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Program can claim to save lives, money

Two years ago, Janice Heald's first pregnancy ended when her baby was stillborn. It was a tragic experience that left her scared, and in need of a helping hand.

She got one from Healthy Start, a Florida program designed to make sure pregnant women get proper health care.

Mrs. Heald was amazed to learn during her second pregnancy that her Healthy Start worker, Holly Sink, made house calls. She offered advice on nutrition and programs that provided food and medical care.

"She was really full of knowledge, and she was ready to help. She was great; I love her to death," Mrs. Heald says.

And two months ago, Janice and Matthew Heald became proud parents of Savannah, a healthy girl.

Not every Florida infant has fared so well.

Florida was the fifth worst state for infant mortality in 1980 and 13th worst in 1990, when nearly one baby in 100 died before mom or dad could light the first birthday candle.

But the latest figures put Florida 25th _ smack in the middle, with an infant mortality rate no higher than the national average.

Ranking 25th out of 50 may not sound impressive, but it is, considering where Florida started.

The state's improvement was the seventh best in the nation between 1990 and 1998. The percentage of babies who die before age 1 has fallen nationwide, but the rate has fallen even faster here.

Overall, Florida's infant mortality successes constitute the biggest improvement in any social indicator reviewed by the St. Petersburg Times for these stories.

Experts say much of the credit goes to Healthy Start, the extensive state government program that helped Mrs. Heald.

The program's success makes it an excellent case study for tackling other challenges, such as improving the state's education system, its supporters say.

With the right focus, approach and financing, they say, the state can make other significant gains.

Lesson One: Define the problem

Public health experts who were fighting infant mortality during the 1980s had one thing on their side. Their objective was compelling and easy to understand: Too many babies are dying. We need to save more.

"The goals," says Debra Bara, executive director of the Pinellas County Healthy Start Coalition, "were very clearly set forth."

Lesson Two: Define the solution

Dr. Charles Mahan, a maternal health expert, told legislators in the 1980s that the way to save babies was clear: More pregnant women needed proper prenatal care. In the long run, this makes for full-term, bigger, healthier babies.

But at one point, pregnant women in Florida did not qualify for Medicaid even if their income was only one-third of the federal poverty level, Mahan says. No wonder poor women weren't making doctor's visits.

So Mahan and his colleagues showed lawmakers piles of studies. These proved that for every dollar the state paid for pregnant womens' doctor visits, it would save $3 by preventing premature births and other medical complications.

The argument worked.

"I think it was that we got smarter about showing them data that they could understand and also we presented it as a business decision: Pay me now or pay me later," says Mahan.

Under Gov. Bob Martinez, a Republican, the Legislature agreed to allow pregnant women to receive Medicaid as long as they earned the federal poverty level or less. By 1989, they could qualify even if they earned 50 percent more than the poverty level.

As time went on and data came in, Mahan gave lawmakers data showing they had saved lives as well as dollars.

Lesson Three: Get a leader

But the biggest push came in 1991, when Florida launched Healthy Start, a comprehensive, well-funded attack on infant mortality.

In a sense, this big push had begun years before, with the birth of a premature, 1-pound, 10-ounce baby named Lawton Chiles IV.

This baby had a grandfather in the U.S. Senate, also named Lawton Chiles. The whole Chiles family was "living on the edge of the threat of death of that child for quite a few months," says Rhea Chiles, the baby's grandmother.

For the senator, this was a turning point, Mrs. Chiles says. He began thinking that "if we were to find in this very snarled ball of seemingly intractable social problems that the country was having . . . if you were to find a thread to pull that snarl out, he thought it would be spending money on the early side. He called it the smart buck."

Chiles took on a new mission. He organized a Senate panel to study infant mortality's causes. When elected governor in 1990, he put infant mortality high on his political agenda.

In 1991, Chiles outlined his Healthy Start proposal, which would eventually mean: Pregnant women could receive Medicaid even if they earned 85 percent more than the poverty level; doctors would earn more money for this work, encouraging them to see mothers on Medicaid; coalitions of volunteers would be given unprecedented power to spend state money in their own communities to fight for healthy babies.

Mahan, who served as state public health officer under Martinez and Chiles, says Chiles had a "remarkable interest" in the cause. He sees a lesson there for other leaders.

"You can't be all things to all people," Mahan says. "You've got to pick one or two things that you're going to be the expert on, and then really be the expert on it. You can probably affect that issue while you're in office."

Lesson Four: Bring the people on board

Healthy Start created coalitions of volunteers around Florida with the power to spend state money on local antismoking programs for moms, parenting classes, transportation for doctor visits and so on.

This not only created localized programs, but also a power base. Last year the coalition helped zap a proposed $1.5-million cut in its administrative budgets.

But this fall, mired in a budget mess, the Legislature considered taking a step backward, at least in the eyes of public health experts.

Florida currently offers pregnant women Medicaid coverage even if they make 85 percent more than the federal poverty level. The Legislature considered reducing that, so the maximum a woman could earn while receiving Medicaid would have been 50 percent more than the federal poverty level. That would have potentially taken away Medicaid coverage from 5,000 pregnant women.

However, advocates believe that those cuts have been put off until at least next July.

It's not a blueprint for everything. But look around, and you can see other causes waiting for something like this to happen.

Consider the "school readiness coalitions" established by the state in 1999. They are designed to prevent many children from failing in school by mobilizing day care dollars early and making sure that children arrive in kindergarten truly ready to learn.

It's a groundbreaking concept that few have heard about. It's a cause in search of its Lawton Chiles.

"What's missing from the readiness movement," says child advocate Jack Levine, president of the Center for Florida's Children, "is political leadership in Florida."

Social

Infant mortality

1990 1998

38th 25th

(9.76 deaths (7.2 deaths

per 1,000 per 1,000

births) births)

NATIONAL AVERAGE

1990 1998

(9.12) (7.2)

Percentage of Florida's population without health insurance

FLORIDA

1990 1999

43rd 43rd

(18.0%) (19.2%)

NATIONAL AVERAGE

1990 2000

(13.9%) (15.5%)

Sources: Times research

Experts point to the state's Healthy Start program, which helped Janice Heald when carrying daughter Savannah, as a model for tackling other challenges, such as education.

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