The U.S. Infant Mortality Rate: International Comparisons, Underlying Factors, and Federal Programs

Elayne J. Heisler
Analyst in Health Services

The infant mortality rate (IMR)—the number of deaths occurring in the first year of life per 1,000 live births—is a widely used proxy for the health status of a nation, and is commonly used for international comparisons. As of 2008, the U.S. IMR was 6.6, a historically low rate for the United States, but a rate that is still higher than the Organization for Economic Cooperation and Development (OECD) average of 4.6. The relatively high U.S. rate—and the number of infant deaths it indicates—concerns some policymakers. In addition, there is concern that the U.S. IMR has leveled off after four decades of decline. Reducing the U.S. IMR has been—and continues to be—a recognized public health objective.

Researchers and policymakers debate the various factors that may explain the high U.S. IMR relative to other developed countries and its recent stagnation. Potential factors include international differences in the recording of live births, different rates of low birthweight and short gestational age births, and racial and ethnic disparities. Researchers conclude that international recording differences do not explain the relatively high U.S. IMR. In addition, the data suggest that racial disparities may only partially explain the relatively high U.S. IMR. Instead, researchers suggest that higher U.S. rates of low birthweight and short gestational age births may explain the relatively high U.S. IMR.

This report examines the U.S. IMR. It identifies the top three causes of U.S. infant death— congenital malformations, disorders related to low birthweight and short gestational age, and sudden infant death syndrome (SIDS). The report focuses on low birthweight and short gestational age, because the United States has relatively high and increasing rates of these births, and research has found that these births can be reduced through policy interventions.

The U.S. IMR varies geographically and is influenced by a number of factors, including the mother’s demographic characteristics (e.g., education, income, or age) and health and health system characteristics. In general, southern states have the highest IMRs and states in New England and the Pacific Northwest have the lowest. The higher IMRs in southern states may be partially explained by higher rates of low birthweight and short gestational age births in these states. In addition, the racial and ethnic composition of a state’s population affects its IMR because of higher IMRs among certain racial and ethnic groups. The IMR is also influenced by health and health system characteristics, including the mother’s health behaviors, such as drinking and smoking, and her access to and use of prenatal care.

A number of federal programs that aim to improve the health status, and the economic and social circumstances, of low-income women and children may reduce the U.S. IMR. These programs include Healthy Start, Maternal and Child Health Services Block Grants, Medicaid, and the State Children’s Health Insurance Program (CHIP). Evaluating whether a particular program reduces the IMR is challenging because individuals may be eligible for multiple programs and because programs target those with IMR risk. Given this, it is difficult to determine the effectiveness of a single program, and it is difficult to determine whether findings that a program does not reduce the IMR are due to characteristics of the program or to characteristics of its participants.

The Patient Protection and Affordable Care Act (ACA, P.L. 111-148) either establishes new or expands existing programs to reduce the IMR. For example, “Strong Start,” funded by the new Center for Medicare & Medicaid Innovation created in the ACA, focuses on reducing the rate of pre-term births, which may also reduce the IMR once implemented.


Date of Report: April 4, 2012
Number of Pages: 34
Order Number: R41378
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Requiring Individuals to Obtain Health Insurance: A Constitutional Analysis

Jennifer Staman
Legislative Attorney

Cynthia Brougher
Legislative Attorney

Edward C. Liu
Attorney Adviser (General)

Erika K. Lunder
Legislative Attorney

Kenneth R. Thomas
Legislative Attorney

As part of the Patient Protection and Affordable Care Act (ACA), P.L. 111-148, as amended, Congress enacted a “minimum coverage provision,” which compels certain individuals to have a minimum level of health insurance (i.e., an “individual mandate”). Individuals who fail to do so may be subject to a monetary penalty, administered through the tax code. Congress has never compelled individuals to buy health insurance, and there has been significant controversy and debate over whether the requirement is within the scope of Congress’s legislative powers.

Shortly after ACA was enacted, several lawsuits were filed that challenge the individual mandate on constitutional grounds. While some of these cases have been dismissed for procedural reasons, others have moved forward. These challenges have now reached the Supreme Court. During the last week of March, the Court heard arguments in HHS v. Florida, a case in which attorneys general and governors in 26 states as well as others brought an action against the Administration, seeking to invalidate the individual mandate and other provisions of ACA. Besides evaluating the constitutionality of the individual mandate, the Court is examining the question of whether the Anti-Injunction Act currently prevents the Court from ruling on the merits of the case. It also is considering the extent to which the minimum coverage provision can be severed from the remainder of ACA, if it is found to be unconstitutional. Finally, the Court is analyzing ACA’s expansion of the Medicaid program and whether it unconstitutionally “coerces” states into compliance with federal requirements. This last issue will be addressed in CRS Report R42367, Federalism Challenge to Medicaid Expansion Under the Affordable Care Act: Florida v. Department of Health and Human Services, by Kenneth R. Thomas.

