might be able to convince more parents to get their children also enrolled at the same time.
As an aside, is that to suggest then that we have not taken maximum benefit of the CHIP Program? "We," meaning the Philadelphians?
I can't speak for numbers, 44 5/24/00 PUBLIC HEALTH - RES. 000042 but it's the general impression statewide is that we still have many children eligible for CHIP who have not enrolled, but I don't know specifically in Philadelphia what those numbers are.
Dr. Tsou, I know that the Governor divides it along certain categories in terms of the expenditures of the tobacco money that goes to several categories. Within those categories, what would be the amount of money that would come to the City of Philadelphia?
As a -- well, that's a fair question. Let me put it this way. This estimated $400 million, if it was purely on a per capita basis, we're talking directly or indirectly through a variety of these pools, something like $65 million that could come to the City of Philadelphia either in support to the Health Departments or to one of the health agencies that 45 5/24/00 PUBLIC HEALTH - RES. 000042 are out there, and it could come in a variety of forms -- you know, the uninsured pool, the long-term care pools, the broad-based health research, and so on. The fact that we actually have some special types of services like academic research programs, which would particularly benefit from the venture capital pool or with the broad-based health research that we have in academic centers suggests that it, in fact, might be even more than $65 million that would come to the City itself. So I don't know the exact number. A lot depends on how the final allocations will come, but a good guess would be, at a minimum, $65 million would come to the City in resources.
Right now, our hospitals carry a burden of the uninsured. Do we have any figures as to how that burden would be lightened in terms of the tobacco --
Well, I think you're going to hear later on from Andrew Wigglesworth, and he probably is best to be able to answer that question.
Thank you very 46 5/24/00 PUBLIC HEALTH - RES. 000042 much. You might want to stick around just for a few moments, not all day, but for a few moments.
I know you have a very busy schedule, but we may have some further questions.
The Chair calls on Andrew Wigglesworth, Delaware Valley Healthcare Council. (Witness comes forward.)
Good afternoon. State your name and proceed with your testimony.
I have written testimony that's in a blue packet that looks like this.
Yes, very nice. Madam Chairwoman and members of the committee, my name is Andrew Wigglesworth. I'm President of the Delaware Valley Healthcare Council. As many of you know, our organization represents and advocates for more than 150 hospitals, health systems, and other provider 47 5/24/00 PUBLIC HEALTH - RES. 000042 organizations in the region. And at the outset, I want to say that we want to commend you for holding this hearing. It's important that these issues be discussed. There are obviously a lot of important challenges facing the health care system, and the tobacco settlement funds, quite frankly, represent an enormous opportunity to begin to address some of the challenges facing in our health care system. First, I can sum up our position very briefly on the Governor's -- and I will summarize my testimony as opposed to reading it, but I can summarize our position on the Governor's proposal very briefly. We strongly support what the Governor and the legislative leadership have committed to in terms of dedicating the tobacco settlement monies to improving health care, or the health of all Pennsylvanians. In many other states, the debate is over whether to go to general tax relief, curb cuts and sidewalks, roads, other things, and the Governor and the legislative leadership are to be commended for basically staking out the position that these monies ought 48 5/24/00 PUBLIC HEALTH - RES. 000042 to be used to address health care issues. We also believe that the Governor has shown leadership in proposing the mix of services, in particularly improving access and coverage to health care, health finance, uncompensated care, looking at some of the issues that may have economic development implications in terms of funding broad-based health care research and health-related activities, as well as funding tobacco prevention and cessation programs. I would like to now, having state that at the outset, briefly describe why we feel it's so important that the settlement monies be corrected towards improving the health of citizens of this region and state. The human tragedy of tobacco-related illnesses is enormous in Pennsylvania in that 22,000 people die each year of tobacco-related illnesses, 30 percent of all cancer deaths are related to tobacco use, 80 percent of all pulmonary disease deaths, it's a leading cause of coronary artery or heart disease. So it's a major impact on our people and on our health care system. 49 5/24/00 PUBLIC HEALTH - RES. billion in tobacco settlement funds over the next years, as I said, represents a unique opportunity to address these challenges. These funds also provide new hope for improving our ability to prevent, diagnose, and treat diseases, to help the many thousands of Pennsylvanians suffering from tobacco-related illnesses. Our position, and we have stated this consistently over -- basically over the past year, since the tobacco funds have been used, is that the monies ought to be used to support health-care services for the uninsured, with a priority towards uncompensated care provided by hospitals, medical research in tobacco-related diseases, health promotion and prevention activities, rehabilitation, smoking cessation programs, health education for children, and improvement of the health-care delivery system and cost containment issues. We also believe that it's very important that these funds supplement -- not supplant -- existing state and actually local expenditures as well. Obviously, if the tobacco 50 5/24/00 PUBLIC HEALTH - RES. 000042 monies are brought in one door and a corresponding amount of State funds, or whatever, are taken out another door, these funds are not going to have a significant impact. We're also pleased that the Governor has recommended that 50 percent of the available funds be directed towards expanding insurance coverage and services to uninsured Pennsylvanians.
As the previous two witnesses have described, 1 in every 10 of our residents are without coverage. 5 percent of the uninsured. And I would point to many of the questions you're asking about the characteristics of the uninsured, how many children, whether they employed, unemployed, are in this booklet that's in the packet, that goes through a lot of those statistics. The trend in terms of uninsured, Pennsylvania, fortunately, has been below the national average in the numbers of uninsured, but over the last decade or so, we have been catching 51 5/24/00 PUBLIC HEALTH - RES. 000042 up with the national rate. And, in fact, our rate of increase in the number of uninsured citizens has been growing faster than the national average. And there were questions earlier about why there are changes in the uninsured. It's due to a lot of things. The Commissioner mentioned the changes in Medicaid, Act 35, welfare-reform confusion over that, the barriers, the application process for Medicaid and CHIP is very confusing, and there are efforts to change that. It's also due to the changing nature of our economy -- a shift from a heavily manufacturing-based economy to a service-based economy that doesn't necessarily carry all the same benefits for workers. All of those factors are at play in terms of creating the number of uninsured. As you know, Pennsylvania hospitals and health systems have had a tradition of providing care to all of those who need, regardless of their ability to pay. The mission actually goes back to Benjamin Franklin, when he established the first hospital in this country in Pennsylvania Hospital. The increasing numbers of uninsured persons, particularly in the context of the 52 5/24/00 PUBLIC HEALTH - RES. 000042 Balanced Budget Act, reduction in Medicare payments, managed care, what's going on in the compression of payments to hospitals, changes in State policy as it relates to Medicaid, is jeopardizing the ability of hospitals to continue to meet this burden in terms of providing services to the uninsured. Last fall, we released a study of uninsured. Across the State, it's about 700 -- in excess of $700 million is provided by hospitals across the State. Of that, in this region, approximately $400 million is provided by hospitals and health systems in this region. So it's over 235 million by hospitals and health systems in the City of Philadelphia itself.
How would settlement and the money alleviate some of that cost? What would be the formula?
