May 19th Special Election

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May 19th Special Election

• Childrens Services and Budget Cuts

Julie Stein Pediatric Leadership for the
Underserved - UCSF April 2009
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Objectives

• Understand the current California budget climate
  and its impact on childrens health
• Understand the propositions -- particularly those
  that affect children on the ballot for the May
  19th Special Election
• Review the history of First 5 and some of the
  local programs supported by First 5 funding
• Review the evidence behind early intervention
• Discuss the impact of Prop 1D on First 5 Programs

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The Budget Climate
How we got here

• 40 billion budget shortfall
• 14.5 billion deficit from 2008-2009 budget
• 25 billion project gap for 2009-2010
• Caused by a deterioration of current and budget
  year revenue collection
• Higher-than-anticipated current-year spending
• Imbalance between the cost of programs and
  services and the revenues from the tax system
• Slowing economy

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The Budget Climate
What has been done

• 10 cut in Medi-Cal provider reimbursement rates
• Currently being litigated
• Requiring every 3mo renewal in Medi-Cal
• Able to lobby for to semi-annual renewal
• Limiting dental benefits for Healthy Families
• Increased Healthy Families premiums co-payments
• Delay in SB 437 implementation for 2 years
• Simplify enrollment for Medi-Cal and Healthy
  Families

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The Budget Climate
What will be done

• 15.8 billion in General Fund spending cuts
• 12.5 billion in increased revenues
• Primarily through a 1 increase in the sales tax
• 5.4 billion in borrowed funds
• Primarily by bonds repaid from future lottery
  proceeds
• 7.9 billion from federal economic recovery bill
• 947.7 million in line-item veto spending cuts

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(No Transcript)
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The Propositions

• 6 ballot propositions proposed by the Governor
  and legislature put forward as a group
• 1A Budget Stabilization Rainy Day Fund
• 1B Education Funding
• 1C Lottery Modernization Act
• 1D Protects Childrens Service Funding
• 1E Mental Health Services Funding
• 1F Elected Officials Salaries

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Proposition 10
First 5 Background

• Children Families Act of 1998
• Created California Children and Families Program
  now known as First 5
• Instituted a 0.50/pack tobacco tax to be
  directed towards children ages 0 5.
• Required that these funds be added to, rather
  than replace, funding for existing programs

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First 5 California
Goals and Programs

• Promote School Readiness
• 140,000 children in Kindergarten readiness
  programs
• Child Development
• 10,818 children benefit from preschool
  improvements (facilities grants, teacher
  training, curriculum support)
• 125,000 children have access to development
  screening and follow-up services

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First 5 California
Goals and Programs

• Improve Health Access
• 105,000 children receive oral health treatment
• 14,085 children have health insurance paid for
• Provide Parenting Tools and Support
• 22,000 home visits for newborns and mothers
• 13,700 education and therapy programs for
  families at risk of child abuse or out-of-home
  placement

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First 5 San Francisco
Healthy Kids

• Funded by Childrens Health Initiatives (CHIs)
  county-based with private / public funding
• gt40 of the state-wide funding come from First 5
• Provides health insurance for children ages 0-18
  not covered by Medi-Cal or Healthy Families
• Up to 300 of FPL (66,000 for a family of 4)
• Undocumented
• Significant enrollment gains in not only Healthy
  Kids, but also Medi-Cail and Healthy Families

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First 5 San Francisco
Preschool For All

• Provides all 4 year old with free part-day
  preschool access reduced cost full-day services
• Limits class size to 24 children
• One teacher for every 8 children
• Provides Teacher Action Grants and bonus funds
  for early childhood educators with BA /MA degrees
• Targeted in high risk neighborhoods - Bayview,
  Excelsior, Mission and Visitation Valley

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Impact of 1D on First 5 Funding

• Redirects 340 million in First 5 reserves
• Temporarily diverts 268 million annually from
  2009-2010 to 2013-2014 from Proposition 10 funds
  to the General Fund
• 54 million from state commission funds
• 214 million from local commission funds
• During these 5 years, the redirected funds would
  be subject to appropriation by the Legislature.

