One of the largest civilian departments in the federal government, the Department of Health and Human Services (HHS) oversees the implementation of numerous health and welfare-related programs. HHS’ budget accounts for almost one out of every four federal dollars, and it administers more grant dollars than all other federal agencies combined. HHS’ Medicare program is the nation’s largest health insurer, handling more than 1 billion claims per year. Medicare and Medicaid together provide health care insurance for 25% of Americans. Many HHS-funded services are provided at the local level by state or county agencies or through private sector grantees. With its large size also has come a large number of troubles and controversies involving birth control, prescription drugs, food safety and more.
Before the federal government established a cabinet-level department to address health issues, lawmakers took a number of steps to create programs and agencies that focused on health-related research and regulation. The earliest effort came in 1798 with the passage of an act to help sick and disabled seamen. This led to the establishment of a federal network of hospitals for the care of merchant seamen, forerunner of today’s Public Health Service.
During the administration of President Abraham Lincoln, the Bureau of Chemistry was created within the Department of Agriculture. This move represented the earliest attempt to address food-related issues, and it helped lead to the founding of the Food and Drug Administration several decades later.
The post-Civil War era would see the appointment of the first Supervising Surgeon (later called Surgeon General) in 1871 for the Marine Hospital Service; the opening of a one-room laboratory on Staten Island for research on disease (the forerunner to the National Institutes of Health); and passage in 1891 of legislation that made the Marine Hospital Service responsible for medical examination of arriving immigrants.
Shortly after the turn of the 20th Century, the Public Health Service was officially established in 1902, and four years later, Congress passed the Pure Food and Drugs Act authorizing the government to monitor the purity of foods and the safety of medicines (another key step that led to the founding of the FDA).
The era following World War I witnessed the creation of two important offices that would later become part of the health and human services department: the Bureau of Indian Affairs Health Division in 1921 (later to become the Indian Health Service); and the National Institute (later Institutes) of Health in 1930.
In response to the economic downturn of the Great Depression, President Franklin Roosevelt’s New Deal brought about several important policy decisions that had long-term impacts on government health programs. The first was the passage of the Social Security Act in 1935, without which future programs like Medicare and Medicaid would not have been possible. In 1938, Roosevelt and Congress adopted the Federal Food, Drug and Cosmetic Act of 1938, which led to the establishment of the FDA. And in 1939, Roosevelt pushed for the formation of the Federal Security Agency, which brought together federal activities in the fields of health, education and social insurance under a single cabinet-level authority.
Although the Federal Security Agency did not last, its founding demonstrated a need to make health matters a top priority for federal policymakers. Subsequently, the Eisenhower administration established a successor - the Department of Health, Education and Welfare in 1953. The 1950s and 1960s would constitute a time of important health policy decisions by federal officials. In 1955, the polio vaccine created by Jonas Salk was licensed, helping lead to the elimination of the crippling disease.
In 1961, the Kennedy administration conducted the first White House Conference on Aging. The following year, Congress adopted the Migrant Health Act that provided support for clinics serving agricultural workers. In 1964, the Surgeon General released the first report on smoking and health, which launched a new debate on the dangers of a previously unquestioned habit enjoyed by millions of Americans. Even more dramatic was the decision in 1965 to create the Medicare and Medicaid programs, which for the first time made comprehensive health care available to millions of Americans. That same year, the Older Americans Act created the nutritional and social programs administered by today’s Administration on Aging. The Head Start program was also created. In 1966, the Public Health Service launched the International Smallpox Eradication program that would lead to the complete elimination of the disease by 1977.
The late seventies saw the Carter administration remove education from the Department of Health, Education and Welfare (creating the Department of Education) and form the Department of Health and Human Services.
Historical Highlights of Health and Human Services
The Department of Health and Human Services (HHS) is a cabinet-level agency that manages a wide array of health and welfare programs. HHS is responsible for regulating food products and new pharmaceutical drugs (Food and Drug Administration), implementing the nation’s biggest health care programs (Medicare and Medicaid), preventing the outbreak and spread of diseases (Centers for Disease Control and Prevention) and funding some of the most important medical research in the world (National Institutes of Health), among other programs.