Well, in particular what -- again, as been mentioned, the Governor has proposed that 50 percent of the monies go for services to the uninsured; 40 percent of it would go to expand insurance coverage, 10 percent of it would go basically to payments to hospitals for 53 5/24/00 PUBLIC HEALTH - RES. 000042 uncompensated care in a variety of forms. We have proposed modifications to the Governor's proposals to say that to the extent that you don't put -- that monies designated for insurance are not expended, they ought to be put into the uncompensated care pool; in other words, kind of a shunt between the 40 percent and the 9 percent. Because we know from our experience with 10 Medicaid and with CHIP, it will take years for people to actually get enrolled, but the people obviously are not disappearing and they're obviously getting sick and seeking care. So, therefore, the monies for the uncompensated care ought to be increased. In terms of the actual dollar amounts that would be allocated to this region, I can provide those to you for the record, but obviously, a lot of legislation that is necessary hasn't been introduced yet, so there are specific formulas. But, basically, hospitals would benefit by people getting coverage that are heretofore uninsured, as well as the direct grants.
But given the projected formula that the Governor has put 54 5/24/00 PUBLIC HEALTH - RES. 000042 forward and since you say that at least a third of that uncompensated is brought out by the hospitals in Philadelphia and the community health centers, within that formula that the Governor puts forward, what would be the monies projected to go towards aiding in terms of the uninsured?
Councilman, that's just it. I can't tell you the specific dollar amount. We have come up with projections that I would be happy to provide to you for the record, but the specific formulas have not been developed yet, the specific programs haven't been developed yet. The concept is there. The Governor's office has not introduced specific legislation at this point. But, again, in terms -- and, in fact, one of the issues that our association, my association, is going through is trying to develop distribution formulas to target the monies on those institutions that serve the disproportion number of uninsured citizens. And every hospital -- and to the extent that there are private, not-for-profit hospitals in this state, it's a matter of omission as well as -- there are levels 55 5/24/00 PUBLIC HEALTH - RES. 000042 of uncompensated care that they're going to provide. But there are some institutions, particularly in this city, that are literally drowning in uncompensated care, and they need to have targeted assistance to those institutions. And while I'm very sympathetic to the City's position about City health centers, I think the tale of the numbers is that in that Dr. Tsou mentioned million, and the numbers that I'm 12 talking about are hundreds of millions. 13 And I would add that Philadelphia's the largest city in America without a public hospital. And that's a good thing. I don't think that we need to have public hospitals, but in terms of the costs that are borne by other cities and other municipalities in other parts of the country, I would suggest that Philadelphia is getting a very good deal, as it were, by virtue of the support that hospitals provide. And what we are suggesting with respect to uncompensated care is that we need -- that hospitals need the support, particularly those that are bearing the disproportionate burden today. 56 5/24/00 PUBLIC HEALTH - RES. 000042 In terms of the key findings of our study in terms of uncompensated care and the characteristics of it, services related to heart and lung disease, trauma, and mental health services are more likely to have uncompensated care. Pennsylvania has no mechanism -- like New Jersey, like New York, like Maryland -- to more equitably distribute the cost of uncompensated care. New Jersey has a specific program that allocates money each year to help bear that cost, as does New York, as does Maryland. Virtually every contiguous state has that. There was a question earlier about the number of uninsured children. There's approximately 267,000, at least in 1998. Now, over half of those children are eligible for Medicaid or CHIP but are not enrolled. So there it points out -- again, sort of underscoring my point about the ability to get people enrolled, even if the insurance is available. Hospitals, in addition to the numerous free care and other community services, are also trying to do their part to try to address the issue of trying to enroll people -- and 57 5/24/00 PUBLIC HEALTH - RES. 000042 particularly children -- in programs, MA and CHIP. Our program First Steps For Healthy Kids was established. It basically is a region-wide program by hospitals to ensure that every child born in the region has a medical home. And one of the particular parts of that is to work with the school systems, work with others to help enroll and provide resources to help cut through some of the maze of bureaucratic requirements and other things to get children enrolled and to address some of the confusion that has resulted of welfare reform. Thousands of children have been enrolled because of that program, and we've working with organizations like PCCY and others to work on a community-wide effort to try to do what we can do to try to make sure that children in particular but others that are eligible for Medicaid and CHIP are taken care of and enrolled.
As I said, we strongly support 50 percent of the dollars being used for services for the uninsured, and I would like to reemphasize that we think it's appropriate for the Governor's 58 5/24/00 PUBLIC HEALTH - RES. 000042 proposal to be amended to include what was an amendment by Representative Taylor to say that to the extent that the monies aren't spent on insurance, they shouldn't go into the Endowment Fund or put into a rainy day fund; they ought to go into expanding the amount of money available to pay for uncompensated care. I know that members of this committee are well aware of the stresses that have occurred on the health care system in Philadelphia, whether it's closure of hospitals, to the largest bankruptcy in -- a nonprofit bankruptcy in the history of the United States, in terms of the Allegheny System, as to be an indication of the types of pressures that the health care system is under. And more needs to be done to address the changes occurring in our health care system. And as one of the previous witnesses has indicated, the tobacco settlement is not a panacea for all of the problems that are facing the health care system, but it is an important first step in a number of different ways. I would also like to echo, in wrapping 59 5/24/00 PUBLIC HEALTH - RES. 000042 up, echo a couple of other comments that were made by the Commissioner, and that is that the Governor's insurance proposal, as he's outlined it, we suggest that it be modified to set the financial participation, the 5 percent copayment or cost-sharing requirement, we think is too high, and that that will serve as a barrier to many of the people needing it to in fact enrolling, and that that ought to be re-looked at and readjusted. It absolutely needs to include prescription drugs. Otherwise, again, the promise -- what we'll do is wind up creating a whole bunch of people that are under-insured as opposed to uninsured. I suppose it's marginally better, but we think that prescription drugs should be included in it. And I think it's also important to, wherever possible, to maximize the use of federal funds, and that is to the extent that we can draw down federal Medicaid match, and whether it's, for example, enabling people with serious medical conditions that are enrolled in the new program under the Governor's proposal to allow them to spend down into Medicaid, much as uninsured people 60 5/24/00 PUBLIC HEALTH - RES. 000042 do today. But we do need to take advantage of all opportunities to draw down additional federal funds. Again, in closing, I know that this reemphasizes -- one, this program represents an enormous opportunity to address some of the problems facing the system. The other items that I did not mention, whether it's home and community-based services for the elderly, it's very important in terms of providing alternatives to nursing home placement and to assist elderly to stay in their homes. The research dollars, the health care -- the venture capital fund can play an enormous role in Philadelphia. In Philadelphia, we have one of the largest concentrations of health care and medical expertise in the world in this city, and we should be working together on a strategic plan, if you will, to make sure that Philadelphia realizes the potential to be a global life sciences center. And those kinds of proposals, whether it's a venture capital fund or the research dollars or other things, will help to achieve that kind of project, and in a positive way, try to grow the 61 5/24/00 PUBLIC HEALTH - RES. 000042 Philadelphia economy where it's appropriate in health care. And so we strongly support those aspects of the Governor's plan as well. I'd be happy to answer any questions that you may have.
Again, I want to commend you for holding the hearing, and I hope that the City and health care organizations, hospitals and health systems can work together to advocate for the appropriate use of these dollars when the issues get considered in earnest in the fall in Harrisburg.
Yes, I do have one, again, related to what is a revelation for me, and that is the still-inadequate usage of the CHIP Program. I had a follow-up question here which you answered, and that is that the Philadelphia School District is actively participating and assisting in raising that bar through PCCY?
