Table Of Contentsharing child and youth development knowledge
volume 29, number 4
2016
Social Policy Report
The Influence of Health Care Policies on
Children’s Health and Development
James M. Perrin Thomas F. Boat Kelly J. Kelleher
Harvard Medical School University of Cincinnati Ohio State University
ABSTRACT
R
ates of health insurance for children have improved significantly
over the past few decades, and more children have insurance than
ever before in U.S. history. Health care does improve child health
and well-being, but growing understanding of social and commu-
nity influences has led health care practitioners to work toward more
comprehensive and community-integrated child health services to
improve child and family well-being. High rates of poverty affect children’s health—
poor children have more acute and chronic illness and higher mortality as well. Children
and youth also have more diagnosed mental health conditions than in years past. This
paper reviews the current state of health insurance for children and youth and contrasts
health services with the needs of children and families. It then describes new models
of health care, including ones that actively connect health care with other community
services, and suggests promising trends in child health care.
From the Editor
Social Policy Report
Volume 29, Number 4 | 2016
ISSN 1075-7031 The health of children in America has primary implications for the future of
www.srcd.org/publications/social- this country. In this report, the Drs. Perrin, Boat, and Kelleher review the
policy-report
progress made in providing health care to children, the changes that have
Social Policy Report occurred in children’s health conditions, the impact of current policies, and
is published four times a year by the potential innovative approaches to providing health care. Children’s health
Society for Research in
could be seen as a success story of policy and practice. Greater than 90% of
Child Development.
children in the United States have some type of health insurance coverage,
Editorial Team
which is the highest it has ever been. Major childhood diseases, epidemics,
Samuel L. Odom, Ph.D.
and severe malnutrition, previous primary causes of childhood mortality have
(Lead & Issue editor)
[email protected] largely dissipated. These have been replaced by conditions such as childhood
Kelly L. Maxwell, Ph.D. (editor) obesity, asthma, mental health, and neurodevelopmental disorders, which
[email protected] are the result of interactions between genetics and social and environmental
Iheoma Iruka, Ph.D. (editor) factors. The overlay of poverty, despite progress in children’s health cover-
[email protected]
age, still creates health disparities between poor and non-poor children. The
Stephanie Ridley (Assistant editor)
authors describe a range of factors that may address this disparity. These
[email protected]
include new models of health policy, health economics, and funding (e.g., the
Director of SRCD Office for
Policy and Communications Affordable Care Act, social impact bonds), new models of health care (e.g.,
Martha J. Zaslow, Ph.D. chronic condition management, behavioral health integration), innovations
[email protected] in health care delivery (e.g., mHealth approaches), and changes in pediatric
Managing Editor training (e.g., emphasis on integration of health and other social services).
Amy D. Glaspie
[email protected] In their commentary, two children’s health leaders also focus on the
Governing Council continued effect of poverty on children’s health. Dr. Dreyer describes the new
Ronald E. Dahl Mary Gauvain policy on poverty and health adopted by the American Academy of Pediatrics,
Lynn S. Liben Kofi Marfo which emphasizes (as did Perrin et al.) integration of services and engagement
Marc H. Bornstein Frosso Motti with other sectors of the community. He importantly points out that health
Natasha Cabrera Seth Pollak
care reform for children is different than for adults, in that it focuses on long-
Robert Crosnoe Deborah L. Vandell
term health outcomes for children that last into adulthood, as contrasted with
Michael Cunningham Natalia Palacios
Kenneth A. Dodge Lonnie Sherrod, ex officio the adult care emphasis on cost containment for chronic disease conditions.
Andrew J. Fuligni Martha J. Zaslow, ex officio Dr. Chaudry, like Dr. Perrin, acknowledges the significant progress made in
Anne Perdue, ex officio promoting children’s health, noting that the proportion of children reported in
excellent health is higher than it has ever been. Again, this positive message
Policy and Communications Committee
is tempered by disparities that poverty continues to create, but he also states
Brenda Jones Harden Taniesha A. Woods
that at this point in time there may be the opportunity to leverage current
Rachel C. Cohen Kenneth A. Dodge
Sandra Barrueco Seth Pollak health care policy to address disparate outcomes. He notes the potential for
Kimberly Boller Robey Champine innovative programs that integrate services, have a two-generation emphasis,
Rebekah Levine Coley Ellen Wartella, ex officio and focus on behavior health in the context of the home.
