Chapter 2 Legislative Update

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     Chapter 2 of the New York State District of the American Academy of Pediatrics (AAP) represents over 1,400 pediatricians, serving as the local organization of the national American Academy of Pediatrics, a 67,000-member organization dedicated to “the health of all children.”  Our members serve as part of all major pediatric practice groups across Long Island, and all children’s hospitals in Nassau, Suffolk, Brooklyn and Queens, including Stony Brook Children’s Hospital, Nassau University Medical Center, NYU-Winthrop Hospital and the Northwell Health System (Cohen Children’s Medical Center).  This area includes over 1 million children.

This report outlines the impact of specific suggested budget appropriations and proposed federal policies on the children and child health workers of Long Island.  It is meant to provide a local perspective on the impact of national policies and be a resource to our representatives.

     As federal policies and discussions regarding appropriations continue, Chapter 2’s Pediatricians want to ensure the needs of our children are met. Meeting these needs requires:

  • Full reauthorization of the Children’s Health Insurance Program as recommended by the Medicaid and CHIP Payment and Access Commission.
  • Robust support for the Medicaid program, which serves ~ 37 million children nationally and ~ 278,000 children (including the Children’s Health Insurance Program) across Chapter 2, many with special healthcare needs. Medicaid represents the dominant federal insurance program supporting children’s hospitals, as ~60% of patients are covered by this program.  Our local and national membership strongly opposes use of state-based waivers of essential health benefits as well as block grant proposals that undermine child health screening, which are significant health threats to children despite the actions of the Senate this past.
  • Full funding of the Agency for Healthcare Research and Quality as a free-standing agency without inclusion or reduced funding as part of integration into the National Institutes of Health.
  • An appropriation of a $1.1 Billion dollar increase in funding for the National Institutes of Health, which provides economic support to the region and underwrites over $156 million dollars in local research grants with no impact on indirect funds.
  • Full funding of medical training programs, including the Children’s Hospital Graduate Medical Education program, which locally supports training for 140 pediatric physicians.
  • Full Support for the Supplemental Nutrition Assistance Program, which serves ~50,000 households with children in Chapter 2.


       On behalf of the approximately 1,400 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists of the New York American Academy of Pediatrics, Chapter 2, which encompasses Long Island, Brooklyn and Queens, We write to express our concerns over aspects of President Trump’s released budget that will negatively impact children across our geographic area.

     We ask you to voice support for—and take important actions to protect—critical budgetary programs which are underfunded to austere levels under the President’s Fiscal Year 2018 Budget Proposal.  These include cuts to research, Medicaid and the Children’s Health Insurance Plan, medical training support, and the Supplemental Nutrition Assistance Program (SNAP).

     President Trump’s budget aims to significantly reduce funding for vital pediatric research and training programs which are of major importance locally to the children under our care.  Funding reductions for these projects are summarized below:




National Institutes of Health (NIH) 34.1 billion 26.9 billion – 7.2 billion
(- 26.8%)
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) 1.38 billion 1.032 billion – 348 million
(- 33.72%)
Environmental Influences on Child Health Outcomes (ECHO) Follow-on to National Children’s Study 165 million 131.4 – 33.6 million
(- 25.57%)
National Institute of Research on Safety and Quality (new institute created by moving Agency for Healthcare Research and Quality into NIH) 324 million 272 million – 47 million
(- 17%)
Health Resources and Services Administration  
                Title VII Primary Care Training and Enhancement 38.9 million – 38.9 million
(- 100%)
                Emergency Medical Services for Children 20.1 million – 20.1 million
(- 100%)
                Children’s Hospital Graduate Medical Education (CHGME) 300 million 295 million – 5 million
(- 1.7%)


The budget also proposes significant cuts to Medicaid and the Children’s Health Insurance Program (CHIP), including Medicaid cuts in excess of what is called for in the American Health Care Act. The document is not clear on the size of those Medicaid cuts, however, but they could be upwards of $1.3 trillion over 10 years. For CHIP, the administration calls for a two-year reauthorization without the recent 23 percentage-point increase in the federal matching rate and without maintenance of effort (MOE) provisions to ensure that states don’t roll back eligibility. It would also reduce the matching rate for children in CHIP over 250 percent of the federal poverty level from the “enhanced” CHIP match rate to the lower regular Medicaid matching rate.

CHIP is a vital program whose importance in ensuring children have access to healthcare is expected to grow.  In Brooklyn, Queens, Nassau and Suffolk counties more than 600,000 children are covered by CHIP (Child Health Plus). As family premiums rise in the employer-sponsored insurance market, data suggests more children will be moved into Child Health Plus, with a projected increase of approximately 6% over the next several years.