We actually did a program -- we worked with PECO Energy, actually 62 5/24/00 PUBLIC HEALTH - RES. 000042 PECO helped us. We distributed through -- under our First Steps For Healthy Kids Program, had distributed, I think, last year, and it's being done again this year, more than 100,000 fliers to school children basically to bring home to alert parents to the availability of CHIP as well as MA. We're also right now working on a proposal to do, in effect, an experimental proposal on specific outreach efforts in particular clusters. We've also encouraged hospitals to partner with schools to assist them in that effort in terms of making sure that children and their parents are aware of the insurance opportunities that are available. There's a whole series of things that I'd be happy to give you sort of the comprehensive look, but the School District of Philadelphia -- I think Superintendent Hornbeck has stated a clear policy or goal of having every child in school in Philadelphia insured, and virtually every child given -- I mean, if you use as a proxy the eligibility for free or reduced-price lunches, and corresponding with the eligibility for CHIP, 63 5/24/00 PUBLIC HEALTH - RES. 000042 virtually every child in the Philadelphia school system is eligible for CHIP, to the extent that they're uninsured. And it's something that we need to do more, and we're working as hard as we can to try to do our part to make sure that that objective is achieved.
I would be very much interested in seeing that that list -- and as a former teacher, I know that repetition breeds learning. Folks have to hear and see information several different times before it connects. So to that extent, I'd be interested in seeing that, to see how we can layer the message, because getting it once, even for adults, doesn't work. And then the only other thing I would recommend is the clergy community, or the faith-based community as another avenue that can be utilized to make sure that the information reaches the very world we're trying to touch.
Right. Through community partnerships, we're working with a whole series of organizations like that, but I think those are good suggestions, and I'll take them 64 5/24/00 PUBLIC HEALTH - RES. 000042 back to my staff to make sure we follow up on them.
Let me just ask you a question. Why do you think it's difficult to have children enrolled into the CHIP Program?
To get them enrolled? Well, you've got -- I mean, it's complicated, but the enrollment process is perhaps not as smooth as it could be. And in the Department of Public Welfare and the Insurance Department, which actually managers the CHIP Program, as opposed to the MA Program, are working together, and they are trying to come up with a common application form, because right now, there are separate applications for the program. They're also trying to get up -- to come up with procedures to basically ensure that the extent that you're ineligible for CHIP, you're automatically moved over to Medicaid, and vice versa, so that there's clear linkages between the 65 5/24/00 PUBLIC HEALTH - RES. 000042 programs. So common application, those linkages. We're also looking at ways and have recommended to the State that there be -- we try once again to out-station eligibility workers at hospitals, because oftentimes, that's where large numbers of people go to seek care that are uninsured, and it would be nice to get those. Part of the problem is also confusion with, as was mentioned before, with welfare reform. People feel that even though there is a clear distinction between Medicaid and the former AFD or TANF payment, that there's a feeling that if you're on the rolls for Medicaid, maybe it's counting towards the lifetime limit on benefits. There's also the issue that in terms of recertification for those benefits -- there was a very positive incentive for people to come in and be recertified because they needed to do that in order to receive the cash assistance. And when there's no longer the cash assistance, sometimes the Medicaid eligibility lapses, and that ought to be -- you know, so there isn't an incentive to go and basically do the paperwork to maintain the Medicaid eligibility. 66 5/24/00 PUBLIC HEALTH - RES. 000042 So there's a whole series of issues that need to be addressed, and there is some activity going on at the State. One of the things that we're working on is seeing whether or not the State -- and I think the State is interested in it, but whether we could, on a pilot basis, try to waive the requirement for income verification. Some other states have done that. But, again, if you use the free and reduced-price lunch eligibility as kind of a proxy, it would suggest that enrolling kids would be a whole lot easier if you didn't have to go through the process of getting all of the income verification materials together and basically submitting that. And if we could waive that requirement, we could get a lot of people enrolled and move forward.
We appreciate your coming in. Sharmain Matlock-Turner, Greater Philadelphia Urban Affairs Coalition. 67 5/24/00 PUBLIC HEALTH - RES. 000042 (Witness comes forward.)
Your testimony is short, right? It's not this book, right?
(Laughs.) It's not too long. I want to thank -- I'm not going to read the whole book. That's a reference document for you.
But I want to thank Councilwoman Tasco, who chairs this committee, as well as Councilwoman Brown, and also Councilman Rizzo and Ortiz, who were here, for hosting these hearings around the tobacco settlement issue. I'm with the Coalition, and we have been looking at this issue today, and I know you're going to hear a lot of information about the various parts of the settlement. We have really focused our attention around cessation and prevention, and so the report that we've presented to you was really our first 68 5/24/00 PUBLIC HEALTH - RES. 000042 look at the whole issue of what's going on around prevention and cessation, and specifically targeting the minority community in Philadelphia -- African-American, Hispanic and Asian -- to make sure that we included them in the discussion as we move forward and try to figure out a way to ultimately get to where Councilman Ortiz stated, and that is where we would have zero amount of money because we would have zero people smoking. And just to add what he said about there being no money. I think some of the numbers that I've seen is that it costs Pennsylvania $3 billion annually to deal with all the costs that go with smoking, so getting the settlement down to zero because no one's smoking is ultimately going to save all of us, I think, a lot of money. I do want to thank you for the opportunity to testify today. The Greater Philadelphia Urban Affairs Coalition, known as "GPUAC," has been around for 31 years and is the region's principal vehicle for the development and implementation of community-based solutions to serious and complex problems, particularly in 69 5/24/00 PUBLIC HEALTH - RES. 000042 minority communities. Our core mission is to enable grassroots groups to do what they do best: reach out to help the disadvantaged communities help themselves. I am pleased to testify today. I've also had the opportunity to testify on the tobacco settlement last summer at the invitation of State Senator Hughes before the Senate Health and Welfare Committee on this issue. My testimony is in three parts today. First, a look at the facts, who in our City is most at risk from smoking; secondly, what can be done to reduce the number of minority teen and minority adult smokers; and third, why GPUAC wants to work with the City on targeted culturally- appropriate health education and advocacy, along with coalition-building, research-sharing, and evaluation. GPUAC recently undertook a preliminary assessment of what the tobacco settlement could and should mean to Philadelphia's minority community. GPUAC's assessment involved investigative research, a preliminary review of the literature, a look at regional news stories 70 5/24/00 PUBLIC HEALTH - RES. 000042 over the last ten years, and interviews of elected officials, legislative staff, and experts in public health, smoking cessation, and prevention. The focus was on gathering information about smoking incidence and impact, the State's current and proposed plans for financial investment and programs, local and national models for working with minority communities, the identification of local leadership programs and resources to reduce smoking, the related gaps in needs, and, finally, recommendations for action for Philadelphia's African-American, Latino, and Asian communities. The report that I have distributed with testimony is a summary of our initial findings and preliminary recommendations for action. The information presented here by GPUAC directly relates to the Governor's plan to support programs that focus on tobacco prevention and cessation. We believe it is important for our city to develop a comprehensive plan to reduce the use of tobacco among all Philadelphians, particularly those whose health status is most at risk. We recommend that funds be appropriated for prevention and cessation 71 5/24/00 PUBLIC HEALTH - RES. 000042 activities, be targeted to Philadelphia's minority groups -- African-American, Hispanic, and Asian citizens.