Kelly Fisher Lonnie Sherrod, ex officio
Rachel A. Gordon Martha J. Zaslow, ex officio On a final note: this is the concluding Social Policy Report for the
Tina Malti Nighisti Dawit, staff liaison
current editorial team. As lead editor, I want to express my appreciation for
Ann Rivera
great collaborators who have been issue editors for this report—Donna Bryant,
Publications Committee
Kelly Maxwell, and Iheoma Iruka, our outstanding copy editing and production
Pamela Cole Marc H. Bornstein
staff, Stephanie Ridley, Leslie Fox, Gina Harrison, and the support of SRCD’s
Marian Bakersmans-Kranenburg Erin Hillard
central office (Amy Glaspie) and the SRCD Office of Communication and Policy
Robert J. Coplan Patricia Bauer, ex officio
Diane Hughes Rob Kail, ex officio (Marty Zaslow). We leave this report in the skilled hands of Dr. Ellen Wartella
Melanie A. Killen Cynthia Garcia Coll, ex officio
and her editorial team.
Vladimir Sloutsky Ellen Wartella, ex officio
Jeffrey Lockman Angela Lukowski, ex officio
—Samuel L. Odom (Issue Editor)
Kenneth Rubin Jonathan B Santo, ex officio
Judith G. Smetana Lonnie R. Sherrod, ex officio Kelly L. Maxwell (Editor)
Mary Gauvain Adam Martin
Iheoma U. Iruka (Editor)
Social Policy Report V29 #4 2 The Influence of Health Care Policies on
Children's Health and Development
The Influence of Health Care Policies on
Children’s Health and Development
H
ow do current health care policies health care services, limiting the effectiveness of health
influence child health and develop- care to improve health. At the same time, greater un-
ment in America? The US has recently derstanding of the importance of early life experiences,
achieved the highest rates of child early education, and family and community influences on
health insurance coverage in history, in child health and development has highlighted new and
part due to state Medicaid expansions changing needs for child health care. Additionally, there
and the continued growth of the state Children’s Health is clear recognition that improving child health requires
Insurance Program (CHIP). Other health care policies— integration across multiple sectors as well as having a
many in the public health arena—influence child health, long-term or life course perspective. Two examples docu-
ranging from infection control programs and policies to ment these needs for new policy directions well—the
public nutrition programs to prevention of injurious expo- effects of poverty on child health and the prominence of
sures to child abuse and neglect reporting to (generally behavioral health issues for children.
ineffective) gun violence prevention programs. For the Poverty affects essentially all aspects of child
most part, these policies provide for basic, not optimal, health and development—higher mortality from serious
health protections and access to health care. childhood illnesses, higher rates of accidents and inju-
Over the past several decades, many of the scourg- ries, higher rates of common chronic health conditions
es of child health—infectious diseases such as diphtheria and resulting disability, less physical endurance as well as
or meningi- poorer school
tis, rickets performance
and severe and graduation
… there is clear recognition that improving child
malnutrition, rates, more
lead poison- health requires integration across multiple sectors as risky sexual
ing, and early and substance
deaths from well as having a long-term or life course perspective. abuse be-
cancer—have haviors, and
diminished or higher rates of
even almost incarceration
disappeared, in part due to effective federal policy on as adolescents. From a health perspective, decreasing
sanitation, food, and health care. The decline of many poverty will improve health status and response to medi-
older diseases has been countered by new epidemics cal treatments as much or more than improvements in
of obesity, asthma, neurodevelopmental disorders, and personal health care services for children. Yet, strategies
mental health conditions, but federal health policy has to diminish poverty among U.S. families are not straight-
moved slowly to address these new issues. Most of the forward and require a multifaceted approach, including
health problems that affect children and youth today work to improve household income, housing, nutrition,
reflect social and community influences rather than jobs, and education among families of young children.