While there is no specific enumerated constitutional power to regulate health care or establish a minimum coverage provision, Congress’s taxing power or its power to regulate interstate commerce may be pertinent. With regard to the taxing power, the requirement to purchase health insurance might be construed as a tax and upheld so long as it was found to comply with the constitutional restrictions imposed on direct and indirect taxes. On the other hand, opponents of the minimum coverage provision may argue that since it is imposed conditionally and may be avoided by compliance with regulations set out in the statute, that the requirement may be more accurately described as a penalty. If so, the taxing power alone might not provide Congress the constitutional authority to support this provision.

In evaluating the minimum coverage provision under the Commerce Clause, one of several issues that may be examined is whether the individual mandate is a regulation of economic activity. Some argue that the requirement to purchase health insurance is economic in nature because it regulates how an individual participates in the health care market, through insurance or otherwise. Conversely, others argue that forcing individuals to participate in commerce in order to regulate them goes beyond the bounds of the clause.

This report analyzes certain constitutional issues raised by requiring individuals to purchase health insurance under Congress’s authority under its taxing power or its power to regulate interstate commerce. It also addresses whether the exceptions to the minimum coverage provision to purchase health insurance satisfy First Amendment freedom of religion protections. Finally, this report discusses some of the more publicized legal challenges to ACA, as well additional issues that are currently before the Court.


Date of Report: April 6, 2012
Number of Pages: 42
Order Number: R40725
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The Ministerial Exception and the Americans with Disabilities Act (ADA): Employment Discrimination and Religious Organizations

Cynthia Brougher
Legislative Attorney

Congress has enacted a number of federal laws banning discrimination in employment decisions, including hiring and firing of employees. For example, the Americans with Disabilities Act (ADA) prohibits discrimination based on disability. Title VII of the Civil Rights Act of 1964 prohibits discrimination in employment if the discrimination is based on race, color, religion, national origin, or sex. The Age Discrimination in Employment Act prohibits discrimination in employment based on age. Exceptions in these laws for religious organizations have reflected long-standing recognition of the autonomy of religious organizations in certain employment decisions.

While these statutory provisions protect religious organizations in selected contexts, religious organizations also have constitutional protection, known as the ministerial exception. The ministerial exception protects the employment relationship between a religious entity and its ministerial employees. Courts have long held that the First Amendment of the U.S. Constitution bars the government from interfering with internal governance of religious organizations, including decisions regarding employment of ministers or ministerial employees. This exception has generally been framed relatively narrowly to avoid undermining the public policy goals of nondiscrimination legislation. Thus, only religious institutions may claim the ministerial exception and may only do so if the employee functions as a minister or ministerial employee. The boundaries of the exception are not yet settled though. In 2012, the U.S. Supreme Court recognized the ministerial exception as a necessary outgrowth of its jurisprudence on noninterference in the internal governance of religious organizations (Hosanna-Tabor Evangelical Lutheran Church and School v. EEOC). However, the Court did not define the scope of the exception and declined to identify a standard for determining whether an employee could be labeled as ministerial.

This report analyzes the history and constitutional bases for the ministerial exception and examines selected statutory provisions reflecting its protections under the ADA and other employment laws. The report examines the distinction between the constitutional and statutory protections for religious organizations and addresses critical questions involved in judicial consideration of the ministerial exception. It analyzes which employees may qualify as ministerial, the extent to which courts may defer to religious entities claiming the exception, and whether the exception may apply to any claim brought against a religious entity.


Date of Report: March 27, 2012
Number of Pages: 18
Order Number: R42464
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The Independent Payment Advisory Board

Jim Hahn
Specialist in Health Care Financing

Christopher M. Davis
Analyst on Congress and the Legislative Process

In response, in part, to overall growth in Medicare program expenditures and growth in expenditures per Medicare beneficiary, the Patient Protection and Affordable Care Act (PPACA, P.L. 111-148, as amended) created the Independent Payment Advisory Board (IPAB, or the Board) and charged the Board with developing proposals to “reduce the per capita rate of growth in Medicare spending.” The Secretary of Health and Human Services (the Secretary) is directed to implement the Board’s proposals automatically unless Congress affirmatively acts to alter the Board’s proposals or to discontinue the automatic implementation of such proposals.