For nearly two decades, CHIP has been a national success story, giving states the ability to provide coverage that meets the needs of families who are employed but still make too little to afford private insurance. Together, CHIP and Medicaid have helped cut the rate of uninsured children to 5%–the lowest level ever recorded (1,2). Congress has most recently demonstrated its continued bipartisan support of CHIP with passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that continued funding of the program.

Services covered under Child Health Plus give children the opportunity to maximize their health.  Benefits are rooted in the science of preventive health and include coverage mental health coverage for children, vision, hearing and dental screening exams as well as occupational and physical therapy.  The programs also covers durable medical equipment, which allows patients such as premature babies, to be discharged home from the hospital instead of an intermediate care facility, reducing costs and promoting recovery. This service also provides children with asthma – the number one chronic disease of children on Long Island – with nebulizers so their disease is controlled with home therapy and outpatient visits, preventing emergency room trips and hospitalization.

The ability to provide these services is heavily reliant upon federal government support through and effective state-federal partnership.  The federal match rate for New York State for the CHIP program is 88%, incentivizing the state to enroll eligible children.  Statewide 94%-97% of eligible children are enrolled in the program. These investments in CHIP have translated to improved access to care across New York State.  Over 96-100% of children enrolled in CHIP-sponsored programs have seen a physician within the year, according to the New York State Department of Health and the National Academy for State Health Policy (3).

The CHIP program provides subsidies anywhere from 150% to 400% of the federal poverty level based on age – an income level of approximately $97,000.  Given that Long Island is among the regions with the highest cost of living nationally, it is clear that this income level may not be high enough to allow parents to purchase health insurance from a commercial provider.

Federal CHIP funding is currently set to expire September 30, 2017. A robust, long-term extension of CHIP funding for at least five years would help stabilize coverage for the 8.4 million children who rely on the program nationally, and provide budget certainty to New York and other states amid potentially significant changes to the broader coverage landscape.

We additionally encourage Congress to maintain the federal Medicaid and CHIP maintenance of effort (MOE) requirement, which ensures that eligibility and enrollment standards for children are not weakened, resulting in increased numbers of uninsured children. Locally, as with the rest of NY State, over 95% of eligible children are enrolled in CHIP, a fact no doubt supported by MOE incentives.

We further ask that Congress not roll back the recently-increased federal financing of CHIP to states. In 2015, Congress funded a 23 percentage point increase in CHIP funding; ending this increase in federal support will have a negative impact on the New York State budget.

The Medicaid and CHIP Payment and Access Commission (MACPAC) recommended supporting a five-year extension of CHIP, with the continuation of CHIP maintenance of effort and a 23-percentage point increase in the federal CHIP matching rate.  We urge our representatives to endorse these key provisions within the program (4).

Overall, CHIP and Medicaid provide significant economic support to children, helping them reach their full potential.  However, often not discussed in the fiscal debate over Medicaid and CHIP funding are the substantial long-term benefits children receive over course of their lifetime as a result of stable, quality health insurance and access to care.  Data from the Georgetown Center for Children and Families, demonstrates that children enrolled in Medicaid, compared to those uninsured, have 9.7% higher rates of high school completion and 5.5% higher rates of college completion (5).  These insured children are also more likely to ascend the economic ladder and contribute to a 7% return on investment in tax revenue compared to federal money contributed toward their insurance (5).


The budget also proposes significant cuts to Medicaid and the Children’s Health Insurance Program (CHIP), including Medicaid cuts in excess of what is called for in the American Health Care Act. The proposed extent of the reductions to Medicaid is estimated to be approximately $1.3 TRILLION over 10 years. For CHIP, the administration calls for a two-year reauthorization without the recent 23 percentage-point increase in the federal matching rate and without maintenance of effort provisions to ensure that states don’t roll back eligibility. It would also reduce the matching rate for children in CHIP over 250 percent of the federal poverty level from the “enhanced” CHIP match rate to the lower regular Medicaid matching rate.

It is critical to ensure that the children of New York and Long Island are not harmed by federal proposals to significantly cut the Medicaid program. Further, we ask for your strong support for long term funding of the Children’s Health Insurance Program (CHIP), which plays a crucial role in the health insurance landscape for children and together with Medicaid has helped the US achieve historic low rates of uninsured children (6).

Health care costs for children are very low compared to adults, and are not driving increases in health care spending.  Children’s healthcare represents only 3% of total healthcare spending (7). Indeed, early investments in children’s health care can be critically important in achieving long term savings in the health care system (8).