infections (although social factors also influence acquisi- Rates of mental health diagnoses have grown rap-
tion of infections and their severity). The circumstances idly among U.S. children and youth. Here, too, children
into which a child is born have stronger relationships to face a highly fragmented system at every level of care
her/his health and development than do genes or direct for behavioral and emotional symptoms. Identification
Social Policy Report V29 #4 3 The Influence of Health Care Policies on
Children's Health and Development
of mental health problems can come from community any applicant meeting eligibility requirements must be
services (e.g., day care or schools), health services, or enrolled. But Medicaid, unlike Medicare, has joint fund-
family referral. Much mental health diagnosis and treat- ing from the federal government and the states, and
ment, especially for low-income children, takes place states maintain oversight prerogatives regarding the
in the public school system. Health and related service state’s Medicaid program. Insofar as Medicaid, too, is an
providers have little incentive currently for early identifi- entitlement program, states are unable to predict their
cation and treatment (or referral) of children and fami- Medicaid expenditures each year. Furthermore, when the
lies for behavioral health, although recent efforts to (re) economy weakens, state revenues fall but more people
integrate behavioral health with the rest of the health meet financial eligibility requirements for Medicaid (and
care sector have promise. Current federal policy in this other public programs). Medicaid, as a joint federal-state
area maintains separation of health and behavioral health program, has much variation across states in payment
services in many situations, from precluding researchers level and services covered. On average, Medicaid pay-
from accessing behavioral health claims for study to poli- ments are about 2/3 the level of Medicare payments
cies that support separation of psychiatric hospitals and for the same service (Rosenbaum, 2014). New York and
institutions from other services. Massachusetts may cover different mental health services
How do current policies affect and improve child and pay very different rates for those services. States
outcomes—and especially help to promote an effective, set eligibility requirements, payment rates, and methods
well-trained, healthy, and competent young adult popula- of payment (e.g., managed care or direct to provider
tion? This report addresses those questions and offers pro- payment), covered services, and scope of benefits (e.g.,
posals to build stronger, cross-sector programs to enhance hospital days or physical therapy may be covered, but
the health and development of children in America. the maximum yearly benefit could be just a few days or
a few treatments). The variations across state Medicaid
programs are dramatic, with little consistency (Kaiser
Health Insurance for
Commission on Medicaid and the Uninsured, 2013).
Children and Families Today
Medicaid, initially limited to children on welfare
Children and youth obtain health insurance through a
or with severe disabilities, now includes many children
combination of public and private sources (Bureau of
with household incomes well above the limits required
Labor Statistics & the Census Bureau, 2014). The majority
for public assistance through the Temporary Assistance to
(although diminishing in proportion) of children still re-
Needy Families (TANF) program, in most states up to 2 or
ceive insurance coverage through a parent’s employment
3 times the Federal Poverty Line (FPL). In the mid-1990s,
benefits. Rates of employer coverage of children’s insur-
Congress passed the Children's Health Insurance Program
ance have slowly dropped over the past quarter century
(CHIP), which provides additional insurance coverage for
(from about 75% in 1980 to about 57% in 2014), in part
children in households with incomes too high for Medic-
due to decreasing family coverage for employees (Bureau
aid but not eligible for employer-based programs (Artiga
of Labor Statistics & the Census Bureau, 2014). In years
& Cornachione, 2016). CHIP, unlike Medicaid, is a block
past, employee benefits usually included health insurance
grant to the states rather than an entitlement program;
for the employee’s household; increasingly, employers
when a state runs out of its yearly grant, it can refuse to
limit health benefits to the employee alone.
enroll new, eligible children. Finally, implementation of
Partly as a result of the decline in employer sup-
the Affordable Care Act (ACA) has helped insure some ad-
port for dependents, public health insurance has grown
ditional children, both because they may be directly eli-
substantially as the payer for children’s health care.
gible but also because increasing coverage for adults has
Medicaid, the major public insurance program for low-
led parents to seek different ways to insure their children
income children, differs from Medicare in several critical
(Artiga & Cornachione, 2016). Generally, insured parents
ways (Iglehart & Sommers, 2015). Medicare, a national
are more likely to try to find insurance for their children
health insurance program for all citizens over age 65,
than are uninsured parents, and the process of enroll-
has national payment rates, full funding from the fed-
ment for the ACA has helped parents determine whether
eral government, and common covered services for all
their children are eligible for Medicaid or other programs.
beneficiaries, regardless of where they live. Medicaid,
While more children than ever before are covered,
like Medicare, is an entitlement program, such that
insurance coverage does not guarantee access. First,
Social Policy Report V29 #4 4 The Influence of Health Care Policies on
Children's Health and Development
large numbers of dentists and pediatricians in the US The incentives in traditional insurance arrange-
do not accept Medicaid for children in their practices ments thus are to increase the number of visits or pro-
because of low payment rates. Second, parents with cedures for which insurance will pay. Yet, the relation-
both private and public insurance have increasing out-of- ship between these services and outcomes that might
pocket costs for a variety of health care expenses from be valued for children and adolescents may be limited.