This recommendation is made because chronic and preventable disease is associated with smoking disproportionately affect these racial and ethnic groups. Here are the fact to back up what I just said: Chronic and preventable disease associated with smoking, disproportionately affect Philadelphia's African-American, Hispanic, and Asian citizens. Smoking remains the leading preventable cause of death. It is on the rise among groups that are hard to reach -- the young, the poor, high school dropouts, and racial minorities. More than 50 years, ago lung cancer, disease that is directly related to smoking, ravaged minorities and the majority population on an equal basis. Today, the lung cancer rate among African- Americans is 63 percent than that for whites. And today, cigarette smoking has risen most dramatically in communities of color. These statistics should not come as surprise. Minority smokers are a target audience 72 5/24/00 PUBLIC HEALTH - RES. 000042 of the tobacco-makers, an industry that advertises heavily in communities of color. In Pennsylvania, percent of all adults are believed to be 5 smokers. 4 7 percent and 28 percent for Hispanics. Asians in 8 Pennsylvania have the lowest incidence rate, at 9 19 percent. 10 The smoking escalation rate among young 11 racial and ethnic minorities is particularly 12 alarming. Twenty percent of African-American high 13 school students smoke, an 80 percent increase 14 between 1991 and 1997. 15 As stated earlier, smoking is the 16 number-one preventable cause of death in the City 17 of Philadelphia. One in every six deaths, an 18 estimated 3,451 persons in 1990, is related to 19 smoking. We know that without intervention, 20 minority cigarette-smoking adolescents will 21 continue to smoke. 22 Since the incidence of smoking for 23 African-Americans and Hispanics in Pennsylvania is 24 higher than average and considerable growth is predicted for these populations in Philadelphia 73 5/24/00 PUBLIC HEALTH - RES. 000042 over the next years, the local public health ramifications are more than serious; they are deadly. We must act now in partnership with one another to reduce the number of adult smokers who are racial minorities and cut the rate in which young minority teens are smoking. National attention is now focused on teen smoking. President Clinton's tobacco proposal announced February 5th seeks to cut teen smoking in half by 2004. The plan is to make cigarettes more expensive and to penalize the tobacco industry. Little is known about how to successfully intervene to stop smoking among minority teens or adults. There is much debate about whether teen smoking in particular is a health issue or a law enforcement issue. What many experts believe is that action is needed on both fronts, that cutting teen smoking means effective law enforcement and targeted culturally- appropriate health education. African-Americans, as well as other minorities, have very limited resources for smoking cessation and prevention activity. This 74 5/24/00 PUBLIC HEALTH - RES. 000042 is just beginning to change. In February, the National Public Radio reported that an increasing number of states are using part of their share of the tobacco settlement for minority health programs. The Federal Centers for Disease Control and Prevention and in the Surgeon General's report, it states that the capacity of tobacco control efforts to keep pace with the patterns of tobacco use and cessation depends on timely recognition of emerging prevalence and cessation patterns and the resulting development of appropriate community-based programs to address the facts involved. The essential role of active community partnerships has been demonstrated in model statewide initiatives which have achieved significant reductions in the incidence of smoking.
California has seen a 35 percent to 40 percent reduction in smoking over 8 years as a result of an annual investment of $90 million per year for the past 8 years. One-third of their funding is used for school-based education and prevention activities, and two-thirds for a 75 5/24/00 PUBLIC HEALTH - RES. 000042 comprehensive anti-tobacco education efforts that include a media campaign, local programs, and surveillance and educational initiatives. Ethnic community networks are funded by the state to ensure the design and implementation of culturally-sensitive strategies. And if you look at our report, you'll see that there are similar results when you take a look at the State of Massachusetts and Florida. In Philadelphia, GPUAC proposes to reverse recent trends in tobacco use by working with the City of Philadelphia community leaders and public health experts to create a minority smoking cessation coalition. The purpose of this coalition would be to develop and implement a comprehensive plan to reduce the incidence and impact of smoking on racial minorities in the City of Philadelphia and to secure sufficient resources to see that the plan is implemented. Over a 5-year period, our goal is to reduce by percent the number of adult smokers 23 who are racial minorities and to cut in half the 24 rate in which young African-Americans and other 25 teens are smoking. And we believe these goals can 76 5/24/00 PUBLIC HEALTH - RES. 000042 be accomplished through education, advocacy, coalition-building, serving as a clearinghouse and resource-sharing on what actually works, and then to make sure that there is an evaluation tool to see whether or not the programs that have been established are actually working in minority communities. Certainly, the Greater Philadelphia Urban Affairs Coalition has a long history of bringing together people in order to solve problems. We suggest that we join with you to make sure that dollars are appropriated for these activities and, most importantly, that minority communities in the City of Philadelphia are specifically targeted because they are the most at risk. Thank you very much.
Just one. When we look at the Governor's list of priorities and the percentage that he's attached to each one of those categorical areas, and when we consider what your 77 5/24/00 PUBLIC HEALTH - RES. 000042 priorities are to be, have you had an opportunity yet to talk through or think through a strategy that reaches a complement between the Governor's preliminary proposal and what your focus is?
We think that certainly, because the Governor has agreed to spend about $60 million annually on prevention and cessation, if they take a look at who is most affected and if they take a look at their own Healthy People 2000 Report and see the incidence of lung cancer and other cancers that are affecting minority communities, they will clearly see that there's a strong need to make sure that once those dollars are appropriated, either at the State level or at the City level, we're hoping that people will remember that the minority community is very, very disproportionately affected by this issue, and that dollars will be put in place to make sure that we can turn that around. We believe that community-based organizations and community people need to get involved in this issue. It's not just enough for people who are experts to be involved, but ultimately, if we're going to have a long impact 78 5/24/00 PUBLIC HEALTH - RES. 000042 of really changed behavior, it's really about bringing community people into the process and giving them an opportunity to talk about what they think will work and to evaluate what other people are proposing.
This is an offhanded kind of question. Have you seen the ads, billboards around town with butthead? And do you know anything about that?
All right. When we sat down to put this proposal together, one of the first issues that really caught our attention as to why we thought it was important to make sure that issue of minorities was talked about, because we took a look at those butthead commercials, and we didn't see that they appeared to be culturally sensitive. It didn't appear they were being targeted for everyone. It seemed as if they were, you know, being handled from someplace, we understand, in Harrisburg, but that there had not been community input. And we think if there had been, you would still see -- you would see things that were more culturally diverse. The Center for Disease Control has 79 5/24/00 PUBLIC HEALTH - RES. 000042 clearly said that in order to have a real impact on reducing smoking, we really have got to have culturally-sensitive programming and advertising that's really going to target all communities. And we hope that in putting this coalition together, that one of the areas we would look at would clearly be advertising. I think we need to get together with -- we have some really great minority advertising firms in the City of Philadelphia. I would certainly suggest to the coalition members that what we'd want to do would be to bring them in and see whether or not there are some opportunities here for us to really put together an effective campaign and advertising campaign that would bring everyone to the table.
Thank you very much. We appreciate your testimony.
Next is Henry Nicholas, President of District Council 1199c. (Witness comes forward.)
