May 15, 2000

Department of Health and Human Services
Office of Program Systems
Room 447D (Attn: Strategic Planning Office)
200 Independence Ave., S.W.
Washington, D.C. 20201

Dear Sir or Madam:

On behalf of the American Psychological Association (APA), I am pleased to submit comments on the draft Updated Strategic Plan for the Department of Health and Human Services for FY 2001-2006. APA is the largest association of psychologists in the world, with 159,000 members and affiliates. APA’s members are deeply involved in scientific research, academic and professional training, health and mental health care, and the use of psychology to promote human welfare. Accordingly, the concerns of APA are very much the concerns of the Department.

We would like to take this opportunity to commend the Department for its well-organized, comprehensive plan. The Department’s stated mission in the areas of public education, services, training, and research is laudable to enhance the overall health status and well being of all Americans across the lifespan, with particular attention to racial and ethnic minorities, disadvantaged individuals, and vulnerable populations. We also wholeheartedly endorse the Department’s core values of accountability, protection against discrimination, prevention of health and social problems, collaboration, and application of current scientific knowledge. We regard these as central to the field of mental health and to the larger health care system. We particularly laud the Department for the attention to the importance of improving health behaviors, mental health research and services, and the elimination of health disparities in minority populations.

We were particularly pleased with the integration of mental health and behavioral issues throughout the plan, including the notable references to mental health among the ten leading health indicators and to improvements in the mental health of individuals, families, and communities as a measure of the Department’s overall success. We share the Department’s view of the importance of health sciences research and recommend that a phrase be included in the introductory vision statement that refers to the importance of an empirical basis for interventions and public education campaigns. While such a reference is already included in some sections, it is not consistently stated throughout the document.

The six goals set forth as the agency’s focus for the next five years are also praiseworthy. Reducing major threats to health and productivity, while improving economic and social well-being, access to health services, quality of health care and human services, and the nation's public health systems are all very timely and important. We would like to take this opportunity to highlight each of these specific goals, both to point out particularly beneficial provisions and to note areas that should be included or strengthened:

GOAL 1 – Reduce the Major Threats to the Health and Productivity of All Americans

The emphasis on modifying health behaviors is certainly appropriate, as is the call for additional research to increase understanding of risk factors, environmental correlates, and potential interventions. While public education is an important part of the response, the programmatic responses are particularly critical. Behavior change is possible and sustainable, but it is too difficult for many people without some reliable external support.

We recommend that this first goal expressly include suicide prevention efforts. Suicide rates have increased dramatically in recent years among young adolescents, African American males, American Indians/Alaska Natives, and the elderly. Such a focus would most appropriately fall under Objective 1.2 regarding the reduction of violence and injuries. The need to develop suicide prevention initiatives and to advance a "national suicide prevention strategy" is conveyed by The Surgeon General’s Call to Action to Prevent Suicide 1999.

Recommendation: Call special attention to the need to prevent hate violence in our communities in Objective 1.2

Given the increasing incidence of hate violence in our country, prevention initiatives should be highlighted in the plan’s discussion of community injury and violence prevention programs. This could be accomplished by rephrasing the second full sentence under Objective 1.2 as follows: "We will support community injury and violence prevention programs that focus on priorities that include preventing youth/school violence, violence against women, and hate violence…"

Recommendation: Include specific reference to sexual orientation in Objective 1.6

In the context of community prevention services to reduce unsafe sexual behaviors, it would be beneficial to include specific reference to lesbian and gay community health centers in the list of Department programs providing prevention and counseling services for high-risk populations. Related to technical assistance for organizations, school curricula and teacher training to help youth avoid HIV infection and reduce unsafe sexual behaviors should be designed to address the unique needs of lesbian, gay, and bisexual youth. This could be accomplished by adding the phrase, "taking into account sexual orientation diversity" following "reduce unsafe sexual behaviors" in the second bullet.

APA wholeheartedly endorses the Department’s goal of promoting and supporting interventions that help disadvantaged and distressed individuals, families, and communities improve their economic and social well-being. We especially value the priority given to low-income families, including children, the elderly, and persons with disabilities. The Department’s continued commitment to help families make the transition from welfare to work through the provision of quality child care and early learning services is vital. As noted in the plan, it is essential to address and eliminate barriers to self-sufficiency for these families, which involves aiding persons with mental and physical disabilities and victims of domestic violence. At the other end of the age continuum, the provision of long-term care services to the elderly is also critically needed.

APA applauds the proposal in Objective 3.2 to conduct research and demonstrations to identify underlying causes of racial and ethnic health disparities. While access to health services is undoubtedly a central issue, there are other issues that must be more thoroughly investigated, such as cultural values and the links between socioeconomic status and health.