HHS’ primary offices are as follows:
Services
Centers for Medicare and Medicaid Services CMS is the federal body responsible for administering Medicare and Medicaid programs. CMS also runs the State Children’s Health Insurance Program (SCHIP), which is jointly financed by the federal and state governments and administered by individual states.
Medicare is a federal social insurance program established in 1965 to provide healthcare coverage for people over 65. The program was expanded in 1972 to include people under 65 with permanent disabilities. Most Americans are entitled to basic coverage under Medicare if they or their spouse have contributed payroll taxes for more than 10 years. Medicare is financed by payroll taxes, FICA and the Self-Employment Contributions Act of 1954. Medicare currently covers more than 40 million people, but with significant coverage gaps—in vision, dental and long-term care. Accounting for a current 14% of the federal budget, Medicare is a highly debated system that draws bipartisan criticism. The gradual privatization of the system—including recently reformed prescription drug coverage—is also highly contested among advocates, lawmakers and lobbyists.
Medicaid is a complex entitlement program for many people who can’t afford adequate health care, including single parents and their children, the disabled and the elderly (some of whom also receive Medicare benefits as so-called “dual eligibles”). It is funded as a joint venture by states and the federal government, with each state determining the exact scope of its program, payment rates and specific eligibility standards. The federal government, meanwhile, establishes general guidelines for the programs and monitors their enforcement through the Centers for Medicare and Medicaid Services (CMS). Participation is voluntary; however, every state has been signed up since the last holdout, Arizona, created its Medicaid variant in 1982. The major sticking point for Medicaid can be summed up in one word: money. Many people view with alarm the gradually escalating costs associated with the program, and some states have had to devote as much as one-fifth of their budgets to sustaining it. Fraud is also a major issue. Medicaid reform of some kind or another is therefore a perennial item on the political agenda.
Administration for Children and Families ACF is a key division within the Department of Health and Human Services.ACF oversees and finances social and economic programs for vulnerable children and families designed to help them develop more independent, self-reliant lives. Targeted groups include Native Americans, persons with developmental disabilities, refugees and legalized aliens. Programs are carried out by state, county, city and tribal governments, as well as public and private local agencies. Critics argue that ACF, a relatively new administration, has been deployed as a forum to push the Bush administration’s more conservative initiatives—funneling money to (discredited) abstinence-only programs and marriage promotion grants.
Health Resources and Services Administration HRSA is responsible for improving access to healthcare for those who are uninsured or otherwise marginalized and/or medically vulnerable. The agency identifies areas of the country that have a shortage of primary and dental care and medical professionals. HRSA administers about 90% of its funding in the form of grants directly to states and public and private healthcare providers, including health professions training programs and a network of 1,000 health clinics.
Indian Health Service IHS provides preventive, curative and community health care to approximately 1.9 million of the nation’s 3.3 million American Indians and Alaska Natives. IHS currently provides health services to approximately 1.5 million of these American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 35 states. IHS services are administered through a system of 12 Area offices and 163 IHS and tribally managed service units. According to US Census data, American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (750% higher), alcoholism (550% higher), diabetes (190% higher), unintentional injuries (150% higher), homicide (100% higher) and suicide (70% higher).
Substance Abuse & Mental Health Services Administration SAMHSA makes grants to various agencies to prevent and treat addictive and mental disorders and furthers its work through public campaigns, system reform, policy and program analysis. SAMHSA seeks to improve the quality and availability of prevention, treatment and rehabilitation services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses. At times the agency has taken public stances on controversial issues, such as treatment of heroin addiction and homosexuality and transgender identity.
Administration on Aging AoA is the official federal agency responsible for home and community-based services and programs related to aging. It also focuses on helping empower Americans before and during their later years to make informed decisions about health care options; ensuring the rights of the elderly to prevent their abuse, neglect and exploitation; and facilitating society to prepare for an aging population. AoA, funded by the Older Americans Act, is part of a federal, state, tribal and local partnership called the National Network on Aging, which currently helps about seven million older people and their caregivers, via 29,000 service providers and thousands of volunteers.
