American College of Preventive Medicine
Policy Committee Report
March 2000

Chair: Bob Harmon
Staff: Mike Barry/Jessica Cafarella  
 

1.0      CONTINUING ISSUES

1.1            Preventive Medicine Residency Funding

ACPM continues to monitor the implementation of the Balanced Budget Act of 1997 with respect to funding for preventive medicine residency programs.

1.1.1   HRSA Title VII /VIII Funding

The administration’s Fiscal Year 2001 budget proposal includes a total of $298 million for health professions programs.  Despite strong support from the Health Resources and Service Administration (HRSA), the administration has proposed eliminating preventive medicine residency funding under Title VII of the Public Health Service Act.  While overall funding for public health workforce development was maintained at FY 2000 levels ($8.1 million), all public health funds under Title VII were dedicated toward creating Public Health Training Centers to improve the competence of the public health workforce.  (A summary of the Health Professions Education budget can be found at http://www.aamc.org/advocacy/ issues/approps/hped01.htm).

In response to the preventive medicine residency funding cut in the FY 2001 budget proposal, ACPM made visits to several congressional offices along with the Health Profession and Nursing Education Coalition (HPNEC) to emphasize the importance of preserving preventive medicine residency funding.   ACPM also initiated a letter writing campaign to Congress by posting an action alert on the listserv of preventive medicine residency directors (see Attachment A for the Action Alert).  The College asked both the residency directors and residents themselves to write letters supporting an appropriation of $50 million in FY 2001 for preventive medicine and public health programs administered under Title VII of the Public Health Service Act.

ACPM also wrote letters to House L-HHS-Ed Appropriations Subcommittee Chairman Porter (R-IL) and Senate L-HHS-Ed Appropriations Subcommittee Chairman Specter (R-PA) thanking them for their past support of preventive medicine residency funding and stressing the need for continued funding (see Attachment A for a copy of the Specter letter and ACPM ’s official statement on Title VII funding). ACPM additionally signed on to a statement prepared by HPNEC urging a funding increase.

1.1.2  Medicare GME Funding

Even with the GME changes made in the Balanced Budget Act (i.e., payment to non-hospital based sites), Medicare GME funds have remained largely unavailable to preventive medicine programs because such funds are only available in patient care settings. No congressional action on Medicare GME is expected this year.

The Medicare Payment Advisory Commission (MedPAC) did not address the potential effects of combining Medicare’s two medical education payments as it had been expected to do in its March 2000 report to Congress.   ACPM has been in contact with MedPAC staff and will update the Policy Committee when MedPAC reports on the issue.

1.2      Tobacco Control

ACPM continues to stay active in the effort to implement strong national policies and legislation to curb tobacco use, including active participation in the ENACT (Effective National Action to Control Tobacco) Coalition — an alliance of over 50 national medical and grassroots organizations.

ENACT has identified five priorities for FY 2001 that ACPM signed on to earlier this year: 1) funding for tobacco prevention at the CDC, FDA, and DOJ; 2) regulating tobacco through the FDA; 3) youth smoking assessments; 4) tobacco tax increase; and 5) regulating Internet sales of tobacco products. 

1.2.1        Funding for Tobacco Prevention

ENACT urges Congress to increase funding for tobacco prevention programs at the Centers for Disease Control and Prevention to $130 million and funding at the Food and Drug Administration to $39 million.  ENACT also continues to support the Department of Justice lawsuit against tobacco companies.   ACPM has made Hill visits stressing the importance of funding the fight against tobacco.   ACPM also is a member of the ENACT appropriations taskforce pushing for funding of anti-tobacco efforts.

1.2.2   Regulating Tobacco Through the FDA

A decision is expected in the late spring of 2000 on the appellate court ruling regarding the FDA’s authority to regulate tobacco sales and marketing.  In the event that the Supreme Court strikes down FDA’s jurisdiction over tobacco products, ENACT will urge congressional action to provide the FDA authority to oversee tobacco products and tobacco manufacturers.

1.2.3   Youth Smoking Assessments

Youth smoking assessments, formally known as “Lookback Legislation,” establish targets for reductions in youth smoking rates and impose financial assessments against tobacco companies if the targets are not reached.   ACPM is a member of ENACT’s youth smoking assessment task force and works with several other organizations to assure smoking assessments remain a legislative priority.