While support for the training of health care professionals is subsumed under the third goal of improving access to health services, we recommend that more attention be directed to this critical aspect. The visibility of this initiative could be enhanced by amending the title of the goal as follows: "Improve access to health services, increase training opportunities for health care professionals, and ensure the integrity of the nation’s health entitlement and safety net programs," and mentioning in the preamble to this goal the importance of training health care professionals to work in underserved areas and with underserved populations. We were especially pleased to learn that efforts will be directed to increase the supply of ethnic minority health care providers to address the pressing health and mental health needs of our nation’s increasingly diverse population. We also support the focus in Objective 3.3 on augmenting personnel in the National Health Service Corps, increasing scholarships for American Indians and Alaska Natives, and enhancing minority student training programs. In this regard, we would like to see a major increase in support for the Minority Fellowship Program and other mental health training initiatives through the Substance Abuse and Mental Health Services Administration (SAMHSA). It should be noted that the National Advisory Council of SAMHSA’s Center for Mental Health Services discussed the critical need to reinstate training as a top priority for the Center at their May 9^th meeting.

Improving the quality of and access to health services for native populations is a critical goal. Among the public health challenges in Native American and Alaskan Native communities is a disproportionate rate of suicide. Given that suicide is the second leading cause of death for 15- to 24-year-old American Indians and Alaska Natives, reference to suicide prevention initiatives should be included under Objective 3.6, which addresses improvements in the health status of these populations. APA encourages the addition of suicide to the list of conditions including diabetes, obesity, injuries…. that heavily affect these populations.

We were pleased to see the inclusion of Objective 3.8 in the plan, which calls for an increase in "the availability and effectiveness of mental health care services." The means to accomplish this objective appropriately includes support for research and knowledge development activities to improve the effectiveness of mental health services. While it is crucial to examine the role of sex, race, culture, and socioeconomic status in treatment outcomes, sexual orientation should be added to this list of key factors. Continued research on the individual and combined effectiveness of behavioral and pharmacological interventions is also much needed, with particular attention to the population of young children. While we were pleased that the importance of developing better preventive interventions was included in this research section, we recommend that support for preventive services should also be included in the following section addressing capacity building in the delivery of community mental health services. This change would help to highlight and preserve the original preventive focus of the community mental health centers. Emphasis in this section is well placed on the need for: culturally appropriate mental health services for underserved populations; interagency collaboration; education of primary care providers in the identification and referral of persons with mental health problems, including those eligible for Medicaid and/or Medicare. One additional suggestion would be to highlight the special needs of some runaway and homeless youth by adding the phrase, "including those youth whose sexuality may place them at risk for family or community violence" at the end of the last bullet in this section.

It should be noted that APA is also a key proponent of the Surgeon General’s proposed "anti-stigma campaign" to educate the public about mental disorders and increase the likelihood that people will seek needed mental health services.

In light of APA’s concerted advocacy for a strong and enforceable Patients’ Bill of Rights, we were pleased to see that Objective 4.3 calling for efforts to "improve consumer and patient protection" includes a statement that the Department likewise intends to advocate for passage of a national Patients’ Bill of Rights. It is laudable that the Department proposes to evaluate and monitor the effectiveness of provider grievance and complaint procedures in its health care programs, including the provision of patient information, the development of user-friendly informed consent documents, and the requirement that participating provider networks meet prescribed standards for grievance and appeal processes. This will hopefully serve as a model for the private insurance industry to emulate.

The focus on errors in the health care system is timely. As is the case in all complex systems, medical errors rarely have a single cause or a single responsible party, but occur when the system of checks and balances breaks down or is overwhelmed. Psychologists who specialize in human factors research are being employed to diagnose problems and recommend changes in other industries such as aviation, and their involvement in proposed responses to the medical error crisis is recommended. Research and evaluation activities, as well as dissemination activities, should emphasize behavioral and human factors studies of communication and practices within health care systems.

GOAL 5 -- Improve the Nation’s Public Health Systems

APA applauds the proposed expansion of investment in basic research, since in many critical areas basic knowledge is needed before clinical questions can be answered. We also support the emphasis on technology transfer. Behavioral research faces more hurdles in the road to marketable interventions than other types of research, in part because there are fewer industrial consumers (e.g., pharmaceutical companies) and fewer trained providers in primary health settings.

National probability and convenience sample data have indicated higher risks for certain health problems among lesbian, gay, and bisexual adolescents and adults. It is thus critical to obtain information about sexual orientation in national health surveys. Accordingly, we recommend inclusion of the following bullet under the first section of Objective 5.1 that calls for improvements in the capacity of the public health system to identify and respond to threats to the health of the nation’s population. The new bullet would read as follows: "improving surveillance for lesbian, gay, and bisexual persons through the addition of sexual orientation to demographic questions in national health surveys and other data collection instruments."

One of APA’s core concerns is the protection of human subjects in research, and we applaud the focused attention this problem is given in the Department’s Strategic Plan. We recognize that all of the scientific enterprise is at risk if the current system of protection is allowed to break down. We encourage research about effective consent practices, as well as additional education and resources for Institutional Review Board members.

In closing, we would like to thank you once again for the opportunity to review and offer comments on the draft Updated Strategic Plan for the Department of Health and Human Services for FY 2001-2006. We hope these comments prove helpful to you. We also appreciate the opportunity for a representative of our association to attend the meeting at the Department on May 19^th to discuss the plan with agency officials and other interested organizations. Our representative will be Ellen Garrison, Ph.D., APA’s Director of Public Interest Policy, who would be pleased to respond to any questions in the interim. She can be reached at (202) 336-6066.

Sincerely,

L. Michael Honaker, Ph.D.
Deputy Chief Executive Officer

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