new, high cost treatments to routine visits. Finally, many Assessment of quality of care in traditional arrangements
children with specialty care needs lack needed services has often focused on assuring performance of certain
because of long wait lists for appointments at regional services, especially monitoring activities (e.g., routine
pediatric specialty centers where the supply of pediatric height and weight, assessment for obesity) and some pre-
specialists remains low. ventive services (e.g., immunizations and certain screen-
These insurance expansions—most in the public ings, such as hearing and vision or lead levels) rather
sector—have led to over 94% of children in the US now than improvements in outcomes or effectiveness.
having some form of health care insurance coverage. Poor Some evidence does indicate that having health
children continue to lag behind middle income children, insurance improves child health, although clearly other
but the gap has markedly factors—family, social, and
narrowed (Bureau of Labor community characteristics—
Statistics & the Census have much more influence
Bureau, 2014). This growth Some evidence does indicate that on a child’s health and
in public insurance for well-being than does health
having health insurance improves
children represents sub- insurance. In general, most
stantial growth in public of the evidence is that
child health, although clearly
investment. Given the health care improves access
major squeeze on discre- other factors—family, social, and to and use of preventive
tionary funding in federal services, especially rou-
community characteristics—have
and many state budgets, tine checkups (Edmunds &
however, this growth has Coye, 1998). Children with
much more influence on a child’s
come at the expense of health insurance appear to
new funding for other pub- health and well-being than does have better dental health
lic services in education or as well (Leininger & Levy,
social and community ser- health care. 2015). But, as an example,
vices (Rosenbaum & Blum, although the US has high
2015; Steuerle, 2014). immunization rates, that
achievement in large part
reflects requirements for adequate vaccination at school
What Does Insurance Cover?
entry rather than the success of health insurance. For
U.S. health insurance has long focused on paying for
very young children, more evidence supports the value of
services provided—in general, the more work done (i.e.,
non-reimbursed services like home visiting and nutrition
more visits, procedures, treatments), the greater the
programs (e.g., WIC) than reimbursed routine prenatal
payments (i.e., fees for services provided). Providers
care (Rossin-Slater, 2015). Addressing the family and com-
(physicians, nurses, hospitals, health centers) must meet
munity issues that have the main impact on children’s
certain requirements for licensure and accreditation but
long-term well-being will require major changes in the
they then receive payment for an array of services mainly
application of incentives in health insurance—moving
focused on disorder assessment and treatment. Public
from a focus on medical care coverage to strategies to
and private payers will pay for a variety of services,
make health care more effective in building healthy com-
increasingly including some preventive care and health
munities (Robert Wood Johnson Foundation, 2014).
promotion, although the original intention of insurance
A sizable number of children experience (individu-
was catastrophic-risk protection against unexpected high
ally) relatively rare and complex conditions such as
(health care) expenses. Preventive services (e.g., immu-
juvenile arthritis, hemophilia, leukemia, brain tumors,
nizations, screening) still account for only a small per-
sickle cell disease, and chromosomal disorders. Although
centage of total health expenditures for children.
Social Policy Report V29 #4 5 The Influence of Health Care Policies on
Children's Health and Development
each condition may be individually rare, adding all ap- less than $13,000 for a family of four. Thus, households
proximately 7,000 rare diseases (most of which manifest must generally be extremely poor to gain TANF eligibility
in childhood) together leads to a large number of chil- (Falk, 2013). State payment rates vary similarly, from a
dren (3.5 million) with conditions that typically require high in New York of $753 per month for a family of three
much expertise and cost in their diagnosis, management, to a low of $170 in Mississippi. TANF rules, outlined in
assessment for complications, and monitoring over time. the Personal Responsibility and Work Opportunity Recon-
This group of children may get a good deal of care from ciliation Act of 1996, also place limits on the number of
community health providers, although most of them years recipients may receive benefits. Furthermore, that
also will need access to care and support from pediatric welfare reform act ended any increase in funds, such that
subspecialists—medical and surgical (Perrin, Anderson, & the total state and federal expenditures for TANF have
Van Cleave, 2014). Pediatric subspecialists, unlike many remained the same for the last two decades, indicating
subspecialties in adult medicine, are relatively few in a loss of about 32% in real dollars from inflation. About
number and typically centralized in specialized children’s a third of households receiving TANF have children with
hospitals and academic programs, often at some distance disabilities in them, limiting parents’ work opportunities
from where their patients with rarer chronic conditions and often requiring much parent caretaking over years.