Thank you so very much, Madam Chairperson and your committee for convening 80 5/24/00 PUBLIC HEALTH - RES. 000042 this testimony. Perhaps it is appropriate that I make clear that the issue before Philadelphia is bigger than the tobacco settlement. In fact, as we speak, the entire health delivery system in Philadelphia is in the intensive care unit, on the respirator, and that the tobacco settlement represents our only visual signs for resuscitation. It is clear that the Philadelphia entire economy is at risk. With the largest concentration of health care in the State being in Philadelphia, when the hospitals are put in jeopardy, so is the Philadelphia economy. Indeed, the Philadelphia budget surplus is projected to run out in the next five years. S. Department of Labor, more Philadelphians are employed by hospitals than any other single entity. And so, what happens to Philadelphia health care determines what happens to the Philadelphia economy. In the last 12 months, 15,000 good-paying health care jobs were lost in Philadelphia. It is estimated that this year, a 81 5/24/00 PUBLIC HEALTH - RES. 000042 like number will occur. So the tobacco settlement represents the only window f opportunity that Philadelphia has, in my opinion, to save itself. I have, over the last six months, have been a part of a coalition, have participated in a significant lobbying effort at the State capitol. And to follow on what Sister Matlock said, we are prepared to be a partner in a massive public relations campaign across the State to make sure that we get the message out. My counterpart in New York 1199 spent more than $15 million to make sure that the $1 tobacco tax got raised, to make sure that a significant part of the tobacco dollars got targeted for health care. We are facing a problem, and although we were first afraid that this would get looped into the budget, the fact that it's delayed will give us an opportunity to prepare, if we are preparing to act in a meaningful way. In our visit to the people on the Hill, and we have met with every senator on the committee out of which this legislation will evolve. And clearly what I heard was what we see 82 5/24/00 PUBLIC HEALTH - RES. 000042 is not what we're going to get, suggesting that -- notwithstanding the fact that the Governor had proposed spending 40 percent of the money in tobacco-related areas. As soon as the bell rings and the horses are out of their stall, everybody will be standing at the gate to chip off his or her piece. And so we might indeed see a disappearing of that 40 percent allocation as we're now speaking of it. But, clearly, Philadelphia, in my opinion, has the most to gain and the most to lose. Because if we do not do something to stop the hemorrhaging in the health delivery system here in Philadelphia, the whole Philadelphia economy is going to start tremoring as if a earthquake was near. For instance, the mother of all hospitals in the Commonwealth of Pennsylvania, if not in the country, the University of Pennsylvania, in the last five months has already laid off 5,000 workers, with another 3,000 in the hopper that will come before the year is out. If the University of Pennsylvania is having problems, you can imagine what's happening with the rest of 83 5/24/00 PUBLIC HEALTH - RES. 000042 the health-care industry in Philadelphia. As a representative of the employees, we have a ringside seat inside of the hospitals, and we know what is happening. Clearly, we believe, politically and organizationally, the only monies that will be available to rescue health care in Pennsylvania is this tobacco money. If we do not forego the opportunity to put up a fight to get our share, irregardless of what happens in November, there will be no new money for health care and health care coverage, irregardless to who gets elected. So the tobacco settlement is a widow of opportunity, and we, as an organization, our union is prepared.
We have already prepared ads for all of the papers in this region. We have already arranged for a major media (unintelligible) in the print media and in the electronic media statewide, but we need help. It is not just our issue; it is everybody's issue. And we are prepared to partner with anyone, any coalition, any organization, putting up our share of the money, marbles, and chalk to make sure that the right message gets played out, and that in the end, we are successful 84 5/24/00 PUBLIC HEALTH - RES. 000042 in achieving a portion of these dollars to take care of the uninsured in Pennsylvania. Senator Hughes's bill goes a long way in moving us into that direction, but it has not passed yet. And I am fearful that before any meaningful legislation that looks out for poor people gets passed, the money might just go up in smoke. It should be interesting to note that the health care professionals project that the cost of health care insurance, over the next 5 years, will rise, will be between 9 and 13 percent. It is also projected that for every percentage rise, 50,000 more Pennsylvanians will be without health care. 2 million people that are uninsured. So as the cost of health care goes up in each percentage point, another 50,000 people fall out of coverage. So this is a big, big issue for the Commonwealth of Pennsylvania, but it is also a bigger issue for Philadelphia because its economy depends on health care. Health care is the largest employer, and if it goes down, we all go down with it, and I did not want to miss the 85 5/24/00 PUBLIC HEALTH - RES. 000042 opportunity to make that point, because it is bigger than everything else. It is the heart of this city, the health care industry. I am prepared to answer any questions.
Is there a coalition effort moving forward in Philadelphia to lobby Harrisburg for this money?
There is a statewide coalition, there is an aggressive grassroots coalition that has been meeting for the last six months. Dr. Tsou and I spent a couple of days in Harrisburg right after he was appointed, going around and meeting with the various legislation. And so we have a clear of the thinking of the Senate side of those who have the authority over the legislation. So we've met with both them, we met with Secretary Peace, who has a big role to play in this issue. So we've been meeting, and when out in recess we went house calling to a number of legislators, so we have been working together. But it is at a crucial juncture, and we have some time between now and September or October, and when the legislation moves, we are 86 5/24/00 PUBLIC HEALTH - RES. 000042 concerned that special-interest groups will take all of the resources, and the Philadelphia economy will die as a result of it. We need to make sure that we get some of that money into Philadelphia.
Dr. Tsou has outlined, and Niles also outlined, the breakdown, the percentage breakdown that the Governor has offered to -- of where to appropriate this money. It's 40 percent for the uninsured and percent 11 for home and health care and 10 percent for 12 uncompensated care provided by the hospitals, 10 13 percent for tobacco prevention and education, and 14 so on. 15 Is there a dissatisfaction or a disagreement about the breakdown of their appropriation of the proposed allocation?
We have a severe problem with the fact that the Governor's proposal does not cover half of those who he took their health care cost away from them, the 263,000 people. He does not cover half of that population in this proposal. The other crucial issue in his proposal is, he refuses to access a more than 50 percent 87 5/24/00 PUBLIC HEALTH - RES. 000042 match in Medicaid dollars that would be available if he would draw down on them, suggesting that he would not draw down on those dollars, although they could significantly cover more Pennsylvanians. He suggests to participate in that way would constitute an entitlement program, and since he's against entitlement programs, he will not draw down on the federal match. And we've been pushing, pushing, pushing in our lobbying effort, getting the Governor to draw down on that money. The federal government would give him 54 cents for every dollar spent, if he would draw, but down since he's ideologically opposed to what he calls "these entitlements," he has steadfastly said he would not go that way. And that's a big piece of our struggle as the campaign heats up.
But you don't disagree that a certain portion of the money should go for tobacco prevention education, do you?
Okay. So I guess 88 5/24/00 PUBLIC HEALTH - RES. 000042 my point is that we have had different people testify this morning for different uses.
I'm closer to the Vincent Hughes legislative directive because it more liberal and covers more people than the narrow limitations that the Governor has put forth. In the Vincent Hughes legislation, he proposes to raise, as did New York, New Jersey, and a number of other states, additional tobacco tax dollars.
