Case Overview, Hearing Screening for Infants
This document provides background information and summarizes the debate over hearing screening for infants. The links to the left will lead you to public documents that we have found.
Hearing specialists strongly believe that testing infants is a cost-effective opportunity to resolve problems before they get worse and become more difficult to remedy. There are solutions for many types of hearing loss but unless a child is deaf, those problems can be difficult for parents to detect. If specialists screen infants they can identify any problems that exist. As Congressman James Walsh (R-NY) put it, "Hearing loss accounts for incalculable anxiety and concern within families and untold millions of dollars of testing to see why children aren’t learning (press release, 2/24/99, www.house.gov/walsh)."
As an issue of public policy, infant hearing screenings dates back to the early 1980s when the Joint Committee on Infant Hearing Screening recommended identification of infants at risk for hearing loss and suggested follow-up audiologist evaluation. In 1993 the National Institutes of Health recommended that all infants undergo hearing screening in the first 3 months of life. By 1999, approximately 20 states have passed laws encouraging such tests, with 12 states mandating the tests.
In 1990 Representative Walsh introduced a bill with a federal mandate for screening tests. The measure didn’t garner enough support for passage but Walsh continued to try to build support for an initiative in this area. After the Republicans took control of the House in 1995 he had to change strategy because, as one respondent put it, "unfunded mandates fell out of vogue." (An unfunded mandate is a requirement from Washington that states or cities offer a program even though the federal government provides no funds to support it.) Congress enacted a law to forbid unfunded mandates in 1995.
In the 1997-98 Congress Walsh offered legislation to avoid the unfunded mandate problem, proposing a grant program enabling states to apply for funds from Washington that could be used to initiate screening endeavors. According to government officials and organizational officials with an interest in the issue, the proposed legislation was opposed by the American Academy of Otolaryngology (AAO) since it allowed audiologists to perform the screenings. Otolaryngologists are physicians who specialize in diseases of the ear, nose, and throat. Audiologists are not doctors but are trained technicians who conduct tests measuring hearing loss. Believing that care would otherwise be compromised, the AAO wanted to ensure that a physician made the initial diagnosis. The audiologists complained that the otolaryngologists were simply trying to protect their financial interests. Whatever its motives, the opposition from the AAO made it that much more difficult to get this bill passed.
Walsh persevered and in the next Congress he got the AAO to sit down at the bargaining table and participate in drafting revised legislation. A compromise was reached and both the AAO and American Speech-Language-Hearing Association (ASHA) began working for passage of the Newborn and Infant Hearing Screening and Intervention Act of 1999. Walsh was able to maneuver to get his bill bundled into the Omnibus Budget Reconciliation Act of 1999 and the hearing program became law when President Clinton signed this catch-all appropriations bill. After the measure passed the Health Resources Service Administration awarded 22 renewable grants to states of about $150,000 each. The passage of this legislation is in many ways just a first step. According to one organizational proponent:
"In round two we hope to get more funding for the states. The federal legislation has really been a catalyst for state action…We need, and hope to get in the next phase of our efforts, major backers in the insurance industry. We’ll next be moving on to pursue state legislation. Our efforts will be pursued [state] House by [state] House, large employer by large employer, insurance company by insurance company. One of our ideas is to create an 'honor roll' of sorts that publicizes model insurance policies."
Although the American Speech-Language-Hearing Association and American Academy of Otolaryngology were the primary interest groups involved in this battle, several other organizations also actively participated, including National Association of the Deaf, the American Academy of Pediatric Physicians, and the Conference of Educational Administrators of Schools and Programs of the Deaf. Senator Olympia Snowe (R-ME) sponsored the companion Senate legislation to Walsh’s House bill. Senator Tom Harkin (D-IA), Senator Edward Kennedy (D-MA) and Representative John Porter (R-IL) supported the issue as well. Representative Walsh, however, was far and away the most significant congressional advocate for this legislation.
Prior to the program’s passage those supporting the legislation pointed out that fewer than 25% of infants were receiving a hearing screening. According to USA Today (24 May 1999), "…30 U.S. newborns a day go home with significant hearing impairment and it will take an average of 2 ½ years for the disability to be discovered." Advocates claim that testing entails a small up-front cost compared to larger costs of diagnosing the problem when the child is already struggling in school. "We have good science indicating that if hearing problems are detected in the first three months of life, and there is intensive treatment by 6 months, children can communicate and develop language skills on par with other children their age." In short, "this is a bill that is good for kids, good for families, good for children’s health, and cost effective in the long run."
It is hard for any politician to say he or she opposes a program that benefits children’s welfare so there is little opposition to the tests themselves. Cost, however, was an issue. According to one lobbyist:
"We found a supplementary argument that might work with those -- especially Republicans -- who weren’t swayed by what we were saying already [about the low rates of screening and its impact on detection]. We talk to them about the cost being paid upfront when you have the best chance to really make a difference. Otherwise, we say, you’ll pay bigger costs later. And there are new studies that validate this point. We give them numbers, evidence, research, and the cost-benefit analysis. There’s lots of things that cost a lot more than this for which we get much less of a benefit. We’ve really been helped on this issue by the fact that this is a small population and it’s easy to articulate the costs and benefits of serving them. With the budget surplus people are looking for meaningful ways to spend money. Plus, the research behind intervention has really taken off. It’s a sexy or popular issue because you can define an achievable goal and the conditions are ripe to achieve it."
Cost, quite likely, is the reason such a modest program of small grants to the states was passed rather than either outright funding for tests or financial incentives for insurance companies to pay for screenings.
A subsidiary issue was that the bill was passed only in the form of an appropriation. There was no authorizing legislation, which is normally required in the congressional process. This “legislating on an appropriation” raised some hackles—Senator McCain (R.-AZ) objected on these grounds—but the congressional leadership supported Walsh’s strategy.
A broader problem is that the larger battle lies in the states. Someone has to pay for the testing and insurance companies oppose including infant hearing screening as part of their standard coverage package. Their argument is simple: if insurance companies pay for a hearing test for infants, they will have to pass on the cost to consumers. There is pressure on insurers to add lots of services while at the same time there is pressure on them to keep insurance premiums down. Insurance companies also claim that “false positives” (an initial diagnosis that mistakenly finds a problem) plague infant screening.
The public’s lack of knowledge is also an impediment to further action on this issue. As one lobbyist noted, "educating people—the public, hospitals, employers, and members of Congress—is key. Most people don’t know how important early screening can be." People simply aren’t aware of what can be done and how cost-effective early diagnosis and treatment is.
The main political venue for this issue is Congress, specifically the Committee on Appropriations for the Departments of Labor, Health and Human Services, and Education. Representative Walsh is a subcommittee chair on Appropriations, giving him substantial power on the committee as a whole. The Health Resources Service Administration is responsible for awarding the screening grants. The state legislatures are now a key arena as efforts are underway to build programs in states that do not have them.