may live. TANF acts as a critical safety net for the few families with
Medicaid, as a joint federal-state program, gener- young children who are eligible for benefits in lifting them
ally serves children within a state’s borders. A child who out of abject poverty. Although a vital source of income
may need to travel to a neighboring or more distant state for the relatively small number of households who are
for specialized care may find that the insurance cover- eligible, TANF fills a relatively small gap in services and
age does not travel with her and may face difficulty in support needed by families raising children with chronic
accessing needed care. Most children’s hospitals provide health conditions and other threats to their health and
specialized care to children in neighboring states as development. Poverty is linked to numerous opportunities
well as in their home communities. While these special- for stressful adverse experiences, and persistent adver-
ized programs may contract with Medicaid agencies in sity can be toxic and contribute to poor behavioral and
neighboring states, these contracts may pay less than the physical health across the lifespan. Policy that addresses
in-state rate for care and can be an obstacle to needed poverty, with understanding of the short- and long-term
specialized treatment. Moves to develop regionalized costs and benefits for individuals and society, should be a
systems of care, with regionalized Medicaid funding, may national priority.
help to improve access (Children’s Hospital Association, The Supplemental Security Income (SSI) program
2015). provides cash assistance to low-income people with se-
vere disabilities, including children. In general, the level
of disability must be quite high—that is, most children
Support For Children Living In Poverty
and Those with Disabilities with chronic health conditions will not meet the high
A number of other programs provide some support for standard of severity that SSI uses (Boat & Wu, 2015).
children and families, especially in low-income house- Approximately 1.3 million U.S. children and youth cur-
holds. The full range of these programs—from nutrition rently receive SSI benefits, and the associated income (up
to housing to juvenile justice—is beyond the scope of to about $8,000 per year) keeps a moderate number of
this report, although all can influence child health. We households with children with disabilities above the FPL.
will focus on two programs with direct effects on pov- SSI is mainly a federally-funded program, although many
erty amelioration and links to health care eligibility: the states supplement the monthly federal benefit. States,
Temporary Assistance to Needy Families (TANF) program through their Disability Determination Services, deter-
and the Supplemental Security Income (SSI) program. mine financial and clinical eligibility for applicants, work-
Both programs provide cash assistance to low-income ing under federal rules and supervision. Raising a child
families but with different purposes. TANF, like Medicaid, with a severe disability usually increases family expenses
is a joint federal-state program, with states having much (many needed services and supplies are not covered by
flexibility in determining eligibility and payment rates. In private or public health insurance), along with decreas-
2012, TANF income eligibility rates varied across the na- ing household income, as often one or both parents must
tion, with a national average of about 50% of the FPL—or limit or quit the workplace to care for a child with a
Social Policy Report V29 #4 6 The Influence of Health Care Policies on
Children's Health and Development
major disability. Thus, these SSI funds help to replace this for major health care cost savings in a short period of
income and allow families to meet some of their addition- time are much more limited. Improvement of child health,
al costs. Moreover, SSI eligibility almost always confers however, represents an appealing long-term strategy for
eligibility for Medicaid enrollment and services. reducing adult health care costs.
Both of these programs, like Medicaid, experience
major variations across states. For Medicaid and TANF,
What Are the Needs of Children and Families
states have much flexibility in determining eligibility and
That Health Care Policies Can Address?
benefits. A recent report also documented wide variations
Several characteristics distinguish children from older
in rates of applications, assessments, and determina-
populations. They have substantially more racial and
tions of eligibility for SSI across the states, although the
ethnic diversity than any other group, and their devel-
reasons for these variations are not clear (and likely do
opment influences what diseases they experience, how
not reflect major variations in rates of severe disability
those conditions manifest at different ages, and how chil-
across the states) (Boat & Wu, 2015). Policy that pro-
dren respond to treatment (Forrest, Simpson, & Clancy,
motes equity in supports and services that improve health
1997; Perrin & Dewitt, 2011). Children depend very much
outcomes should have a beneficial impact on the health
on adults—initially, parents and family and later, teach-
of the U.S. population.
ers and others—for their health care and developmental
needs. Although in general, children are healthier than
Recent Trends In Health Care Payment other populations, they too experience much chronic
The high rates of inflation in health care expenditures have illness, at increasing rates over the past decades. And
led to much interest in finding new ways to diminish the finally, they have much higher rates of poverty than any
growth of health care costs. The Affordable Care Act, espe- other age group, and poverty has pervasive influences on
cially as implemented through the Center for Medicaid and health and wellness and on growth, development, and
Medicare Services (CMS), has supported experimentation educational achievement.