Now, those people who have testified and those people who are here today, how do we join together so that Philadelphia comes out with one voice and one plan? Because when you go to the door and you're divided, then they tend to -- legislators or government administration decides to do or develop their own plan because "those folks can't get their act together." So we need to coordinate your requests and come up with a plan that's pushed by all of 89 5/24/00 PUBLIC HEALTH - RES. 000042 the people, whether it's for health care coverage or prevention or home-based care or whatever, that there is a joint effort that you all support, and that you're not competing for those dollars.
We've been out on the territory for the last eight months, and I can testify that for the most part, 99 percent of all of the players on this issue are indeed on the same page. The Delaware hospital Council, we're on the same page; Dr. Tsou, we're on the same page; Sister Matlock, who just testified, we're on the same page, and we want to get on her page, because if she can help raise the significant dollars to help spend the necessary public campaign that we must do on this issue, we are prepared to be a major partner in that effort.
As a matter of record, who are other members of the coalition that you're referring to? You've mentioned Dr. Tsou.
Yeah. There are a number of people. All of the major grassroots organizations have been meeting either in my 90 5/24/00 PUBLIC HEALTH - RES. 000042 office or their office for the last eight months preparing the issue. We've sent out more than 600 pieces of legislation to the business community across the State, we have sent out a significant mailing to all of the labor across the State. And so we have not just been Philadelphia-based; we've been building a coalition statewide. The Philadelphia AFL-CIO is on the board and all of the community organizations have been participating.
That's is helpful to know in terms of underscoring Councilwoman Tasco's point, that we -- there's more than an indication, but a reality that the coalition from Philadelphia is indeed speaking with one voice.
And our coalition has been a player in moving the Hughes legislation. We are at Children's Hospital when it was for announced and we were in Harrisburg the day it was first unveiled there, so we have been out on the edge of the debate for the last eight months.
Is this what we received in the Pennsylvania Consumer Health Coalition? 91 5/24/00 PUBLIC HEALTH - RES. 000042
Thank you very much, Mr. Nicholas. Nice to see you again. Catherine Balsley, Philadelphia School District. (Witness comes forward.)
Good afternoon. Thank you for coming. Would you identify yourself for the record, please.
Yes. Good afternoon. My name is Dr. Catherine Balsley, and I'm the Director of Curriculum for --
Forgive me for not recognizing you as "Dr." I apologize.
Forgive me for not saying "Dr." It's on the list here.
That's quite all right. I'm the Curriculum Director for the Philadelphia Public School System. Thank you for the opportunity to share comments related to the 92 5/24/00 PUBLIC HEALTH - RES. 000042 State's proposals under consideration for the expenditure and use of the Commonwealth's tobacco settlement. As a lifelong advocate for child and adolescent health and Curriculum Director for this nation's fifth largest school district, I would like to propose for consideration just one recommendation, and is that we lobby for the development of a statewide infrastructure to support school-based comprehensive health education, including tobacco prevention education that will provide for funded technical assistance through CBOs to communities and direct noncompetitive funding to local school districts. This recommendation specifically calls for a stronger collaboration between the Pennsylvania Department of Health and Department of Education to ensure several things: The adoption of State academic standards for health and physical education, K through 12; The implementation of State-based surveillance and program evaluation systems. For example, the Centers for Disease Control and 93 5/24/00 PUBLIC HEALTH - RES. 000042 Prevention's Youth Risk Behavior Survey and health education assessment to the PSSA, which is the Pennsylvania State System of Assessment; Adequate resources for the implementation of evidence-based tobacco prevention curricula and teacher training; Adequate funding for the development of school health councils, community coalitions, and tobacco-focused youth-serving community-based organizations; And, finally, increased access to smoking cessation programs specifically targeting youth. In essence, this recommendation is a deliberate and intentional effort to focus attention and a fair share of the potential resources on the population most at risk, most vulnerable, least cared for or about, yet most likely to benefit from tobacco-related disease prevention initiatives -- our young people. Over the span of my 27 years as a health education teacher and school administrator in Philadelphia, I have become increasingly frustrated, many times angered, and mostly 94 5/24/00 PUBLIC HEALTH - RES. 000042 disheartened by the lack of cooperation between the State Departments of Health and Education in addressing the very specific health and education needs of our children and youth. Salient examples of this lack of cooperation include the lack of coordinating funding priorities, the lack of promoting health promotion initiatives, and the lack of collaborating with youth-serving community-based organizations to ensure that youth health issues are fairly represented in the broader adult community. If there is one important lessen to be learned from the past 12 years in dealing with the AIDS epidemic, it is to make it a priority to build and sustain a coordinated support system of prevention, education, and services that begins in the early years with school-aged youth. I want to give you just three short, but significant, examples to illustrate the importance of developing statewide infrastructure to support school-aged tobacco prevention education. First, it is very important to collect quality data so that one can make wise 95 5/24/00 PUBLIC HEALTH - RES. 000042 programmatic and funding decisions. It is generally agreed that the tobacco use begins in teen years. Nationally, more than 6,000 persons under the age of try their first cigarette each 6 day. About 1 in 10 middle school students and 7 more than a quarter of high school students are 8 current cigarette smokers. Although national data 9 is more important, it too often allows for denial, 10 and parents may say, Well, that may be true over 11 there, but not in my school, not in my community, 12 or not my child.
13 In the Philadelphia public schools, we 14 are able to monitor and, thus, more accurately 15 describe smoking behavior among our youth because 16 we implement the Youth Risk Behavior Surveillance 17 Survey biannually. The YRBS is part of the 18 Centers for Disease Control surveillance system that monitors adolescent health behaviors. 9 percent, of our high school students have tried smoking. Current use is less than a quarter, or 23 percent. Of those who reported to smoke cigarettes, almost 12 percent of them purchased them from a store, and 96 5/24/00 PUBLIC HEALTH - RES. 000042 87 percent of them smoked on school property. These data provide us with important information about patterns of behavior that have very serious public health and education implications. Such a system of surveillance at the State level could help lay the foundation for shaping public policy and developing specific and targeted prevention strategies and activities at the local level. Second, it is generally thought that prevention education is key to tobacco control. There is very strong evidence to suggest that school-based, evidence-based curricula, combined with adequate teacher training, can significantly reduce or delay adolescent smoking. Yet there are no adopted State standards or planned instruction for health education, no State assessments for health instruction, and few District dollars are ever spent purchasing health education textbooks, instructional resources, or for teacher professional development. In my own experience, the average elementary middle school budget for health instruction is less than $100 per year for the 97 5/24/00 PUBLIC HEALTH - RES. 000042 entire school. And if I could just show you, up here in my hand, I have one penny. This amounts to one penny spent per child per year on health instruction in any public school in the State of Pennsylvania. CDC recommends between $4 and $6 per child annually. Certainly, we do not get our fair share or are we equal partners at the table. Third, like with all else, school cannot do this alone. School-based efforts must be linked with the broader community of partners that can provided the wrap-around services and political support necessary to address the issues of tobacco control and health advocacy from many perspectives. Organizations such as TEACH, the American Cancer Society and the American Lung Association are essential partners and leaders in promoting healthier children. Funding opportunities to these organizations must be strengthened so that they can continue to advocate for those who are powerless to advocate for themselves. The development of a statewide infrastructure to support school-based comprehensive health education, including tobacco 98 5/24/00 PUBLIC HEALTH - RES. 000042 prevention education, is critical to our success in tobacco control. We must advocate for a stronger collaboration between the Pennsylvania Department of Health and the Pennsylvania Department of Education. We must also diligently campaign for a stronger focus on prevention efforts for our youth. They are, after all, the promise of our Commonwealth. Thank you again for making this opportunity available.