Research
National Institutes of Health NIH produces some of the most important medical and scientific research in the United States. Eighty three percent of NIH’s funding is distributed to scientists, medical researchers and university professors both in the US and abroad. NIH also conducts its own research at its 27 institutes and centers. Some of NIH’s researchers have been criticized for accepting money from pharmaceutical companies, while its leader has publicly criticized the policies of President George W. Bush.
Centers for Disease Control and Prevention CDC leads public health efforts to prevent and control infectious and chronic disease, injuries, workplace hazards, disabilities and environmental health threats. It is also responsible for producing and distributing health information internationally. While the CDC is globally recognized for its scientific research and epidemiologic investigations, newly-emerging issues such as terrorism, environmental threats and a rapidly aging population continue to challenge its capabilities. Although the CDC is supposed to prevent and control infectious disease, it has been accused of blatantly withholding information regarding such diseases as syphilis, autism and Guillain-Barré Syndrome.
Agency for Healthcare Research and Quality AHRQ sponsors research to improve the quality of health care in the United States. The agency works to elevate health care quality, reduce medical-related costs and expand healthcare access for more Americans. Almost 80% of AHRQ’s budget is awarded as grants and contracts to researchers at universities and other research institutions across the country. Early in its history, the agency became heavily involved in a controversial healthcare reform plan that almost led to AHRQ being eliminated. Since then, the agency has maintained a low profile, void of controversy.
National Toxicology Program NTP is an interagency program that provides data addressing a wide variety of issues important to public health. NTP works to safeguard public health by identifying the effects of chemicals used in everyday items and at what level of exposure they have the potential of becoming hazardous to humans. NTP has attracted controversy because of its policy of allowing some industries to self regulate their own products and because of its extensive use of animals for testing.
Agency for Toxic Substances and Disease Registry ATSDR is a federal public health agency under the umbrella of the Centers for Disease Control (CDC) based in Atlanta, Georgia. The agency’s mission is to prevent harm to human health and diminished quality of life from exposure to hazardous substances found at waste sites, in unplanned releases and in other sources of pollution present in the environment. ATSDR identifies communities where people might be exposed to hazardous substances in the environment. But as far as investigations go, ATSDR cannot enforce any regulations by closing down a plant or other business. It can only make recommendations to the Environmental Protection Agency. The ATSDR has worked on a variety of different cases and projects, including aiding New York City in establishing a registry to assess short and long term health effects from the World Trade Center collapse, sampling the dust and air after the collapse of the World Trade Center, testing the water and soil at Camp Pendleton for lead, copper and other chemicals, as well as monitoring the effects of asbestos and identifying sites that have high concentrations of it.
Regulation
Food and Drug Administration
FDA regulates a wide range of medical and food products. From reviewing new medicines to inspecting food processing centers, the FDA plays a role in approximately $1 trillion worth of products each year. The FDA is comprised of chemists, pharmacologists, physicians, microbiologists, veterinarians, pharmacists, lawyers and other professionals. Despite all of the expertise employed by the agency, the FDA has struggled to carry out its mission to protect Americans from harmful drugs and foods. In recent years, the agency’s reputation has plummeted amid controversies involving the approval of certain pharmaceutical drugs and allowing tainted foods to reach consumers.
According to USAspending.gov, the Health and Human Services Department has spent $67.4 billion so far this decade on contractors totaling 50,858. The biggest expenditures were for drugs and biologicals ($4.8 billion), computer and telecommunications services ($3.8 billion), biomedical basic research ($3.7 billion) and laboratory equipment and supplies ($3.1 billion).
The biggest spenders among HHS departments were the National Institutes of Health ($26.2 billion), the Centers for Disease Control and Prevention ($14.6 billion) and the Centers for Medicare & Medicaid Services ($7.95 billion).
The top 10 recipients of HHS dollars include major pharmaceutical companies and defense contractors:
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SAIC, Inc.
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$2,863,414,838
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Merck & Co.
