From Child Health Coverage to Healthy Child Development: Federal Health Reform Opportunities to Improve the Health of America's Youngest Children

Abstract

For more than two centuries, environmental, social, economic, and clinical care advances have improved the health of our children and the prosperity of our nation. However, for the first time in our history, America faces the sobering prospect that our children will grow up less healthy and live shorter lives than their parents. The First Lady's Childhood Obesity Initiative is one, but only one, step to alter this prospect. The Child Health Insurance Program Reauthorization Act (CHIPRA), enacted in early 2009 to increase children's health coverage, included provisions and some demonstration funding to improve child healthcare quality outcome measurement and address childhood obesity. Although improving the content of children's healthcare received little public attention in the national debate on health reform, the Patient Protection and Affordable Care Act included a number of provisions offering federal guidance and funding opportunities to expand primary and preventive child health services. Medicaid reimbursements for primary care will be increased in most states, commencing in 2014. New federal support is provided to states and communities to establish home visiting cetners, healthcare innovation zones, and community transformation grants—all of which have the potential to improve children's health.If these federal actions are to succeed in practice, however, the pediatric community must play a pivotal role in their design and implementation. Actions must address environmental, social, economic, and clinical care issues, with the pediatric community playing a lead role in developing clinical care for children that also improves children's environmental, social, and economic prospects. In many respects, this starts with the content and quality of primary and preventive health services for children. Having the right care is especially important from birth through age 5 years, because these earliest years establish health trajectories that extend into adulthood.1Halfon N. Hochstein M. Life course health development: an integrated framework for developing health, policy, and research.Milbank Q. 2002; : 80Google Scholar There are several elements to providing the right care for young children:•Accessing care at recommended intervals allows child health care practitioners to function as a nearly universal point of contact for young children and their families. This provides the opportunity for screening and responding to a child's physical, social, and developmental needs.2Child and Family Policy Center and Voices for America's ChildrenThe child health story book: Policy opportunities to improve children's healthy development. Voices, Washington, DC2009Google Scholar•Providing comprehensive, “whole child” care allows health care providers to identify and address the full spectrum of factors that affect children's health and well-being. This life-course approach to child health is needed to ensure that all factors affecting children's healthy development are addressed.3National Research Council and Institute of MedicineChildren's health, the nation's wealth: assessing and improving child health. The National Academies Press, Washington, DC2004Google Scholar•Practicing family-centered and family-oriented care not only acknowledges parents' central role in setting and maintaining positive health trajectories; it also encourages practices to collaborate with other community service providers and support systems.4Schor E. Family pediatrics: report of the task force on the family.Pediatrics. 2003; 111: 1541-1571PubMed Google Scholar This is essential not only to identify and respond to risk factors, but also to strengthen protective factors,5Catalano R. Hawkins J. The social development model: a theory of antisocial behavior.in: Hawkins J. Delinquency and crime: current theories. Cambridge University Press, New York1996: 146-197Google Scholar build on assets,6Benson P. All kids are our kids: what communities must do to raise caring and responsible children and adolescents. Jossey-Bass, San Francisco2000Google Scholar and foster resiliency.7Henderson N. Benard B. Sharp-Light N. Resiliency in action: practical ideas for overcoming risks and building strengths in youth, families, and communities. Resiliency in Action, San Francisco1999Google Scholar It entails working to strengthen family and social capital8Belsey M. AIDS and the family: policy options for a crisis in family capital. Department of Economic and Social Affairs of the United Nations Secretariat, New York2005Google Scholar and eliminate “toxic stress” that is at the root of many severe health problems in children.9National Scientific Council on the Developing ChildExcessive stress disrupts the architecture of the brain. The Center on the Developing Child at Harvard University, Cambridge, MA2005Google Scholar The American Academy of Pediatrics' Bright Futures program offers evidence-informed guidelines for the provision of such high-quality well-child care, responding to social and medical determinants of health.10Hagan J. Shaw J. Duncan P. Bright futures: guidelines for health supervision of infants, children, and families. American Academy of Pediatrics, Elk Grove Village, IL2008Google Scholar In a key provision, the Patient Protection and Affordable Care Act requires insurance plans to cover the preventive care and screenings described in Bright Futures, with no cost sharing requirements. The Commonwealth Fund's support of 3 rounds of Assuring Better Child Health and Development (ABCD) initiatives has fostered innovation in putting such practices into wider use within state Medicaid programs, by which most children with special needs are covered. As important, the ABCD initiative has helped to identify the policy processes that facilitate such change.11Kaye N. May J. Abrams M. State policy options to improve delivery of child development services: strategies from the eight ABCD states. National Academy for State Health Policy, Portland, ME2006Google Scholar Other exemplary state initiatives, such as Connecticut's Help Me Grow program, Vermont's Child Health Improvement Partnership, and Community of Care of North Carolina, offer promising strategies to identify and respond to medical and social determinants of health, with pediatric practices linked to community systems of support.2Child and Family Policy Center and Voices for America's ChildrenThe child health story book: Policy opportunities to improve children's healthy development. Voices, Washington, DC2009Google Scholar These approaches all offer ways to improve routine primary health care practices to produce physically and developmentally healthy children. Although federal legislation has not focused explicitly on the content of primary and preventive child health services, it has created multiple opportunities for the development and the diffusion of innovative approaches to improve child health outcomes.12Rogers E. Diffusion of innovation.5th ed. Free Press, New York, NY2003Google Scholar Particularly for young children, a major share of this diffusion can only occur when the pediatric community collaborates with state agencies and child advocates to make full and creative use of the Medicaid and Child Health Insurance Program. There are exemplary initiatives on which to build, and leadership is needed within states to adapt, expand on, and learn from them. Even the most comprehensive and high-quality health care can only do so much. The communities in which children live and learn are powerful influences on children and their families. The disinvested neighborhoods of poor, immigrant, and minority children pose hazards that will require community-building and individual service strategies if gaps in child health outcomes (let alone social, economic, and justice gaps) are to be addressed.13Bruner C. Schor E. Clinical practice and community building: addressing racial disparities in healthy child development. National Center for Service Integration, Des Moines2008Google Scholar As influential members of their communities, pediatric practitioners have an active advocacy and public education role to play in local coalitions that address broader community conditions that place children at health risk.14Fine A. Hicks M. Health matters: the role of health and the health sector in place-based initiatives for young children. W.K. Kellogg Foundation, Battle Creek, MI2008Google Scholar Several new federal health care options focusing on community health centers and other safety net providers offer additional venues for pediatric practitioners to affect children's health and development. Along these lines, the California Endowment has focused some of its grant making on collaborative, community health building strategies, which may pose the most promise for achieving health equity in the United States.15Mayeno L. Multicultural organizational development: a resource for health equity. CompassPoint Nonprofit Services monograph series supported by The California Endowment, San Francisco, CA2007Google Scholar In short, federal health reform has created opportunities to re-shape and improve pediatric practice, but taking advantage of these opportunities requires pediatric leadership at the state and community levels. Exemplary practice needs to become standard practice in primary pediatric care. Without making substantial changes in the content, processes, and quality of child health care, America is likely to experience the sobering and very costly prospect of less healthy children and adults. This is preventable, provided the pediatric community takes a leadership role in when can lead and a supporting role to other community efforts when those efforts require pediatric support.