Thank you very much. And in this effort, what is the Philadelphia School District doing in terms of galvanizing support for your proposal?
Well, the School District of Philadelphia is actually not only a leader in the State of Pennsylvania, but a leader in the nation. We do not depend on operational funds to do our work. We are very busily out there getting grants and foundation funds to put together a very comprehensive health education program. We have considerable funding from the Centers for Disease Control. 99 5/24/00 PUBLIC HEALTH - RES. 000042 I, over the years, have participated in many state organizational meetings, lobbying activities, and that's why I said I was so frustrated by the inability of the State to move an agenda of health education forward. And I am hopeful that City Council and, through our lobbying efforts, can push the agenda of comprehensive health education at the State level, because what the bottom line is, in schools, if it's not tested, it's not taught. And we know that the diseases of today, the most important and significant causes of morbidity and mortality, are caused by things that we can prevent, the kinds of behaviors and life choices that we make, and one is tobacco use.
Have you sought the support of our State legislators?
I have, many times, on many coalitions. The American Cancer Society has a very powerful lobbying effort and a coordinated school health council that meets in Harrisburg on a regular basis. I mean, there are a number of initiatives. But I'm honestly think the bottom line 100 5/24/00 PUBLIC HEALTH - RES. 000042 is that we do not value children enough to say that prevention efforts are where we need to put our dollars. And I was hopeful that you would ask me the question, do I think the Governor's priorities, in terms of the allocation of resources, is --
No, I don't. I absolutely think we need to have the courage to say that we need to put resources not only into youth but into prevention education, that we must focus prevention. We know we can prevent the diseases through research-based or evidence-based programs, and we must put the dollars there to be able to do that.
Well, they do have 10 percent for tobacco prevention education, based on best practice models developed by the Center for Disease Control.
That's correct, and 10 percent is hardly anything for what it is we need to do in the schools.
It's not enough. 101 5/24/00 PUBLIC HEALTH - RES. 000042
You know, I just remind you, this one penny, one cent for the health education of each child is clearly not enough.
Okay. Well, maybe your group can work with the other local groups to try to and modify the proposal.
I do want to thank you for your very eloquent testimony and restate what Councilwoman Tasco has said. Please make a point to meet, introduce yourself to Sharmain Matlock-Turner. Given the focus of their proposal and your interest, there's an opportunity there, as well as to Henry Nichols. Is Henry still here?
Rachael Milenbach and Jeffrey Barg. 102 5/24/00 PUBLIC HEALTH - RES. 000042 (Witnesses come forward.)
Good morning. My name is Rachael Milenbach, and I'm Director of the Tobacco Control and Prevention Program at the Health Promotion Council of Southeastern Pennsylvania. " Our organization has provided tobacco control services to Philadelphia and the four surrounding counties since 1993. Our programs and activities include prevention and education, smoking cessation, youth access to tobacco, secondhand smoke, and community empowerment. " I am also here as coordinator for TEACH, and I'm the Treasurer of the Coalition for Tobacco-Free PA. 103 5/24/00 PUBLIC HEALTH - RES. 000042 TEACH has been at the forefront of many activities that have served to improve the quality of life as it relates to tobacco use for all Philadelphians and our suburban neighbors. For example: We spearheaded the effort to remove all tobacco and alcohol advertising from SEPTA buses. For three years, we gave many grants to community groups throughout the region who wanted to address tobacco use prevention and cessation within their own community. We worked closely with Philadelphia City Council to pass two tobacco control ordinances that hold merchants accountable for selling tobacco products to children either through over-the-counter sales or vending machines. These two ordinance points, which you passed in 1995 and 1998, have made a tremendous difference in the ease with which children and adolescents can buy cigarettes, which is the only product on the market today, which, when used as intended by the manufacturer, will kill out of individuals. We're here today to listen to many 104 5/24/00 PUBLIC HEALTH - RES. 000042 representatives of organizations who are voicing their opinions on how the Commonwealth share of the 1998 multi-state tobacco settlement should be allocated to best serve the residents of Philadelphia. Councilwoman Brown, I appreciate foresight in holding these hearings so that we, as a city, can work better with Governor Ridge and the Pennsylvania State legislature. At the time, how the settlement monies will be used is in their hands. I'm here today to help ensure that we communicate to Harrisburg in a strong and united voice how Philadelphia will most benefit from this one-time opportunity. The Health Promotion Council and TEACH strongly recommends that the Pennsylvania State Legislature appropriates percent of the tobacco 18 settlement monies to tobacco control and 19 prevention. The Centers for Disease Control has 20 issued a detailed guideline for use of the funds, 21 outlining the various synergistic parts of an 22 effective program. These recommendations were 23 developed to address each state's needs and to 24 assist in developing a budget for a statewide 25 comprehensive tobacco control program. In their 105 5/24/00 PUBLIC HEALTH - RES. 000042 calculations for Pennsylvania, the CDC concludes that percent of the settlement money be devoted 4 to tobacco control in order for the State to have 5 a truly effective program. 6 We also recommend that the Pennsylvania 7 State Legislature uses the plan developed by the 8 Pennsylvania Department of Health, whereby the 9 money is distributed by the lead agency in each 10 county. In Philadelphia, the lead agency would be 11 the Philadelphia Department of Health. 12 The Ridge Administration has proposed 13 this plan, but it is hardly a foregone conclusion, 14 and there is no shortage of special interests 15 lobbying to have funds marked for their own 16 organizations. 17 The Pennsylvania Department of Health 18 has developed and implemented the State's Tobacco 19 Control Program since the beginning. Their 20 considerable expertise and experience must be 21 utilized if Pennsylvania is to have any chance of 22 using the settlement monies effectively for 23 tobacco control. 24 We also recommend that the funds which 25 are ultimately allocated to tobacco prevention and 106 5/24/00 PUBLIC HEALTH - RES.
000042 cessation be spent on effective tobacco control projects with organizations that have experience and a proven track record in tobacco control. How tobacco settlement money is spent will be carefully scrutinized. To apportion funds out to organizations with no prior experience will set us up for failure and prove the tobacco industry's claim that tobacco control programs don't work. Instead, let's fund those who have experience and set up programs to provide technical assistance and training for those who want to join the tobacco control movement. I want to digress for a moment in terms of what you just said to Dr. Balsley. One of the things that TEACH does is, we hold coalition meetings. Right now, we meet as a five-county coalition every other month, and certainly, everyone who's here, such as Sharmain Matlock-Turner, Henry Nichols, and other folks, and anybody, really, is invited to come to our TEACH meetings.
We have over a hundred 107 5/24/00 PUBLIC HEALTH - RES. 000042 member organizations. I don't have the list with me, but I'd be happy to get it to you.
It's very diverse. It's five county. It's Asian, African-American, Latino. There's schools, there's professionals, there's hospitals, there's pharmacists, there's students, there's citizens who care deeply about this issue. The only -- in order to join TEACH, all you have to do is agree with our mission statement. There's no dues, it's open to anyone. Over the years, we've had a wide variety of people come and go, and it's a great thing. When we have our meetings, it's always very exciting. And as we end, we realize what a full two hours that we've had and how much networking everyone does with each other and all of the ideas that come out of getting together and talking on a regular basis.