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$2,384,650,585
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Westat, Inc
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$2,117,195,587
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Sanofi Pasteur MSD SNC Sigle SPMSD
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$1,681,527,521
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GlaxoSmithKline
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$1,392,443,263
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Wyeth
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$1,170,849,726
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Research Triangle Institute Inc
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$1,156,129,714
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Lockheed Martin
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$1,045,138,008
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Northrop Grumman
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$966,528,985
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Veritas Capital Fund II, LP
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$809,789,386
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Other contractors include High Performance Technologies, which received a $50 million contract in 2006 to provide information technology services to the Food and Drug Administration. Kaiser Permanente, United Health Group Inc., Vanderbilt University and Harvard Pilgrim Health Care won first-of-their-kind contracts from the FDA to help research the effects of pharmaceuticals on large patient populations after drugs go on the market. Each contractor will get $1.3 million over the next five years to provide data to the FDA from their databases.
Some HHS funding is distributed in the form of research grants. The NIH is a prime distributor of such moneys to
higher education
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hospitals
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medical schools
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research institutions
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non-profits
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Health Officials and FEMA Trailers
When the federal government failed to respond adequately to the destruction leveled on New Orleans by Hurricane Katrina, the Federal Emergency Management Agency (FEMA) took the brunt of the criticism. However, FEMA was not the only department to be dressed down by Congress. After FEMA decided to distribute thousands of mobile home trailers to those left homeless by the disaster, health officials at the Agency for Toxic Substances and Disease Registry (ATSDR) failed to alert officials about the presence of formaldehyde in the trailers.
The chemical, used in interior glue, was detected in many of the 143,000 trailers sent to the Gulf Coast in 2006. Residents of the FEMA trailers reported breathing difficulties, persistent flu-like symptoms, eye irritation, and nosebleeds. Tests on a number of FEMA trailers by the Sierra Club showed that 83% had levels of formaldehyde in the indoor air at levels above the Environmental Protection Agency recommended limit.
In April 2008, the House Committee on Science and Technology’s Subcommittee on Investigations and Oversight held hearings into how and why ATSDR failed to protect public health when those trailers were found to be emitting dangerous levels of formaldehyde. At the hearing, it was revealed that Dr. Christopher De Rosa, a leading government expert on formaldehyde, had tried to alert his superiors about the toxicity levels of the government trailers in New Orleans but was repeatedly ignored. Ultimately, he was demoted. His superiors later admitted that they should have followed his advice, but they did not address why they “reassigned” him to a new position.
Bush SCHIP Guidelines
In April 2008 the GAO challenged new guidelines handed down by the Bush administration regarding the State Children’s Health Insurance Plan (SCHIP). In a letter issued directly to states, the new rules prohibited states from using federal funds to cover children in families 250% or more above the poverty line ($53,000 for a family of four) until almost all children under 200% of poverty ($43,000) were covered.
The GAO said the administration illegally bypassed Congress to issue the rules, which constituted a policy change. The Bush administration refuted the GAO opinion and planned to ignore its recommendations. The conflict sprang from a long-standing debate between an administration that wants to cut federal healthcare spending and push towards privatization, and a Democratic Congress seeking to increase spending in response to rising medical costs and diminishing benefits coverage.
White House Suppresses CDC Data on Global Warming
In October 2007, officials with the Centers for Disease Control and Prevention (CDC) testified before Congress on the effects of global warming - only what they said was first edited by the White House. Portions were deleted that mentioned diseases that could prosper due to global warming. Altogether six pages were removed from the original twelve-page draft including mention of specific health concerns caused by climate changes.
The edited version stated that “climate change is anticipated to have a broad range of impacts on health of Americans and the nation’s public health infrastructure.” However the original statement said that “the public health effects of climate change remain largely unaddressed” was removed, and the testimony mainly focused on the preparedness of health agencies with general problems.
Medicare, Medicaid Funds Misspent
In 2007 the Government Accountability Office (GAO) reported that 9%, or about $90 million of the $1 billion that Congress appropriated to the Centers for Medicare And Medicaid Services during implementation of the 2003 Medicare Modernization Act was spent on “numerous questionable payments.” The GAO raised questions regarding contractor oversight, wasteful contracting practices, contract terms, internal control deficiencies and backlogs.
Medicare Prescription Drug Reform
In 2003, the Republican-controlled Congress and the Bush administration pushed through one of the most important and controversial changes to Medicare in the history of the program. Supporters and opponents of Medicare were not happy with the final product.
Critics decried the “huge costs” of the new law that called for privatizing the Medicare system. Medicare advocacy groups disparaged the legislation, calling it the “beginning of a battle over the soul of the Medicare program.”