1.2.4        Tobacco Tax Increase

ENACT supports the Administration’s call for an increase in the tobacco excise tax of 25 cents per pack of cigarettes.  The Institute of Medicine of the National Academy of Sciences and a National Cancer Institute panel have both stated that increased tobacco prices may be the single most effective deterrent to tobacco use.  ENACT is working to increase tobacco taxes by distributing a pamphlet on the efficacy of increasing tobacco prices during FY 2001 Hill visits.

1.2.5        Internet Sales of Tobacco Products

Internet tobacco sales have grown exponentially.  The ENACT coalition believes that Congress should take action to ensure that the Internet is not used to circumvent state and federal laws governing the sale and distribution of tobacco products.  ENACT supports H.R. 2914 sponsored by Rep. Marty Meehan (D-MA) that requires Internet tobacco sellers to develop a system to verify the age of the buyer at delivery.  ENACT also is working to get tobacco added into legislation (H.R. 2031) restricting the sale of alcohol over the Internet.

1.3            Medical Privacy

HHS ’ draft regulation on “Standards for Privacy of Individually Identifiable Health Information” was published in the November 3, 1999 Federal Register, with public comments due by February 17, 2000 .  (Additional information on the proposed regulation can be found on the Department of Health and Human Services’ web site at http://aspe.hhs.gov/admnsimp/).

ACPM submitted official comments on the privacy regulation in February 2000 expressing its overall support of the privacy regulation and highlighting areas of concern to the College (see Attachment B for a copy of ACPM ’s comments).  In advance of submitting comments, ACPM attended HHS’ briefings on the proposed regulation, hosted by the American Medical Association and attended by national medical specialty societies.  In its comments, ACPM stressed the research value of retaining the ability to re-link patients with certain information that is not identifiable under the proposed regulation (e.g., date of birth, geographic region of residence). ACPM also argued that allowing state laws to preempt the proposal federal regulation could prove a major stumbling block to multi-center research studies.  The final privacy regulation is expected from HHS later this year.

1.4            Antibiotic Resistance

The issue of reducing the prevalence of antibiotic resistance in humans through banning the subtherapeutic uses of antibiotics in livestock is an ongoing issue for ACPM that was addressed at the November 1999 Policy Committee meeting.  At the meeting, the Policy Committee discussed the position statement of the Council of State and Territorial Epidemiologists (CSTE) on infectious diseases, which addressed the issue of animal feed and antibiotic resistance (see Attachment C for a copy of the CSTE statement).  The statement was circulated to the Committee following the meeting and was supported by all responding committee members.  A copy of the position statement has been included in the materials for the March 23, 2000 , Board of Regents meeting, at which time the Board will be asked to adopt CSTE’s position statement as official ACPM policy.

1.5            Universal Access Statement

At the November meeting, ACPM endorsed the policy statement on universal access to health insurance developed by the AMA and six other specialty groups.  The Board supported the Policy Committee’s recommendation that ACPM draft a cover letter urging a shift in focus from insurance to access, coverage for other preventive services, and strategies for funding the proposal. ACPM signed on to the policy statement and is in the process of drafting a follow-up letter emphasizing the prevention angle suggested by the committee.

1.6            Coverage of Preventive Services

1.6.1        Medicare Wellness Act

In September 1999, Senator Bob Graham (D-FL) introduced the Medicare Wellness Act of 1999 (S. 1618) to add several new preventive benefits to the Medicare program —including screening and/or counseling for hypertension, tobacco, glaucoma, hormone replacement, vision and hearing, osteoporosis, and cholesterol.  (A complete copy of the Medicare Wellness Act can be found at http://thomas.loc.gov/cgi-bin/query/z?c106:S.1618:).  At the November 1999 meeting, the Policy Committee recommended ACPM write a letter endorsing the legislation.  The committee agreed that the letter should advocate for an associated drug benefit as well as a focus on high priority preventive issues.  The Board endorsed the committee’s recommendation.

Congress did not take action on the Medicare Wellness Act last year.  However, ACPM has learned that the Medicare Wellness Act was scheduled to be re-introduced at a press conference March 8, 2000 .  Prior to the re-introduction, Sen. Graham’s office informed ACPM that the act would be revised to incorporate a nutrition therapy benefit for people with renal disease, diabetes, and cardiovascular disease, as recommended by a December 15, 1999 Institute of Medicine report.  Graham’s office also indicated that the act also would be supported by Rep. Sander Levin (D-MI) and Rep. Mark Foley (R-FL).   ACPM will draft a letter to Sen. Graham and Reps. Levin and Foley following re-introduction of the Medicare Wellness Act.