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Impact of ID on First 5

• Changes the way First 5 can use funds direct
  services only
• Tobacco revenues will go towards the diverted
  fund portion before going to First 5
• Permanently allows the county to borrow local
  commission funds for that countys general fund

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Poverty Development
Why it Matters

• Emphasis on early intervention
• Studies show that inadequate cognitive and
  emotional stimulation and psychosocial stress
  associated with poverty delay child brain
  development and impede learning with long-term
  effects
• Children who are persistently poor from birth
  through 4 years-old score as much as 4060 of a
  standard deviation lower on intelligence tests
  than children who are never poor during this
  developmental period

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Poverty Development
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Poverty Brain Development

• Brain development (measured by achievement test
  and MRI) affected by chronic stress.
• Differences in emotional support in the home
  account for a significant portion of the variance
  in children's verbal, reading, and math skills.
• Maternal education, family structure, prenatal
  care, infant health, nutrition, and mother's age
  are taken into account

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Early Intervention Evidence

• The RAND cooperation evaluated 9 programs to
  determine if targeted interventions benefited the
  intended children and families
• Targeted early interventions were defined as are
  those intended to overcome the cognitive,
  emotional, and resource limitations that may
  characterize the environments of disadvantaged
  children during the first several years of life.

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Early Intervention Outcomes

• Gain in emotional or cognitive development
  usually in the short-run
• Improvements in educational process and outcomes
• Increased economic self-sufficiency
• Reduced levels of criminal activity
• Improvements in health-related indicators

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Chicago Child-Parent Center
Early Intervention Example

• 1000 low-income minority children born in
  1979-1980 completed preschool and kindergarten
  through one of the Child-Parent Center (CPC)
  program sites
• Control group 550 children in alternative
  full-day kindergarten available to low-income
  families considered treatment as usual

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Chicago Child-Parent Center
Outcomes

• Educational Attainment
• High school completion (63.7 v. 71.4, p0.01)
• 4-year college attendance (10 v 14.7, P0.02)
• Crime
• Felony arrest (16.5 vs 21.1, P0.02)
• Rates of incarceration (20.6 vs 25.6, P0.03)
• Health Status and Mental Health
• Health insurance coverage (70.2 vs 61.5,
  P0.005)
• gt1 depressive symptom (17.4 vs 12.8, P0.06)

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Perry Preschool Program

• 123 disadvantaged African American children
• Part-time preschool weekly home visits
• By 2nd grade, higher achievement scores and were
  less likely to receive special education services
• By age 27, more likely to have graduated from
  high school, had significantly higher earnings,
  own homes and second cars, and were less likely
  to receive welfare or be involved in crime
• By age 40, more likely to be employed, have
  higher salaries, own homes, and have savings
  accounts less likely to have committed a crime
  or used illegal drugs

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The Abecedarian Project
Intervention at the Extreme

• Full-day, year round, center-based care in
  infancy through kindergarten entry
• 111 infants enrolled between 1972-1977
• 57 randomly assigned to the center-based
  intervention and 54 in the control group
• Curriculum focused on cognitive and language
  development
• Healthcare on site from a staff pediatrician

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The Abecedarian Project
Outcomes

• 1.8 grade years higher in reading
• 1.3 years higher in math
• More likely to attend a 4-year college (36 v.
  14)
• More likely to have skilled job (47 v. 27)
• Less likely to have their first child at lt18yo
  (26 v 45)

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The Abecedarian Project
Cost Benefit Analysis

• 2.51 cost-benefit ratio for every dollar spent
  on the program, taxpayers saved 2.50
• Based on
• Higher incomes of participants
• Reduced need for education and governmental
  services
• Reduced health care costs