In your statement about having -- an organization having a proven track record in tobacco control, there are groups 108 5/24/00 PUBLIC HEALTH - RES. 000042 who certainly have some interest in providing education, who might not have the special track record in tobacco control but certainly have a track record in community outreach and deal with other groups.
I think you do yourself a disservice by saying that it should be only those people with a track record 'cause what we're trying to get here is a coordinated effort to go to Harrisburg. The first thing you're going to do a disservice is by going disjointed to the legislators, and that what we want to see is a coordinated effort.
And not have this "us-against-them" kind of mentality, which will be disregarded in Harrisburg, and you know that.
Okay. I didn't mean for it to come across like that. It doesn't necessarily mean when I say that that, you know, they have to have already provided programming, you know, to children or whatever. I know that the Urban Affairs Coalition 109 5/24/00 PUBLIC HEALTH - RES. 000042 has been working very hard on tobacco. I'm really -- for, I think, about a year and a half, if not longer. And clearly, from their testimony, they've delved into the issues, they understand them, they've learned a tremendous amount. So even if they haven't, you know, provided actual programs, I think they're still in there. When I say that, what I'm referring to is that when we -- for the tobacco prevention money, when it's divvied up and groups are going, you know, to do whatever it is that that they propose to do with the money, just for all of our sakes, that we know that the money's going place where good results will come. And they're an excellent organization and I have no doubt that they wouldn't do an excellent job. And, as you said before, we also all need to be working together. You know, another group, for example, is Uptown Coalition, who haven't gotten here yet today. I believe they'll be here this afternoon, in terms of being very involved with tobacco control in Philadelphia. So we welcome all of them. I just think we need to all be working 110 5/24/00 PUBLIC HEALTH - RES. 000042 together and supporting each other. And if there's things that we can do based on our years of experience that, you know, we can share, we do a tremendous amount of training and we've done technical assistance. And, you know, our phones ring constantly with people calling in different parts of the five counties who are doing something. So we need all of us, and we need a lot more people to really reach into all parts of the community to make a difference.
I'll return to my testimony now. To begin, I will explain why tobacco control programs are important. Nicotine is an addictive drug. In fact, scientists have found it to be as addictive as crack and heroin. Because it is legal and historically has been used casually and without concern for the consequences, it has become far and away the most common and serious addiction in the United States. The majority of smokers began smoking as teens or preteens. Many regret having ever started and then try different strategies to 111 5/24/00 PUBLIC HEALTH - RES. 000042 quit. Some are successful in quitting right away, some succeed after many attempts, some succeed after a frightening medical experience. Others continue trying and are never successful, some give up trying and never stop. It is no accident that cigarettes are addictive. They are a high-tech product, a drug-delivery device engineered by the companies that manufacture them, with scientific precision towards the single goal of selling more cigarettes. Commercial cigarettes contain hundreds of chemical additives, although none of these chemicals are required to be revealed on the label. Cigarette smoke contains thousands of chemicals and has been listed as a Class A carcinogen by the USA EPA. The chemicals found in cigarette smoke are even more dangerous and explain the overwhelming scientific data on the harmful effects of secondhand smoke. Secondhand smoke is the third leading cause of preventable death in country, killing 53,000 nonsmokers each year. I'm going to skip ahead. What I would 112 5/24/00 PUBLIC HEALTH - RES. 000042 have included statistics from the Pennsylvania Department of Health that looks at what the economics of cost of smoking is statewide and then also in Pennsylvania.
Your testimony will be put into the record in its full presentation.
Right. The one notable point to make here is that in Philadelphia, 3,110 people died from smoking-related deaths in 1997, which is the moat most recent data that we have from the Pennsylvania Department of Health right now. The good news is that tobacco control programs work when adequately funded. There's a national network of tobacco control advocates who meet annually, and via e-mail and other methods, we work with each other. There's a tremendous amount of knowledge, there's a tremendous amount of programs that have been tried. Some of have worked, some haven't worked. When people say that tobacco control programs don't work, I think they're probably not fully entrenched in the tobacco control movement 113 5/24/00 PUBLIC HEALTH - RES. 000042 and don't truly have a sense of the wonderful people who are out there and who are working so hard and have been working so hard for decades on this issue. I want to tell one quick story. I think it illustrates again what Dr. Balsley was talking about in terms of youth and in terms of reaching out to them and providing services that help them to make intelligent decisions. Last Friday, I spoke to a community of 7th to 12th graders and their teachers. The experience was typical. After fully participating during class, many young people came up to me at the end. The comments ranged from, "You have sufficiently scared me, I am going to quit. What you said about secondhand smoke is scary. How can I protect myself? I have asthma, I smoke, and I feel terrible all the time. Can you help me quit?" This story is typical. We've done thousands of presentations and reached thousands of youth in Philadelphia, in the counties, in school community settings, and we're welcomed with open arms and very, very appreciated by the 114 5/24/00 PUBLIC HEALTH - RES. 000042 communities who have had our staff come in and work with them. To reiterate what Dr. Balsley said, I hope that in the money that comes for prevention and cessation, that we really can provide quality school prevention programs and quality smoking cessation really for every school and for every child in Philadelphia who wants it. I'm going to skip over things that I think other people have talked about a little bit. Okay, I'll end here. I urge Council to actively support the allocation of percent of 14 the tobacco settlement monies for tobacco 15 prevention and cessation activity. We hope that 16 decisions will be made clearly and logically and 17 not because of the politics and other issues that 18 sometimes get in the way. 19 Philadelphia is home to a majority of 20 the State's seasoned tobacco control advocates. 21 We are ready for the responsibility and we will no 22 disappoint you. We are also well-connected, as 23 someone else pointed out, with advocates from 24 throughout the State. We work closely with the 25 Pennsylvania Department of Health, we are members 115 5/24/00 PUBLIC HEALTH - RES. 000042 of the Coalition for a Tobacco-Free PA. We will continue working with our colleagues to make Philadelphia and Pennsylvania a healthier place to live. Thank you.
Thank you. Could you just briefly tell me how the ordinance on the vending machines -- have you done any monitoring or evaluation of the bill?
Yes, we do. We have pretty extensive evaluation. I can also get that to you. Basically, it's made quite a difference. Initially, when we started doing under-aged tobacco-buying surveys, our kids consistently were able to go into stores, and 85 percent of the time, they were able to purchase cigarettes with no questions asked. A couple of changes have taken place as a result of passage of the law and enforcement of it. We work with L&I, they write citations for merchants who are found selling cigarettes illegally to kids. They've been a wonderful organization to work with. 116 5/24/00 PUBLIC HEALTH - RES. 000042 What we have now is, we have signs posted virtually in every store in the City saying -- because that's a part of the provision of the law, that you have to have a sign posted. In the beginning, there were very few signs up. We have a much, much higher percentage, and I can get you the exact numbers of merchants who are asking for ID. And that simple intervention makes a big difference. Most importantly, we've brought the citywide rate down to just below 50 percent, and that's been consistent over time. We've broken our data down by neighborhood, and there's been neighborhoods who, at times, when we went out, did a series of buys in a particular zip code, they had 0 percent. This is astounding. Philadelphia has the highest compliance -- you know, the highest sales rates to youth typically in the State.