with new ways to incentivize preventive care for high-risk The past few decades have seen much change in
older populations—groups with high rates of hospital and the health conditions that children face. Many serious
emergency department care. Based mainly in Medicare infectious diseases have disappeared with effective im-
and not Medicaid, these strategies have begun to apply munization programs (e.g., measles, diphtheria, tetanus,
new notions of prevention and keeping populations healthy meningitis). Tuberculosis affects far fewer children than
(or healthier). Payment approaches have included sharing in decades past; many conditions that would have led
financial risk with providers—if providers can cut costs for to early death now have treatments that have greatly
populations, for example, by decreasing hospital use, the improved life expectancy for those who experience them
provider may share in the savings accrued. Providers have (e.g., leukemia, complex congenital heart disease, cystic
responded by implementing health care teams, dedicated fibrosis). Main causes of death today among children and
case management, new health status monitoring technolo- adolescents are accidents and suicides rather than mal-
gies (including extensive use of mHealth), home care, and nutrition and epidemics (Rosenbaum & Blum, 2015).
others. Payers, with Medicare leading the way, have experi- These strong improvements in child health have
mented with new ways to pay for health care, including been accompanied by major growth in four groups of
incentives to meet newer quality standards, sharing savings common health conditions among children: obesity,
through implementing new programs, and fully capitated asthma, mental health conditions (e.g., depression,
arrangements, where providers get a fixed dollar amount anxiety, attention deficit hyperactivity disorder), and
for providing a full range of services to a defined popula- neurodevelopmental conditions (e.g., autism spectrum
tion over some time period (Burwell, 2015). These strate- disorders, adverse consequences of prematurity). Diagno-
gies have worked relatively well for specific populations ses of these conditions, not typically fatal, have experi-
that have traditionally used large amounts of health care enced huge growth over the past half century. Parents in
services, achieving lower expenses in a relatively short 1960 reported less than 2% of children as having a chronic
period of time (18-36 months) (Powers & Chaguturu, 2016). health condition severe enough to interfere with their
Applying a similar short-term savings approach works less lives on a daily basis. That percent has grown by over
well for children who generate only a small fraction of 400% to a rate today of over 8% (Field & Jette, 2007).
total U.S. health care costs, and where the opportunities
Social Policy Report V29 #4 7 The Influence of Health Care Policies on
Children's Health and Development
And rates of less severe chronic conditions (usually in the adults, the co-occurrence of mental health conditions
same four categories) have also grown such that some with chronic diseases such as heart disease or diabetes is
studies indicate that 25-35% of people under age 20 years associated with much higher costs (Melek et al., 2013).
will have experienced some chronic health condition in Children with chronic health conditions have higher rates
their first two decades (Van Cleave, Gortmaker, & Per- of mental or behavioral health concerns as well. The
rin, 2010). Some of this growth does represent improved opportunities within the health sector include address-
survival owing to advances in medical and surgical care ing mental health concerns on all visits, systematic early
that have improved the outcomes of young people with identification through screening, building on longer-term
conditions such as spina bifida and cystic fibrosis, but the trusting relationships to institute treatment, and provid-
large majority reflects the growth of these four common ing services directly in the health sector (see below for
condition groups. Recent data also note well the growth co-location of mental health practitioners in pediatric
of disability among young Americans of working age, settings as well as parent training activities carried out
with increasing numbers having severe obesity, mental in pediatric practices) (American Academy of Pediatrics
health impairments, or developmental disorders that Task Force on Mental Health, 2010; Institute of Medi-
limit their ability to pursue cine & National Research
educational opportunities Council, 2014). Given the
or employment (Field & substantial role of public
Jette, 2007). Given the substantial role of public schools in mental health
Mental and be- care provision, it is also
havioral health play an schools in mental health care critical to have effective,
increasing and critical role ongoing collaboration be-
provision, it is also critical to have
in any consideration of tween schools and (other)
child health and its impact health providers. Unfortu-
effective, ongoing collaboration
on long-term health out- nately, budget constraints
comes. For example, most between schools and (other) in school districts have
mental health disorders of diminished availability of
health providers.
adults have their roots in health care personnel in
childhood or adolescence. schools. Similar attention
For several decades, child to early childhood health
mental health was treat- has been even more spotty
ed—and paid for—as a set of conditions separate from in preschool and child care settings.