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Cost Benefit Analysis

• Enriching Children, Enriching the Nation - Public
  Investment in High-Quality Prekindergarten
• Analysis of targeted for 3-4 year olds in lowest
  25 of the income distribution and universal
  prekindergarten for all 3-4 year olds
• Estimated year-by-year costs, budget saving, and
  revenue impacts from 2007 through 2050
• Including crime reduction and earnings potential

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Cost Benefit Analysis

• Targeted to lowest income 3-4 year olds
• Benefits gt costs after 6 years
• By 2050, the annual budgetary, earnings, and
  crime benefits would total 315 billion
• 3.18 1 budget impact
• Universal prekindergarten
• Benefits gt costs after 9 years
• By 2050, annual benefits would total 779 billion
• 2.00 1 budget impact

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Impact of 1D on First 5 Funding

• Redirects 340 million in unspent First 5
  reserves
• Temporarily diverts 268 million annually from
  2009-2010 to 2013-2014 from Proposition 10 funds
  to the General Fund
• 54 million from state commission funds
• 214 million from local commission funds
• During these 5 years, the redirected funds would
  be subject to appropriation by the Legislature.
• Permanently allows the county to borrow local
  commission funds for that countys general fund

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Impact of 1D on First 5 Funding
Local Impact on San Francisco

• Loss of at least 3.6 million annually for 5
  years
• Potential loss of 18 million in school readiness

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Impact of 1D on First 5 Programs

• Developing/renovating preschool facilities
• Training preschool teaches and child care
  providers
• Funding the administration of the Childrens
  Health Initiatives
• Training and recruiting dentists and other health
  professionals
• Coordinating services for children by leveraging
  federal Medicaid dollars

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Arguments in Favor

• Temporary shift of money
• Money is still going to childrens services
• Money is coming from reserves which are not
  currently being used
• Failure to pass will mean sending Legislators
  back to the drawing board and potentially deeper
  cuts statewide for health

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Arguments Opposed

• Takes money away from local health and education
  programs and puts it into the pool of
  state-administered funds
• Goes against voter initiative Proposition 10
• Takes money away from targeted (and proven) early
  childhood interventions

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Action

• Raise awareness with friends and family
• Submit an op-ed piece or letter to the editor
• Sign up for advocacy alerts from AAP-CA
  aapcalifornia_at_aol.com
• Facebook Group - No on Prop 1D

VOTE on May 19th!
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References

• The California Budget Project, Navigating the
  Social and Economic Context of Californias
  Budget, March 2009
• California Statewide Special Election Voter
  Informaion http//www.voterguide.sos.ca.gov/
• Shannon Udovic-Constant, MD AAP-CA State
  Government Affairs Vice-Chair
• First 5 County Commission Annual Reports,
  2007-2008
• Fact Sheet First 5 San Francisco
  http//www.first5sf.org/
• Fiscella K, Kitzman H Disparities in Academic
  Achievement and Health The Intersection of Child
  Education and Health Policy Pediatrics 2009
  1231073-1080
• Noble KG, Tottenham N, Casey BJ. Neuroscience
  perspectives on disparities in school readiness
  and cognitive achievement. Future Child 2005
  15(1)71-89
• Dearing E. Psychological costs of growing up
  poor. Ann N Y Acad Sci 2008 1136324-332
• Karoly et al. Investing in Our Children What We
  Know and Don't Know About the Costs and Benefits
  of Early Childhood Interventions. RAND
  Cooperation 2008.
• Reynolds et al. Effects of a School-Based, Early
  Childhood Intervention on Adult Health and
  Well-being. Arch Pediatr Adolesc Med. 2007
  161(8) 730-739
• Poverty and Early Childhood Intervention. FPG
  Snapshot. No. 42. (Frank Porter Graham Child
  Development Institute, University of North
  Carolina, Chapel Hill, North Carolina) April 2007
• Lynch, Robert. Enriching Children, Enriching the
  Nation -Public Investment in High-Quality
  Prekindergarten. Economic Policy Institute. May
  2007