1.6.2  Other Coverage Issues

ACPM has been monitoring the issue of Medicare prescription drug coverage.  President Clinton is proposing to allocate $400 billion from the projected federal government surplus to cover prescription drugs and restructure Medicare to extend the program’s solvency past 2025.  This allocation still is short $168 billion over ten years that the Congressional Budget Office has said would be needed to add prescription drug coverage. ACPM will continue to support Medicare prescription drug coverage and seeks guidance from the Policy Committee on if and how to best stay involved in Medicare reform.

The Medicare Coverage Advisory Committee (MCAC) is another potential mechanism through which prevention issues can be addressed.   ACPM Policy Committee members Ron Davis and Halley Faust serve on MCAC.  MCAC was established by the Health Care Financing Administration in 1998 to provide independent expert scientific advice to HCFA in its evaluation of Medicare coverage and to help the agency make sound decisions based upon good science.   ACPM will continue to monitor MCAC on upcoming issues as a means of identifying important preventive service coverage issues.

1.7            Appropriations

The administration released its FY 2001 budget proposal on February 7, 2000 .  The administration’s proposal includes a 3 percent increase in funding to the Health Resources and Services Administration (HRSA), up from $4.7 billion in FY 2000 to $4.8 billion in FY 2001.  The proposal also includes a $1 billion (5.6 percent) increase for the NIH, with a total budget appropriation of $18.8 billion.  A bipartisan group of Senators, led by Senate L-HHS-Ed Appropriations Subcommittee Chairman Arlen Specter has introduced a “sense of the Senate” resolution that supports the continued drive toward doubling the NIH budget.  S. Res. 253 introduced February 7 states that funding for the NIH should be increased by $2.7 billion in FY 2001.  The CDC’s budget under the administration’s FY 2001 proposal is $3.5 billion, an increase of approximately 7.5 percent from FY 2000 funding levels of $3.3 billion. (More comprehensive information from the administration’s FY 2001 budget proposal, including organizational tables, can be found at www.aamc.org/advocacy/issues/approps/start.htm).

ACPM has been actively lobbying as a member of the Coalition for Health Funding, CDC Coalition, Friends of HRSA, and HPNEC for appropriations that support preventive medicine activities.

ACPM has learned that the House and Senate Budget Committees announced an agreement on a FY 2001 budget resolution that includes a $10.5 billion increase over last year’s funding level in discretionary defense and domestic programs.  The President’s budget request was $37 billion more than FY 2000.  No details on the agreement were available at the time of this writing, other than much of the additional dollars will support higher defense spending.  There is considerable support, however, for adding $2.7 billion in funding for NIH as the third down payment in doubling that agency’s budget in five years.   ACPM also learned that the House and Senate were completing mark-ups of the supplemental appropriations bill that would repeal the delayed obligations for NIH, CDC, and other public health agencies.  In one final development, the House Rules Committee has held two of three planned hearings on the pros and cons of biennial budgeting.  From a public health perspective, locking in funding for programs in two-year increments could hurt growth and limit responsiveness to changing needs if funding is too low.  For analysis of the biennial appropriations process, go to http://www.cbpp.org.

2.0      EMERGING ISSUES

In the past four months, ACPM has become involved in or initiated dialogue around several emerging issues of importance to the preventive medicine community.  Below are brief descriptions of these issues and ACPM involvement to date.

2.1            Patient Safety

Patient safety issues were near the top of the public policy agenda in late 1999 with the release of the Institute of Medicine report on medical errors, “To Err is Human: Building a Safer Health System.”  The report estimated that anywhere from 44,000 to 98,000 Americans die each year because of medical errors.  The IOM recommended a four-tier approach to reducing medical errors, including establishing a national focus on medical errors, mandatory error reporting, increased standards for safety, and creating safety systems inside health care organizations (see Attachment D for a copy of the IOM recommendations).  (A copy of the release on this report can be found at http://www4.nationalacademies.org/news.nsf/isbn/0309068371?OpenDocument).

