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How Important Are Children? The Clash For ResourcesTHE NATION'S TOTAL indebtedness is approaching $9 trillion, and annual federal budget deficits have been at record levels in recent years. The president’s 2008 spending plan sets as his goal a balanced federal budget—a dramatic policy shift for a chief executive who, since 2001, has presided over large deficits while cutting taxes. This political reality (analysts say that President Bush is calling the bluff of Democrats) may present that party’s new congressional majorities with its greatest challenge: saluting its pledge to demonstrate greater fiscal responsibility than Republicans while, at the same time, promoting ambitious domestic policies that call for substantial additional spending. Ground zero for this coming debate will center on a war that has grown increasingly unpopular; not far behind will be issues encircling whether all of Bush’s tax cuts should be made permanent, the future of entitlements, the challenges posed by immigration, and how best to allocate scarce resources among an array of other competing claims that bid for them. One such bidder is the collective voice that advocates on behalf of the nation’s children: the stewards of our future. That voice has grown louder in recent years, in part because of a growing recognition that good health during childhood is a precursor to adult health. But in politics, the interests of children have paled in comparison to the resources devoted to the elderly, who wield far more influence and have real needs as well. There have been successful recent efforts to expand coverage for uninsured children and better prepare them for adulthood, but, as this thematic issue emphasizes, a nation as wealthy and creative as the United States needs to accelerate its commitment to its next generations through both private and public action. James J. Heckman, the Nobel Laureate at the University of Chicago, put it well recently in the journal Science: "Investing in disadvantaged young children is a rare public policy initiative that promotes fairness and social justice and at the same time promotes productivity in the economy and in society at large." Our lead paper is a call to arms by Neal Halfon, Helen DuPlessis, and Moira Inkelas, who assert that nothing short of transformation will fix a "fragmented and underperforming U.S. system of child health services." They take a direct shot at what has long been a key element of Democratic dogma: "System transformation will require a major reorganization of the cat’s-cradle of federal funding streams.... This will not be an easy task. Like Social Security, many of these categorical funding streams are sacrosanct among their respective advocacy constituencies, so any attempt to reorganize and reform how they function will meet with enormous resistance" (p. 323). Many of the other papers in this volume focus on the multiple challenges that children in low-income families face in reaching adulthood in a healthy state. Janet Currie and Wanchuan Lin report that impoverished children bear a disproportionate share of ill health—poverty matters. Since many children go to school sick, they say, the role of schools in preventing and treating illnesses holds great, if largely untapped, potential. Julia Graham Lear touts this "hidden" system of care and points out that schools, health professionals, and community leaders in Austin; Miami; and Washington, D.C., are exemplars in the effective uses of this asset. Other contributions include an overview of the coming debate over reauthorization of the State Children’s Health Insurance Program (SCHIP) by Genevieve Kenney and Justin Yee and the case of Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit by Sara Rosenbaum and Paul Wise. Lisa Simpson, a pediatrician who recently became director of the Child Policy Research Center at the Cincinnati Children’s Hospital Medical Center, served as our editorial adviser for this issue, working closely with senior editor Sarah Dine. We also acknowledge with gratitude the support of three foundations that made publication of this thematic issue possible: the California Endowment, the Nemours Foundation, and the David and Lucile Packard Foundation. All three foundations sponsor ambitious programs to improve the lives of children through a variety of education, health, and social initiatives. Among many activities, the California Endowment has emphasized the expansion of insurance coverage to children in low-income families in that state, focusing particularly on undocumented immigrant children, who face the highest barriers to care. The Nemours Foundation, which has long provided medical care services to sick children in Delaware and Florida, has launched a new effort to develop a prevention-oriented child health system. Debbie Chang, who heads the effort, and colleagues discuss their early lessons in this issue (p. 466). The Packard Foundation, long a stalwart in advocating universal insurance coverage for all children, places great emphasis on maximizing the enrollment of eligible children in public insurance programs.
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