and distinct from the other conditions that children ex- Families seek responses to their needs in a delivery
perience. Prevention in mental health gained little atten- system that is a good deal broader than medical care,
tion. Community physicians and pediatric subspecialists incorporating a wide array of community, public health,
had little incentive or support to identify mental health education, and other services (Perrin et al., 2007). These
conditions early or to prevent them through effective service systems are highly fragmented, and families’
parent counseling or referral to community agencies. As access to and use of services depends on many factors,
a result, children with moderate to severe mental health including financing, physical access, knowledge, and
conditions were not identified until they had quite severe beliefs. In mental and behavioral health, fragmenta-
symptoms, where earlier identification and interven- tion is particularly obvious, with some care from mental
tion could have had major benefit. In more recent years, health clinicians and primary care providers, especially
payers and program leaders, including a number of state in screening and identification of younger children, but
Medicaid programs, have begun to address this separa- a good deal more in public schools and for many in the
tion and are working to reintegrate behavioral health juvenile justice system. Current incentives for collabora-
into general pediatric care. tion across sectors are limited, but the opportunities that
The effects of persistent mental health problems could accrue from coordination and collaboration are
on children’s functioning are clear, along with greater substantial (Cuellar, 2015).
recognition that mental health conditions also gener- Asthma, obesity, mental disorders, and neurodevel-
ate or complicate many other health conditions. For opmental conditions all reflect an interaction of genetic
Social Policy Report V29 #4 8 The Influence of Health Care Policies on
Children's Health and Development
susceptibility with the influences of social and other en- chronic condition management, behavioral health in-
vironmental phenomena. Their prevention and manage- tegration, improving early childhood experiences, and
ment require a multidisciplinary and multi-institutional linking households with critical community services. The
response, not something that the health care sector growth of common chronic conditions has led to greater
alone can manage. It will, nonetheless, be critical to find use of nurses or nurse practitioners to monitor care and
ways to prevent the onset and severity of these condi- progress over time and to help children and families with
tions, or the nation will face larger numbers of citizens adherence to medical treatments. Greater recognition of
who depend on public institutions and services for their mental health needs among children and the interconnec-
livelihood, and fewer young people resilient and capable tion of behavioral issues with health and illness has led
to participate effectively in the nation’s economy (Field to programs of co-locating or integrating mental health
& Jette, 2007). professionals in pediatric practice (Kolko & Perrin, 2014;
Over the past decade, increasing evidence has Williams, Shore, & Foy, 2006). Other programs to support
documented the importance of early life experiences for better attention to behavioral health in pediatric care
the well-being of young children—influencing their readi- have included primary care physician backup systems in
ness for school and literacy at age 8 and their ability to over 30 states, where physicians can easily and expedi-
succeed in adolescence and young adulthood. Particularly tiously consult a mental health practitioner by phone to
difficult circumstances lead to “toxic stress,” where very help care for behavioral issues in the practice (Sarvet et
young children face persistent adversity with consequent al., 2010). Increasing understanding of the critical im-
impact on their neuroanatomy and the functioning of portance of early childhood has led practices to include
their brain and other body systems. Toxic stress, much home visiting and other parent support programs among
more prevalent among poorer children (although not lim- their services or to collaborate with home visiting pro-
ited to children growing up in poverty), can have perma- grams in the community. A focus on two generation health
nent effects on the developing child (American Academy (child and parents) as essential for child well-being has
of Pediatrics, Committee on Psychosocial Aspects of begun to achieve traction in some pediatric health care
Child and Family Health, 2012). Family functioning is a settings. Finally, many practices have incorporated staff
strong predictor of child developmental outcomes and members who are or become knowledgeable about com-
health. Child health and development are inextricably munity culture and resources, learn to refer households to
intertwined—healthy children grow better, develop more appropriate community services, and follow up to assure
skills, and have better school readiness. Similarly, chil- that families receive the services they need (Berkowitz
dren whose development has had support from parents et al., 2015). In all of these cases, family members (and
and community services are healthier, pursue less risky children in developmentally appropriate ways) are central
behaviors, and have lower rates of the common chronic members of the team—teams reflect co-production with
mental health and other health conditions in childhood patients and families.