In February, President Clinton unveiled his plan for improving patient safety, which called for a nationwide system of reporting medical errors, somewhat like the system used by airlines to report aviation safety hazards.  The President also endorsed virtually all other recommendations made in the IOM’s report, including the goal of reducing medical mistakes by 50 percent over 5 years.  The President asked Congress for $20 million to create a Center for Quality Improvement and Patient Safety, as part of the Agency for Healthcare Research and Quality in HHS.  He urged states to adopt their own reporting requirements within three years.

Congress has held several hearings during the current session on the issue of patient safety.  Legislation introduced February 8 by Sens. Arlen Specter and Tom Harkin (D-IA) would establish grant programs for states to develop systems for collecting medical error data.  Reports collected by the states would be forwarded to federal researchers who would analyze the causes of error and propose solutions.  The legislation also would establish fifteen voluntary demonstration programs on error reporting.

The AMA, the American Hospital Association, and other health associations have opposed mandatory reporting of errors, saying it could expose doctors and hospitals to more lawsuits and that doctors and hospitals will be reluctant to discuss the lessons that could be learned from their mistakes.

ACPM recently attended briefings on patient safety at the AMA.   ACPM also has fostered discussion of patient safety on its newly-created Policy Committee listserv and received feedback that this is an area in which ACPM should become involved.

2.2      Obesity/Nutrition

The fight against obesity in our nation is a growing challenge that impacts prevention of many other diseases and medical conditions.   ACPM recently has joined the National Alliance for Nutrition and Activity as one of 65 member organizations that will work to implement measures aimed at curbing obesity and encouraging healthy eating/lifestyles.   ACPM also is working with members of the Policy Committee to submit comments on the draft “Dietary Guidelines for Americans” published jointly by HHS and the U.S. Department of Agriculture.  Comments on the guidelines are due March 15.

2.3           Gun Safety

The visibility of gun violence and school shootings in the media this past year once again raises the question of whether ACPM should become active in the issue of gun safety.   ACPM seeks guidance from the Policy Committee on the relative importance of this issue and whether ACPM should take an active policy stance (see Attachment E for the ACPM Draft Policy Guidelines on Gun Violence).   ACPM recently signed on to the Alliance for Justice’s First Monday 2000 campaign on gun safety, which shows a short film on gun violence at campuses and in communities to help encourage advocacy for gun safety.

2.4      Workforce Development

In recent months, several ACPM members have expressed concern that preventive medicine and public health qualifications often are of little value when applying for positions that should be enhanced by clinical and population medicine skills.  A challenge that has been raised is how members of the preventive medicine community should present themselves to potential employers so employers will specify physicians with preventive medicine training when recruiting for positions that could best be done by preventive medicine physicians.

ACPM has asked Policy Committee members via its listserv whether there are policy initiatives that could be taken by ACPM and other national organizations representing public health physicians to make preventive medicine qualifications and experience more attractive to the job marketplace.  Responses have been mixed. ACPM hopes to continue this discussion with the Policy Committee at its March meeting.  The committee also will be asked to consider a job market resolution drafted by committee member Joel Nitzkin (see Attachment F for a copy of the job market resolution).

3.0           Informational Items  

3.1     Food Safety

ACPM attended a briefing at the Food and Drug Administration January 13, 2000 to discuss the “Food Safety Strategic Plan” drafted by the President’s Food Council.  (Information on the FDA’s complete food safety initiative can be found at http://vm.cfsan.fda.gov/~dms/fs-toc.html).   ACPM also submitted comments in February to the FDA on the Food Safety Strategic Plan (see Attachment G for ACPM ’s comments).

3.2            Folic Acid Fortification

At its November meeting, the Policy Committee recommended ACPM write a follow-up letter to the FDA presenting additional evidence on the need to strengthen the FDA standard on folic acid fortification to prevent neural tube defects.  In addition, the committee recommended ACPM form a strategic alliance with other appropriate organizations to push the issue.   ACPM recently submitted the letter to the FDA Commissioner (see Attachment H for a copy of the letter).  Also, ACPM joined the National Council on Folic Acid, which is committed to the cause of reducing birth defects by promoting the consumption of folic acid among women of childbearing age.

3.3            Prostate Cancer

At the November 1999 meeting of the Policy Committee, committee members were given a copy of the draft joint statement on prostate cancer screening developed by the American Cancer Society, ACPM , the American Academy of Family Physicians, and the American College of Physicians.  The draft also was reviewed by the Practice Guidelines Committee and the Board, although few comments were received.  A copy of the draft will be redistributed to the Policy Committee under separate cover for comment.  ACS, AAFP, and ACP have yet to take action on the joint statement since November 1999, affording ACPM the opportunity to submit comments before the statement is finalized.