Nationally over 37 million children (40% of the total population under 18years) rely on Medicaid for healthcare coverage.  Thus, Medicaid is a cornerstone of children’s coverage and its pediatric benefits are considered the gold standard for child health, particularly for children and youth with special health care needs, about 45 percent of whom rely on Medicaid or CHIP (9).  Medicaid works for children partly because it provides evidenced-based coverage for children and invests in preventive care, such as vaccinations, autism screening and lead screening in addition to hospitalizations.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT), based on the American Academy of Pediatrics’ Bright Futures Manual, offers comprehensive health, mental health, vision and dental coverage for children. This wide-ranging preventive care is highly cost effective, preventing costly hospitalizations. Immunizations covered under EPSDT are among the world’s greatest public health achievements.  In the United States, saves $13.5 billion in direct costs per birth cohort, with total cost savings to society estimated at $68.8 billion (10).

From a cost perspective, Medicaid efficiently serves children.  Children account for approximately half of Medicaid beneficiaries but only roughly 20-25% of the costs of the program overall (11).  Children in the Medicaid program have essentially equal access to health care compared to children who are privately insured, despite having a per-child cost that is ~60% of those of children who are privately insured (12).

Ironically, it is precisely these outpatient preventive services which the President’s budget hopes to under-fund, proposing reductions in financing for outpatient care, preventive screenings and outpatient healthcare supports with proportionately moderate changes to expensive in-hospital coverage.

Medicaid, together with CHIP provides a lifeline of coverage to approximately 2.4 million children in New York State. Based on data from the KIDSCOUNT Data Center, the number and percentages of children under 18 years enrolled in Medicaid per Congressional District from 2013-2015 are listed:

Congressional  District Number of Children Percent of Child Population in District
1 61,000-70,000 16-19%
2 27,000-29,000 17-19%
3 14,000—16,000 8-10%
4 27,000-32,000 17-20%
5 76,000-79,000 43-45%
6 44,000-52,000 33-36%


President Trump’s budget recommends a $7.2 billion (~27%) reduction in National Institutes of Health (NIH) funding.  Ironically, this recommendation comes almost immediately after Congress recognized the value of public support for science and approved a bipartisan Omnibus funding package which included an increase of ~ $2 Billion for the NIH.

Within the austere recommendations, the National Institute of Child Health and Human Development (NICHD) was disproportionately, underfunded.  NICHD suffered a greater than proportional decrease compared to other institutes. The budget recommends a $348 million (34%) cut for NICHD. The National Children’s Study follow-up, the Environmental influences on Child Health Outcomes (ECHO) program, would suffer a $34 million, 26% cut (13).

Pediatric research is an essential investment and has yielded significant results.  NICHD funds critical research into the health and development of children, helping address health concerns in children that can become costlier later in life.

Since the government began public investment in pediatric research, new treatments, cures and testing has greatly enhanced the lives of babies and children.  Since 1960, investments in pediatric science have yielded a 77% reduction in the infant mortality rate (14).This drastic reduction has occurred as premature babies once considered stillborn or non-viable are now routinely surviving and thriving due to advances in care of premature newborns.  Development of new testing methods has resulted in improved newborn screening technologies.  These tests, which are routinely administered after birth, can detect life-threatening diseases such as Cystic Fibrosis, Sickle-Cell Anemia and various other diseases which allow for prevention and early treatment, preventing death and improving quality of life.  Increased public investment for HIV/AIDS research has reduced the chances a baby born to an HIV+ mother will have the disease by 90% — an almost negligible level (15).

The Society for Pediatric Research, which represents over 2,500 of the most eminent pediatric scientists in the nation, held a Congressional Briefing last April in which the role of life-saving medications such as pulmonary surfactant (which helps premature infants breathe) was outlined as a landmark discovery in pediatrics.  The American Academy of Pediatrics stated it was one of the “Seven Great Achievements in Pediatric Research.”   During the briefing it was noted that, every insight in the discovery, understanding, development and clinical trial of this lifesaving medication was supported by NIH.

Public funding for research also provides significant funding to support jobs and the economy across Long Island.  Cohen Children’s Hospital was a site for the National Children’s Study and ECHO programs, support for research supports Stony Brook Children’s Hospital as well as pediatric-focused research at Cold Spring Harbor National Laboratory and Brookhaven Laboratories.  The significant economics of this has translated into local support by both parties.  Rep. Peter King, for example, has annually circulated “Dear Colleague” letters in support of NIH funding and Rep. Tom Suozzi voiced his support for research support at a meeting at Cold Spring Harbor Labs earlier this year.

According to the Federation of Societies for Experimental Biology, the amount of NIH funding the 6 Congressional Districts of Long Island is listed below.

