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From the Editor |
To What Are Children Entitled? Coming Challenges
In a polarized political environment the likes of which may be unique in modern American times, there are ever fewer issues upon which Republicans and Democrats (and their current standard bearers, George W. Bush and John Kerry) agree. One item that resonates with both parties is a strong belief that all children should have an equal opportunity to achieve success in their lives. But most politicians, in their more candid moments, will concede that the United States, the wealthiest country the world has ever known, is falling far short of this goal. In search of reasons why, Health Affairs thought that a worthy use of its pages would be to explore the status of children in our increasingly multiracial, multicultural society. Papers in this thematic issue focus on the policies and practices that shape children through the use of America’s pluralistic health care system. However, it is the array of forces, many beyond the reach of health care, that ultimately spell the future of children and pose a formidable societal challenge to improving their lives. Living in an impoverished family heads the list, as C. Everett Koop, surgeon general under Ronald Reagan, asserts in an interview (p. 180) with Fitzhugh Mullan and as research documents: "The older I get [Koop is eighty-seven], the more I understand the relationship of poverty in a child and poor outcomes in everything else. I’m not beating a socialist kind of drum here. I think as we look to the future, unless we take into account what a severe role poverty plays in the lives of many children, we will never be able to achieve good child health in the United States."
We were enabled in this thematic publishing effort by the generous support of the Nemours Foundation, a private enterprise that devotes most of its resources to meeting the acute care needs of seriously ill children in Delaware and Florida. W. Jeff Wadsworth, president and chief executive officer of Nemours, recently said: "Our nation is capable of formulating plans that look beyond the current generation. It is in the self-interest of the nation to look over the horizon, to use our collective expertise to find new solutions, to put children’s health and well-being at the top of the list of our priorities." While Nemours will continue to devote most of its resources to helping children who face diabetes, cancer, and other life-threatening diseases, it recently created a new division to promote broader community and public health strategies for children, initially by addressing the problems of child obesity in Delaware but in the future moving to other issues and locales.
The news about children certainly has some bright sides. Mortality rates for children have fallen dramatically over the past several decades, although African Americans lag well behind whites in this regard. Medical progress has virtually eliminated some serious medical conditions, although, as Lisa Simpson (who was also our editorial advisor on this thematic issue) notes (p. 126), childhood health services are generally based on far less evidence than are adult services. Medicaid and the State Children’s Health Insurance Program (SCHIP) are providing more extensive public insurance coverage for children than ever before, but many parents are failing to avail themselves of these programs, making more aggressive outreach efforts critical. In a recent (12 July 2004) speech, Senate Majority Leader Bill Frist urged that in the next twenty-four months, through a "streamlined process," the estimated 5.6 million children who are eligible for these programs but not participating should be enrolled.
Although both political parties support broader public coverage, their approaches increasingly diverge, as reflected in the statutory underpinnings of Medicaid and SCHIP. Medicaid, which Democrats have championed since its enactment in 1965, is a federal entitlement program that guarantees eligible children access to a generous benefit package without cost-sharing requirements. Republicans have made repeated but unsuccessful attempts to transform Medicaid by converting it into a block grant to the states. By comparison, SCHIP, enacted in 1997 by a Republican-controlled Congress and only lukewarm support from the Clinton administration, entitles participating states, rather than children, to receive federal contributions for children’s health assistance. States in turn have broad discretion to define this assistance in terms they deem most appropriate.
After this yearlong publishing exercise, we have concluded that there is a crying need for a thorough national examination of children that includes all of society’s diverse segments. A logical place to begin would be the National Children’s Study, a long-term environmental impact assessment that Congress has authorized but has thus far failed to fund (see www.nationalchildrensstudy.gov/news/e_update_072004.cfm). What better time than now, when President Bush has vowed to "leave no child behind" and Senator Kerry has pledged to improve the lives of children if he wins his bid for the White House, to move forward with this study?
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