Health Care Reform Center

Judith S. Palfrey, M.D.

Medical and scientific advances have reduced the rates of acute childhood illnesses and childhood mortality and increased the positive outcomes of a wide variety of serious childhood illnesses; nevertheless, children’s health in the United States currently falls short. Our infant mortality rate is higher than that of 29 other countries, and the United Nations Children’s Fund (UNICEF) ranks the United States last among 21 developed countries in terms of children’s health and safety.¹ The children’s health community is looking to health care reform to improve access, provide needed preventive and comprehensive benefits, and develop quality initiatives for all children and youth through the medical home. The medical home is a system of comprehensive, family-centered, culturally appropriate services, through which all children and young people would be provided care, with appropriately enhanced services for those with special health care needs. A number of components are essential if reform is to benefit children and young people adequately.

Lack of insurance affects care and outcomes.² On the basis of the latest U.S. census figures, 7.3 million American children (9.9%) were uninsured in 2008. Rates varied widely among states; the percentage of children who did not have coverage ranged from 3.4% in Massachusetts to 19.1% in Nevada (see map).³ Despite the passage of the Children’s Health Insurance Program Reauthorization Act (CHIPRA), 5 million to 6 million children may remain uninsured because of eligibility requirements and the current recession. Furthermore, CHIPRA will expire in 2013. Health care reform legislation must ensure sustained universal coverage that includes all children and young people. The proposed expansion of family coverage to include family members up to 26 years of age would fill a particularly troublesome insurance gap, and the ban on exclusion of persons who have preexisting conditions is a welcome correction.

Uninsured Children in the United States in 2008, by State.

Data are from U.S. Census Bureau.³

To ensure access, health insurance must provide adequate payment for providers. Currently, the average state Medicaid program pays providers at a rate that is 72% of Medicare rates. This low payment rate forces many providers to limit the number of patients with public coverage whom they accept. The health care bill under consideration in the House of Representatives (H.R. 3200) would raise Medicaid payment rates to 100% of Medicare rates within 3 years. Thus, children who depend on public insurance would come much closer to having access to health care that is equal to that of children with private insurance.

Prevention is cost-effective, and preventive care provided during childhood for conditions such as obesity and hypertension will help avert serious disease in adulthood. For example, it has been predicted that reducing the prevalence of obesity to 1998 levels by 2023 would have major health and economic effects (see table).⁴ The incorporation into health care reform of measures that promote the provision of preventive care without copayments, as the national Bright Futures initiative recommends, along with the expansion of eligibility for Medicaid’s Early Periodic Screening, Diagnosis, and Treatment program, would be a major gain for children.

Support for coordinated care is essential for the optimal delivery of health care. Medical homes in pediatrics provide continuous medical coverage, bringing together primary care, specialty services, emergency services, and hospitals.⁵ The House reform legislation incorporates the medical home concept, which it considers both a quality enhancement and a cost-control measure. Most important is the related financial support for additional coordination of care, which would probably take the form of a per-member-per-month fee paid in addition to the fee for service. As proposed, H.R. 3200 includes an important step that will benefit children by funding pilot medical home programs under Medicaid.

Caring for children and adolescents with chronic conditions or special needs requires coordinated subspecialty care as a vital component of the medical home approach. Access to such care relies on having a robust subspecialist workforce, but owing to the increasing costs of medical education and limited compensation, there is a shortage of physicians in pediatric subspecialties. Thus, reform legislation will need to ensure the recruitment and retention of clinicians both in primary care and in subspecialty fields.

Many of the current reform proposals include programs that would have a highly favorable effect on children’s health. As the legislation makes its way through Congress, it will be critical to ensure that the new programs are adequately funded and are protected by means of other assurances at the federal and state levels. If all children have access to financially supported medical homes that emphasize prevention, health care reform will truly benefit children — and society at large.

Dr. Palfrey is the President-elect of the American Academy of Pediatrics. No other potential conflict of interest relevant to this article was reported.

Source Information

From the Division of General Pediatrics, Children’s Hospital, Boston.

This article (10.1056/NEJMp0908051) was published on October 7, 2009, at NEJM.org.

References

1. Child poverty in perspective: an overview of child well-being in rich countries. Innocenti report card 7. Florence, Italy: UNICEF Innocenti Research Centre, 2007. (Accessed September 22, 2009, at http://media.npr.org/programs/atc/features/2007/feb/childreport.pdf.)
2. Szilagyi PG, Schuster MA, Cheng TL. The scientific evidence for child health insurance. Acad Pediatr 2009;9:4-6.
3. U.S. Census Bureau. Current Population Survey — Table HI05: health insurance coverage status and type of coverage by state and age for all people: 2008. (Accessed September 22, 2009, at http://www.census.gov/hhes/www/cpstables/032009/health/h05_000.htm.)
4. DeVol R, Bedroussian A. An unhealthy America: the economic burden of chronic disease. Santa Monica, CA: Milken Institute, October 2007.
5. Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics 2008;122:e922-e937. [Free Full Text]