Congressional  District Funding Level Number of Institutions
1 $77,396,591 10
2 $151,912 1
3 $66,523,955 6
4 $887,516 2
5 $1,047,555 1
6 $1,608,750 1

These funds fuel a vital economic engine for our districts, providing support for highly-educated scientists, technicians and physicians.  Since part of these funds are allocated to clinical trials, NIH support also allows all residents to benefit from cutting-edge research should they have pediatric cancer, heart disease or a congenital abnormality.

President Trump’s budget also calls for reductions in essential funding for facilities and administration (F&A) expenses at research institutions. Reimbursements for F&A (also known as “indirects”) are vital to ensuring research institutions can carry out their core missions; cuts to F&A reimbursements are, therefore, cuts to research funding and will inevitably lead to less research being conducted.

“Indirects” provide significant benefit not only to researchers, but to the institutions which support the researcher to whom the grant has been awarded.  Particularly for pediatric physicians-researchers, these funds provide for research administrative support and facility costs, which also help to nurture young researchers and graduate students who are embarking on research careers.  Thus these costs are pivotal to ensuring the economic benefit of NIH funding is as widespread as possible.


The budget would also completely eliminate the Agency for Healthcare Research and Quality (AHRQ). In its stead, it proposes creating a new institute at NIH called the National Institute for Research on Safety and Quality. But it would only be funded at $272 million, down from AHRQ’s current $342 million in funding (a 17% cut).

The mission of AHRQ is to produce peer-reviewed scientific evidence which makes healthcare in the United States safer, more cost-effective and of higher quality.  Unlike the National Institutes of Health, which focuses on the basic and molecular science which drives scientific inquiry, AHRQ aims to fund projects with an immediate and substantial impact on the delivery of U.S. healthcare.

Locally, AHRQ serves many local healthcare providers.  The agency provides authoritative guidelines for treating many common medical conditions, helping to maintain a high standard of care.  According to AHRQ-published reports, three major AHRQ grants are currently funded at the Feinstein Institute for Medical Research at North Shore University Hospital. Three additional grants investigating coronary disease are active at the State University of New York at Stony Brook.  Together, AHRQ projects provide an estimated ~$2 million dollars in direct investigational research to improve the health of Long Island’s population, including children.

AHRQ is among the most cost-effective scientific agencies within the federal government.  Hospital-acquired conditions are a significant contributor to increased medical costs.  Many of these infections are preventable, and thus hospitals with high rates of these infections receive reduced Medicare payments through the Affordable Care Act (16).  This increased accountability to healthcare organizations for potentially-preventable conditions could not have been implemented without AHRQ support.

AHRQ-grants – many of which are provided to our members – supported projects which reduced hospital –acquired infections from central line catheters by 40% (17, 18).  This project has contributed to a 49% reduction in central catheter associated blood stream infections from 2010-2013 (19).  Savings from AHRQ –associated projects aimed at improving the quality of healthcare and reducing complications is estimated by the Department of Health and Human Services at $12 Billion dollars, and credited with saving over 50,000 lives (16, 19).

AHRQ is a major supporter of practical research projects which benefit children.  In the past two years, the agency has provided funds to hospitals across the country which has been used to improve electronic medical records for children with special health care needs and to investigate how social media can be used to influence teens to adopt healthier lifestyles.  Projects also examined the utility of text messaging as a tool to help young smokers quit and to promote vaccination against viruses which can cause cancer (17).


     The budget completely eliminates all but a couple of the Title VII and Title VIII health professions training programs, including the $38.9 million Title VII Primary Care Training and Enhancement Program. The Children’s Hospital Graduate Medical Education (CHGME) program is recommended for a $5 million (1.7%) cut.

The Children’s Hospital Graduate Medical Education (CHGME) program was created to reflect the unique needs of hospitals which specialize in serving our most vulnerable citizens – our children.  Medical centers which care for adults receive, as part of Medicare payments, a fee allotted toward financing the education of medical school graduates training in their chosen medical specialty.  These funds represent the federal government’s interesting in ensuring an adequate physician workforce capable of caring for adult patients.

Children’s hospitals, which primarily treat Medicaid-insured patients receive no such financial support, and thus rely on CHGME appropriations to fund education for physicians training to be pediatricians.  For almost 2 decades this funding was subject to the annual appropriations process at levels between $235-$317.5 million dollars (20).  This range created significant uncertainty for over 220 children’s hospitals across the country, including our two local institutions, Stony Brook University Children’s Hospital and Cohen Children’s Medical Center.