3.4            Clinical Research Enhancement Act

The Clinical Research Enhancement Act (S. 1813) was introduced by Senators Bill Frist (R-TN), James Jeffords (R-VT), and Edward Kennedy (D-MA) in FY 2000.  (Full bill text for S. 1813 can be found at http://thomas.loc.gov/cgi-bin/query/z?c106:S.1813:). The CREA amends the Public Health Service Act to provide additional support for and to expand clinical research programs.  It is designed to create funds for training and infrastructure that will support health professionals who want to pursue careers in clinical investigation.  The CREA passed the Senate under a unanimous consent agreement November 19, 1999 and was passed to the House for consideration in FY 2001.

Earlier this year, ACPM endorsed a letter drafted by the American Federation for Medical Research to House Commerce Committee Chairman Thomas Bliley (R-VA).  The letter called on the Commerce Committee to support discharge of the CREA from the Commerce Committee so that it could be considered by the House.  At the time this report was written, no action had been taken on CREA by the Commerce Committee.  AFMR was holding Hill visits with Chairman Bliley to discuss the issue.   ACPM will continue to support CREA and work with the AFMR to stress its importance to Congress.

3.5            Drug and Alcohol Safety

ACPM has signed on to a letter drafted by the National Council on Alcoholism and Drug Dependence supporting legislation (H.R. 3413) introduced by Representative Lois Capps (D-CA) that would authorize $25 million for community and school (including college) based programs to prevent underage drinking.

3.6            Anthrax

In February 2000, a House subcommittee recommended that the Pentagon suspend its program requiring all 2.4 million military personnel to receive a vaccine against the deadly germ anthrax.   ACPM solicited responses from its Policy Committee members via the listserv on whether ACPM should weigh in on the congressional report.  It appeared to be the consensus of the committee members that, until there is more evidence-based research in the area, ACPM should continue to monitor the issue without comment. ACPM has formed an expert panel on the anthrax vaccine for future consultation.

4.0           OTHER ACPM ACTIVITIES

4.1      AMA House of Delegates

ACPM was an active participant in the Annual Meeting of the AMA House of Delegates (HOD) in December, 1999.   ACPM continued its role in staffing the Section Council on Preventive Medicine, which provides a caucus for the preventive medicine specialty organizations to have a voice in AMA policy making.  In conjunction with the HOD meeting, ACPM facilitated a meeting of a small group of Section Council representatives to refine the Council's Rules and Operating Procedures.

In addition to advocating for policies that affect preventive medicine, ACPM sponsored two resolutions at the HOD meeting.  One called for the AMA to initiate discussions with appropriate national and state organizations and individuals about launching a multi-state effort to use ballot initiatives to direct allocation of tobacco settlement funding for tobacco prevention, cessation, and treatment for related disorders.  This resolution easily passed the House.  The second resolution, developed by ACPM 's Young Physician Section, called for AMA to endorse criteria for evaluating the quality of health information on the Internet.  That resolution was referred to the AMA Board of Trustees.

4.2      Coalitions and Committees

By participating in several coalitions, ACPM is able to more closely monitor policy activities of federal agencies and national organizations in areas of interest to preventive medicine and more easily form strategic alliances with these organizations.  The Coalitions in which ACPM participates or supports include: Effective National Action to Control Tobacco (ENACT), Partnership for Prevention, Friends of HRSA, CDC Coalition, Health Professions and Nursing Education Coalition, the Coalition for Health Funding, AAMC Ad Hoc Group for Medical Research Funding, National Environmental Health Coalition, Friends of NIOSH, Friends of A HCP R, Partners for Annual Pap Smears, the Coalition for Consumer Health and Safety, the National Council on Folic Acid, the National Alliance for Nutrition and Activity, and the STD Coalition.

ACPM also participated in the Institute of Medicine ’s Non-Governmental Liaison Panel to the Committee on HIV Prevention Strategies.

Through Coalition meetings, sign on letters and coordinated Capitol Hill visits, ACPM remains a visible member of the public health community as it helps to fight for public health and prevention dollars.  In addition, ACPM staff participate in a variety of listservs and electronic discussion groups to stay abreast and contribute to the national debate around a variety of policy issues.