The EPA's Commitment to Children's Environmental Health: History and Current Challenges.

Children's environmental health (CEH) has a 25-year history at the US Environmental Protection Agency (EPA), during which the agency has advanced CEH through research, policy, and programs that address children's special vulnerability to environmental harm. However, the Trump administration took many actions that weakened efforts to improve CEH. The actions included downgrading or ignoring CEH concerns in decision-making, defunding research, sidelining the Children's Health Protection Advisory Committee, and rescinding regulations that were written in part to protect children. To improve CEH, federal environmental statutes should be reviewed to ensure they are sufficiently protective. The administrator should ensure the EPA's children's health agenda encompasses the most important current challenges and that there is accountability for improvement. Guidance documents should be reviewed and updated to be protective of CEH and the federal lead strategy refocused on primary prevention. The Office of Children's Health Protection's historically low funding and staffing should be remedied. Finally, the EPA should update CEH data systems, reinvigorate the role of the Children's Health Protection Advisory Committee, and restore funding for CEH research that is aligned with environmental justice and regulatory decision-making needs. (Am J Public Health. 2022;112(1):124-134. https://doi.org/10.2105/AJPH.2021.306537).

Re-envisioning EPA and its work in the post-Trump era: perspectives from EPA employees.

The Trump administration has severely curtailed the work of the United States Environmental Protection Agency (EPA). The EPA has rolled back environmental protections, lost ground on addressing climate change and environmental justice, and shed large numbers of experienced staff. All of this has accelerated a longer-term decline in EPA resources, expertise, and authority. Here, we present perspectives of EPA employees and retirees on reconfiguring and strengthening the agency to address current and future environmental health problems, based on qualitative data obtained through 100 semi-structured interviews with 76 current and former EPA employees. Interviewees emphasized a number of internal and external issues, including a hyper-partisan context in which the agency operates, lack of public understanding of the extent of domestic and global environmental problems, budget shortfalls, staffing and leadership challenges, reduced scientific capacity and use of science in decision-making, insufficient attention to environmental justice, and lagging technology. We argue that reforms cannot only be expert-driven but must also come from the public, incorporating community driven solutions and focusing on remedying environmental injustice.

Health Expenditure Concentration and Characteristics of High-Cost Enrollees in CHIP.

Devising effective cost-containment strategies in public insurance programs requires understanding the distribution of health care spending and characteristics of high-cost enrollees. The aim was to characterize high-cost enrollees in a state's public insurance program and determine whether expenditure inequality changes over time, or with changes in cost-sharing policies or program eligibility. We use 1999-2011 claims and enrollment data from the Alabama Children's Health Insurance Program, ALL Kids. All children enrolled in ALL Kids were included in our study, including multiple years of enrollment (N = 1,031,600 enrollee-months). We examine the distribution of costs over time, whether this distribution changes after increases in cost sharing and expanded eligibility, patient characteristics that predict high-cost status, and examine health services used by high-cost children to identify what is preventable. The top 10% (1%) of enrollees account for about 65.5% (24.7%) of total program costs. Inpatient and outpatient costs are the largest components of costs incurred by high-cost utilizers. Non-urgent emergency department costs are a relatively small portion. Average expenditure increases over time, particularly after expanded eligibility, and the share of costs incurred by the top 10% and 1% increases slightly. Multivariable logistic regression results indicate that infants and older teens, Caucasian children, and those with chronic conditions are more likely to be high-cost utilizers. Increased cost sharing does not reduce cost concentration or average expenditure among high-cost utilizers. These findings suggest that identifying and targeting potentially preventable costs among high-cost utilizers are called for to help reduce costs in public insurance programs.

Enrollment, expenditures, and utilization after CHIP expansion: evidence from Alabama.

OBJECTIVE: In October 2009, Alabama expanded eligibility in its Children's Health Insurance Program (CHIP), known as ALL Kids, from 200% to 300% of the federal poverty level (FPL). We examined the expenditures, utilization, and enrollment behavior of expansion enrollees relative to traditional enrollees (100-200% FPL) and assessed the impact of expansion on total program expenditures. METHODS: We compared unadjusted mean person-month-level expenditures and utilization of expansion enrollees and various categories of existing enrollees and used a 2-part modeling strategy to examine differences after controlling for enrollee characteristics. We used probit models to examine adjusted differences in reenrollment behavior by eligibility category. RESULTS: Expansion enrollees had higher total monthly expenditures ($10.33, P < .05) than traditional ALL Kids enrollees, including higher outpatient ($5.35, P < .001) and dental ($0.85, P < .01) expenditures but lower emergency department (-$1.34, P < .001) expenditures. Expansion enrollees had marginally lower utilization of emergency department services for low-severity conditions and higher utilization of physician outpatient visits. Expansion enrollees were 4.47 percentage points (P < .001) more likely to reenroll before their contract expiration date than traditional ALL Kids enrollees. As of October 2012, expansion enrollees accounted for approximately 20% of ALL Kids enrollment and expenditures. CONCLUSIONS: The expansion population was characterized by moderately higher health expenditures and utilization, and more persistent enrollment relative to fee group enrollees who are subject to the same levels of cost sharing and annual premiums. Although states are prohibited from changing program eligibility until 2019, the costs associated with the expansion population will be important to future policy decisions.

Impact of boron deficiency on Xenopus laevis: a summary of biological effects and potential biochemical roles.

The toxicity of boron has been understood for many years. However, limited data currently exist concerning the nutritional essentiality of B in chordates. Results from an ongoing research program evaluating the nutritional essentiality of B in the South African clawed frog, Xenopus laevis, found that X. laevis fed a low-B diet in a low-B culture media produced a substantially higher number of necrotic eggs and fertilized embryos than frogs fed a boron-sufficient diet. Markedly decreased embryo cell counts at mid-blastula transition and an increased frequency of abnormal gastrulation were also noted in embryos from adult frogs fed the B-deficient diet. By 96 h of development, none of the larvae collected from the B-deficient adults and maintained in low-boron culture media developed normally. Reproductive effects associated with B deficiency in female Xenopus included ovary atrophy, oocyte necrosis, and incomplete oocyte maturation. In males, a decrease in testis weight and sperm count was noted. These studies suggest that these adverse effects resulting from B deficiency could be found during gametogenesis, gamete maturation, embryonic development, and larval maturation. The studies also confirmed that B deficiency was capable of interrupting the X. laevis life cycle. Additional studies evaluating the role of B in the thyroid axis and the oocyte plasma membrane progesterone receptor provide the first line of direct evidence for a biochemical role of boron in X. laevis. Combined together, this research program provides firm evidence that B is nutritionally essential in X. laevis.