The annual IPAB sequence of events begins each year, starting April 30, 2013, with the Chief Actuary of the Centers for Medicare & Medicaid Services calculating a Medicare per capita growth rate and a Medicare per capita target growth rate. If the Chief Actuary determines that the Medicare per capita growth rate exceeds the Medicare per capita target growth rate, the Chief Actuary would establish an applicable savings target—the amount by which the Board must reduce future spending. This determination by the Chief Actuary also triggers a requirement that the Board prepare a proposal to reduce the growth in the Medicare per capita growth rate by the applicable savings target. The Board cannot ration care, raise premiums, increase cost sharing, or otherwise restrict benefits or modify eligibility. In generating its proposals, the Board is directed to consider, among other things, Medicare solvency, quality and access to care, the effects of changes in payments to providers, and those dually eligible for Medicare and Medicaid. If the Board fails to act, the Secretary is directed to prepare a proposal.

Board proposals must be submitted to the Secretary by September 1 of each year and to the President and Congress by January 15 of the following year. Board proposals are “fast-tracked” in Congress, and IPAB proposals go into force automatically unless Congress affirmatively acts to amend or block them within a stated period of time and under circumstances specified in the act. Section 3403(d) of the act establishes special “fast track” parliamentary procedures governing House and Senate committee consideration, and Senate floor consideration, of legislation implementing the Board or Secretary’s proposal. These procedures differ from the parliamentary mechanisms the chambers usually use to consider most legislation and are designed to ensure that Congress can act promptly on the implementing legislation should it choose to do so. PPACA also established a second “fast track” parliamentary mechanism for consideration of legislation discontinuing the automatic implementation process for the recommendations of the Board.

The Board’s charge is to develop proposals for the Secretary to implement that reduce the per capita growth in Medicare expenditures, not to reduce Medicare expenditures. Therefore, while the CBO projects that the cumulative impact of the Board’s recommendations from 2015 through 2019 will reduce total spending by $15.5 billion, during the same period, Medicare expenditures will total $3.9 trillion with average spending per beneficiary forecast to increase from $13,374 to $15,749. While the Board’s potential impact on total expenditures is likely to be relatively small compared to overall Medicare expenditures, its impact on particular Medicare providers or suppliers may be significant, particularly if the Board alters payment mechanisms.

The President’s FY2013 budget, as submitted to Congress on February 13, 2012, includes a proposal to strengthen the IPAB. On March 22, 2012, the House passed a combined version of the Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011 (H.R. 5) that contained provisions from H.R. 452, the Medicare Decisions Accountability Act of 2011, which would repeal the IPAB.


Date of Report: March 26, 2012
Number of Pages: 40
Order Number: R41511
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Overview of Health Care Changes in theFY2013 Budget Proposal Offered by House Budget Committee Chairman Ryan

Patricia A. Davis
Specialist in Health Care Financing

Alison Mitchell
Analyst in Health Care Financing

Bernadette Fernandez
Specialist in Health Care Financing

On March 20, 2012, House Budget Committee Chairman Paul Ryan released the Chairman’s mark of the FY2013 House budget resolution together with his report entitled “The Path to Prosperity: A Blueprint for American Renewal,” which outlines his budgetary objectives. On the same day, CBO issued an analysis of the long-term budgetary impact of Chairman Ryan’s budget proposal based on specifications provided by House Budget Committee staff. The House Budget Committee considered and amended the Chairman’s mark on March 21, 2012, and voted to report the budget resolution to the full House. H.Con.Res. 112 was introduced in the House March 23, 2012, and was accompanied by the committee report H.Rept. 112-421. H.Con.Res. 112 was agreed to by the House on March 29, 2012.

A budget resolution provides general budgetary parameters; however, it is not a law. Changes to programs that are assumed or suggested by the budget resolution would still need to be passed by separate legislation. Chairman Ryan’s budget proposal, as outlined in his report and in the CBO analysis, suggests short-term and long-term changes to federal health care programs including Medicare, Medicaid, and the health insurance exchanges established by the Patient Protection and Affordable Care Act as amended (ACA, P.L. 111-148, P.L. 111-152).

Within the 10-year budget window (FY2013-FY2022), the budget proposal assumes that certain ACA provisions would be repealed, including those that expand Medicaid coverage to the nonelderly with incomes up to 133% of the federal poverty level, and those provisions that establish health insurance exchanges. The proposal would also restructure Medicaid from an individual entitlement program to a block grant program. Beyond the 10-year budget window, beginning in 2023, the budget proposal assumes an increase in the age of eligibility for Medicare and the conversion of Medicare to a fixed federal contribution program.

This report summarizes the proposed changes to Medicare, Medicaid, and private health insurance as described in H.Con.Res. 112, the accompanying committee report, Chairman Ryan’s “Path to Prosperity” report, and the CBO analysis. Additionally, it briefly examines the potential impact of the proposed changes on health care spending and coverage.


Date of Report: March 29, 2012
Number of Pages: 16
Order Number: R42441
Price: $29.95

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