Adding to the firestorm was a report by Public Citizen (based on analysis of federal lobbying disclosure records) that uncovered massive special interest lobbying from pharmaceutical and managed care industries, including a combined expenditure of $141 million and 952 individual lobbyists in 2003 - or nearly 10 lobbyists for each US Senator. Nearly half of these hires had “revolving door” connections to Congress, the White House or the executive branch.
The centerpiece of the 2003 legislation was a voluntary entitlement program for prescription drugs under “Program D,” funded by tax breaks and subsidies. The overhaul provided for issuance of discount prescription drug cards in 2004, preventative benefits in 2005 and implementation of the prescription drug plan in 2006.
A month after the 2003 bill was signed, its 10-year cost estimate rose to $534 billion - more than $100 billion more than the figure presented to lawmakers by the Bush administration during deliberations. The lower figure helped garner unlikely support from Republicans who had promised to vote against the bill if costs were over $400 billion. A Salon.com article reported that the Administration had intentionally withheld the higher estimate - and that an official threatened to fire Medicare Chief Actuary Richard Foster if he revealed the real figure. By early 2005 the budget had risen to a 10-year estimate of $1.2 trillion.
Time to Rethink the Disastrous Medicare Legislation
(by Stuart M. Butler and Robert E. Moffit, Heritage Foundation)
Morning-After Pill
For three years HHS officials found themselves in the middle of a hotly-debated issue over allowing pharmaceutical companies to sell so-called “morning after” pills without a prescription. The debate began when Barr Pharmaceuticals filed for permission to sell its Plan B pill over the counter to women of all ages. The pill had been available as a prescription-only drug since 1999. Plan B prevents pregnancy by stopping the ovary from releasing an egg and may also prevent fertilization, if taken within 72 hours after having sex.
When the Food and Drug Administration first balked at approving Plan B, the decision came as a surprise because a panel of independent experts assembled by the FDA voted to recommend that the drug be sold over the counter. The majority concluded that the drug was not only effective, but that women could be trusted to use it correctly without a doctor. The FDA normally followed the recommendations of its advisory panels.
Barr Pharmaceuticals then revised its application to sell Plan B to consumers 16 and older. The FDA countered by saying 17 and older was okay, then rescinded that plan and raised the age restriction to 18 and up. At one point, a top FDA scientist resigned in protest over what she claimed was political interference in the approval process. Susan F. Wood, assistant FDA commissioner for women’s health and director of the Office of Women’s Health, said she left because then-Commissioner Lester M. Crawford acted on instructions from within the administration to stall Plan B’s approval. Crawford himself wound up leaving the FDA before the controversy was resolved, which led to a delay in a replacement taking over because Plan B supporters in Congress held the nomination hostage as leverage to force the Bush administration to grant FDA approval.
Those involved in the Plan B debate mirrored many of the same groups involved in the debate over abortion.
For
Supporters of the effort to allow over-the-counter sales of “morning after” pills included many Democrats in Congress, including US Senators Hillary Rodham Clinton and Patty Murray. Other supporters included pro-choice advocates, liberal women’s organizations and even some FDA scientists. They claimed there was no harm in removing the prescription requirement for Plan B and other pills like it, since the FDA had already vetted the medication when it was first approved for sale in the late 1990s. Allowing the pills sales without a prescription would help reduce unwanted pregnancies and, thus, abortions, argued proponents.
Against
Opponents of allowing non-prescription sales of morning-after pills included Concerned Women for America, a conservative women’s organization, American Association of Physicians and Surgeons, Family Research Council, Safe Drugs for Women, religious organizations and many Republicans. President Bush never publicly opposed FDA approval of Plan B, but some suspected that the President may have exerted pressure on the agency to delay its decision. Many opponents were opposed entirely to morning-after pills, with or without a prescription, because of their belief that pregnancy begins with the fertilizing of the egg - thus, Plan B represented just another form of abortion. Opponents also claimed that non-prescription use of Plan B would create a public health hazard by causing an increase in sexually transmitted disease.
Background
FDA Sued Over Unlawful Approval of Morning-After Pill: Coalition of medical professionals and family groups ask court to reverse FDA's decision
(Life Site News)
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