According to the American Academy of Pediatrics, children’s hospitals represent 1% of the hospitals nationally but train over 50% of the entire pediatric workforce.  Locally, both Stony Brook and Cohen Children’s train over 140 pediatric residents annually, and many stay in New York to practice.  Nationally, the CHGME program allows for the training of up to 6,000 pediatricians annually.  A report commissioned by the Health Resources and Services Administration analyzing the 2009-2010 academic year specifically noted the program was achieving its goal of strengthening the pediatric workforce (21).  Recent data from the American Board of Pediatrics shows that as children’s hospitals have increased pediatric training positions, the number of pediatricians has grown relative to the child population, thus helping to resolve nationwide disparities in the pediatric workforce, which translate to little or no healthcare access for children with complicated medical conditions who require subspecialist care.

For comparison, adult medicine has roughly 36 specialists for every 100,000 patients, while in pediatrics; there are only 13 per 100,000 children (22).  According to the Health Resources Services Administration and the Children’s Hospital Association, these shortages create untenable wait times for certain sub-specialists.  The average wait time is 8-9 weeks for pediatric neurologists and 7 weeks for a pediatric endocrinologist, with four states having none of these physicians (23).

Locally, significant difficulty exists in obtaining appointments for pediatric rheumatology and behavioral-developmental pediatricians.  Currently, the wait time for new appointments with a physician who specializes in treating children with behavioral-developmental disorders such as autism is approximately 6 months at both the children’s hospitals on Long Island.


The budget would maintain level funding ($286 million) for the Title X family planning program, but proposes to eliminate all federal sources of funding for Planned Parenthood, including from Title X and Medicaid. It also calls for large overall reductions to the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition, the budget calls for reductions in nutrition programs such as the Supplemental Nutrition Assistance Program (SNAP) and numerous education programs.


Supplemental Nutrition Assistance Program (SNAP) on Long Island

An estimated 16 million children live in households where food is scarce and over half of all SNAP recipients are children.  Without important social supports like Medicaid, WIC and SNAP to provide low-income families with food and preventive health services, our patients are in danger. The American Academy of Pediatrics considers child poverty a significant social determinant of health and one of the greatest “diseases” of children.

According to a recent report from the U.S. Department of Agriculture, households with children had a substantially higher rate of food insecurity (20.0 percent) than those without children (11.9 percent) in 2012.

Seventy-two percent of the 47 million SNAP beneficiaries are in families with children.  As pediatricians and child health experts, we understand that hungry children are less likely to be healthy, suffer developmental delays and have behavioral problems that hurt their academic performance and provide a life-long educational and social disadvantage.

In our Chapter catchment area,, an estimated 1.1 million households receive food assistance (24).  The numbers of households with children based on Congressional District are summarized below from data obtained from the US Department of Agriculture in 2017.

Congressional  District Number of Households with Children
1 5,733
2 6,923
3 3,348
4 5,668
5 19,492
6 9,738

The economics of investing in children are highly favorable, resulting in over an $8 return for every dollar spent.  Given these margins, SNAP is a highly beneficial child-investment program that can aid in promoting children from poverty.

Children deserve strong policies that protect them against hunger, improve their nutrition and in turn help their families afford access to healthy food. The President’s FY 2018 Budget Proposal fails to meet these needs.


The Fiscal Year 2018 budget proposal released earlier this summer by the White House disproportionately harms children. The cuts included in this budget to programs like Medicaid, the Supplemental Nutrition Assistance Program, National Institutes of Health, Agency for Healthcare Research and Quality are so extreme that the programs would be unable to function as safety nets leaving millions of children, without any option for vital services like health care and nutrition.

The American Academy of Pediatrics rejects any proposal that would roll back progress for children and leave vulnerable families worse off, and that’s exactly what the President’s Fiscal Year 2018 budget proposal would do.

We look forward to the opportunity to further discuss the local impact of this proposal on children locally, as we experience the benefits of these programs daily in our offices and remain strong advocates for their health and well-being.

Thank you for all you do for children,

Shetal I. Shah MD FAAP
American Academy of Pediatrics, New York Chapter 2
Legislative Chairman


Dr. Steve Goldstein, President

Dr. Shetal Shah, Vice-President

Dr. Robert Lee, Secretary

Dr. Sara Kopple, Treasurer


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  3. Genevieve Kenney et al.,Medicaid/CHIP Participation Rates Among Children: An Update. September 2013.
  4. U.S. Department of Health and Human Services (2016). “FFY 2015 Number of children Ever-Enrolled in Medicaid and CHIP,” 2016, available at
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  17. Department of Health and Human Services, Agency for Healthcare Research and Quality, Justification of Estimates for Appropriations Committees. Fiscal Year 2015.
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