and adulthood (Campbell et al., 2014). As addressed Financial support for these practice innovations has
above, policies that promote better family functioning been limited; private payers rarely reward these innova-
and support of children can broadly improve children’s tions in traditional payment schemes because they often
health and development. focus on non-professionals, diverse settings, and linkage
of social and educational services with medical care,
areas without a history of health care payment. Equally
New Models of Health Care
challenging, Medicaid (the largest payer for child medi-
Recognition of the unaddressed and changing needs of
cal care) has been much less active in child health care
children and families in the presence of changing finan-
reform than with adults. To date, the development of
cial incentives has fostered the development of new
federal policy around value-based purchasing has largely
models of care. Most of these include the concept of
been driven by Medicare policy including the encourage-
medical homes and some elements of interdisciplin-
ment of both accountable care organizations and bundled
ary care teams—associating medical professionals with
payment initiatives. Primary care clinicians participating
other professionals who can expand the work and at-
in the transformation to team-based care and related
tention of the health care program (Patient-Centered
initiatives complain that they do so at their own financial
Primary Care Collaborative, n.d.). Team functions (not
risk (Chesluk & Holmboe, 2010).
specific team members) tend to fall into four main areas:
Social Policy Report V29 #4 9 The Influence of Health Care Policies on
Children's Health and Development
Nevertheless, many clinicians and a few health The use of ACO contracting to transform care is
systems have learned the value of these changes and have shifting incentives markedly in some places, but a larger
worked to obtain external funding or to reorganize the fi- effect in practice transformation will likely come from
nancing of the practice to support the changes. In a number the bundled payment initiatives undertaken by Arkan-
of states, Medicaid programs have supported innovations, sas (Chernew et al., 2015), Ohio, and other states. The
developing some incentives for practices similar to those in provision of incentives for providers that meet minimum
Medicare (i.e., care coordination, behavioral health inte- quality standards and save money, with corresponding
gration, and chronic care management) (Centers for Medi- penalties for high cost providers for specific diagnoses
care & Medicaid Services, n.d.; Hervey, Summers, & Inama, and procedures, results in tight referral networks of low
2015). The largest of these are the statewide accountable cost providers and careful followup of high cost patients.
care organizations (ACOs) undertaken by a handful of states Notably, these efforts include partnerships among Medic-
to enroll all Medicaid managed care children and adults aid and the largest private insurers so that all providers
into provider networks that take both clinical and financial are affected.
risk for the patients. Anecdotal experience to date suggests Together, these efforts have started a movement
that cost growth in these ACOs has been lower than overall to better use newer measures of quality (Anglin & Hos-
Medicaid cost growth in the respective states (Lloyd, Hous- sain, 2015; Blumenthal & McGinnis, 2015). What should
ton, & McGinnis, 2015). CMS has fostered both the start and indicate value in child health care? What outcomes should
expansion of some of these and related experiments in care health care payers (public and private) use to assess care?
transformation. Where do patient
With innova- and parent expe-
tion grants and rience of care and
With innovation grants and systems improvement
systems improve- partnership ap-
ment awards pear in measures?
awards from CMS, states have experimented with
from CMS, states Would school
have experiment- a variety of programs, some focused on specific readiness at age
ed with a variety 5, literacy at age
chronic conditions (obesity, asthma), others on
of programs, 8, and high school
some focused on graduation serve
behavioral health integration in primary care, and
specific chronic as good mea-
conditions (obesi- still others with bundled payments for episodes of sures? Quality of
ty, asthma), oth- life, functioning
ers on behavioral care, an intermediate payment state between fee at a high level,
health integration and freedom from
for service and capitation.
in primary care, health symptoms
and still others and conditions
with bundled pay- are potentially
ments for epi- important con-
sodes of care, an intermediate payment state between fee siderations. In behavioral health, increasing evidence
for service and capitation. indicates the greater importance of improving functioning
The statewide ACO initiatives have not had specific and academic performance than controlling symptoms
measurement or quality incentives for care focused on (Cuellar, 2015).
children, but fourteen pediatric health systems around the
country have engaged in exclusive pediatric risk contracts
Training the Pediatric Workforce
while many more have plans to do so (Makni, Rothen-
While pediatric training has evolved in response to
burger, & Kelleher, 2015). These efforts have had dedi-
emerging needs of children over the last several decades,
cated pediatric networks and child specific goals for care
several gaps remain for residency and fellowship training
improvement. Two have published evaluations suggesting
that deserve attention. These include health promotion
modest quality improvements and significant cost savings
and prevention in general, parent and family health and
(Christensen & Payne, 2016; Kelleher et al., 2015).
Social Policy Report V29 #4 10 The Influence of Health Care Policies on
Children's Health and Development
