PEDIATRICS Vol. 122 No. 4 October 2008, pp. 843-849 (doi:10.1542/peds.2008-2143)
SPECIAL ARTICLE |
A National Agenda for America's Children and Adolescents in 2008: Recommendations From the 15th Annual Public Policy Plenary Symposium, Annual Meeting of the Pediatric Academic Societies, May 3, 2008
a Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
b Department of Pediatrics, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma
c Department of Federal Affairs, American Academy of Pediatrics, Washington, DC
d Department of Pediatrics, University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
e Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
f Department of Pediatrics, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, Michigan
g Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York
h Department of Pediatrics, Howard University College of Medicine, Washington, DC
Key Words: AAP—American Academy of Pediatrics • NIH—National Institutes of Health • CHGME—Children's Hospital Graduate Medical Education • SCHIP—State Children's Health Insurance Program
Politicians savor "photo ops" with children—the younger the better—yet rhetoric notwithstanding, children's issues rarely rise to the top the nation's priority list. With pressing national issues, both domestic and foreign, the 2008 elections will likely continue in this pattern. A recent study from the Urban Institute estimated that children's share of domestic federal spending declined from 20.2% in 1960 to 16.2% in 2007, with another decrease projected to 13.8% in 2018 if current spending and revenue policies are continued.1
It is clear that strong and articulate advocacy is needed to reverse these trends. To this end, leaders of 5 major pediatric organizations have joined to develop a set of proposals to guide advocacy on behalf of children and adolescents in the 2008 elections. The setting was the 15th Annual Public Policy Plenary Symposium held at the annual meeting of the Pediatric Academic Societies in Honolulu, Hawaii, on May 3, 2008. Presidents of the 4 sponsoring societies (American Pediatric Society, Society for Pediatric Research, Academic Pediatric Association, and American Academy of Pediatrics [AAP]) participated together with the president-elect of the Association of American Pediatric Department Chairs. Each took responsibility for addressing a specific area of interest that was refined over the preceding several months with 2 conference calls and electronic communications. Summaries and recommendations follow.
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UNDERSTANDING THE CONSEQUENCES OF POVERTY ON CHILD AND ADOLESCENT HEALTH |
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Phyllis A. Dennery, MD, President, 2007–2008 Society for Pediatric Research
In the coming years, a larger portion of the US workforce will have been raised in poverty than ever before. This bodes poorly for the productivity and future success of our nation. Because of the demand for highly skilled workers to develop and manage new technologies and the relative functional illiteracy and innumeracy of a large proportion of US workers, our labor force is weakened compared with other nations.
Citizens who have grown up in poverty have diminished cognitive and social skills as well as suboptimal health.2 In addition to its impact on cognitive and brain development, childhood poverty is greatly associated with an enhanced rate of morbidity and mortality.3 There is increased obesity attributable to higher energy density and higher intake of animal sources in the diet. Poverty-related malnutrition in early life predisposes to obesity later in life. In some geographic areas such as the southeast United States, the prevalence of obesity is highest (>18%), and this is a result of the area's poverty rate to a significant extent.4 There are also associations of childhood poverty with obstructive sleep apnea, cardiovascular disease, asthma, and diabetes.5,6,7 Therefore, it is clear that the socioeconomic status of a child affects not only his or her cognitive skills but also his or her overall health.
Fortunately, when disadvantaged children were placed in early intervention programs, the percentage of children graduating from high school, not needing special education, earning more, and owning a home was increased significantly,2 which indicates that we have ways of intervening and improving the outcome of our children. However, the rate of return was a function of age: the older the child, the less likely the return on the investment in human capital.2 It is also likely that there is a narrow window in which this ability to rectify the damage exists. Additional research is needed to define the window of opportunity during which intervention will be successful.
As pediatricians and pediatric researchers we must advocate for health education and disease prevention but also investigate the impact of poverty on the developing child. Research at molecular, physiologic, genetic, epidemiologic, psychosocial, and clinical levels is needed to develop interventional strategies to maximize outcomes for these children. An investment by our nation in research initiatives to better understand the role of poverty on later outcome is much needed. Continued support of the Pediatric Research Initiative of the Children's Health Act of 2000 and new monies for the National Children's Study are required. Developing an Institute for the Study of Poverty in Children is another mechanism for providing new funds for this important endeavor. There could also be partnering with international organizations such as the World Health Organization that have familiarity with such studies. These investments could have long-ranging benefits of improving the productivity and efficiency of the US workforce.
As stated by James J. Heckman, PhD, the recipient of the Nobel Prize in economic sciences in 2000, and his colleagues2 "we need to invest in the very young," because "early learning begets later learning and early successes breed later success." In contrast, "the later in life we attempt to repair early deficits, the costlier the remediation becomes." Our nation's standing as an economic superpower depends on the success of future generations and their well-being.
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RESEARCH AS THE FOUNDATION FOR IMPROVING CHILD AND ADOLESCENT HEALTH |
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William W. Hay, Jr, MD, President 2007–2008 American Pediatric Society
Research is fundamental to solving problems that impair child and adolescent health. Children, for the most part, are healthy, but they do suffer from many diseases that have a major impact on their health and their ability to contribute successfully to their environment. Why are we not doing better with respect to solving the problems that cause illness and prevent healthier lives in children?
A principal problem is insufficient research into how to solve these problems, which stems largely from insufficient research funding and is underscored by the recent lack of increase in National Institutes of Health (NIH) funding. The 2009 request for NIH funding of $29.2 billion represents the sixth consecutive year that the president's budget for the NIH failed to keep pace with biomedical inflation.8,9 Funding now is in negative territory, negating the advantages produced by the 1999–2004 budget doubling.10 The NIH budget doubling was done for good reason. Funding for biomedical research through the NIH in the late 1980s and early 1990s was discouragingly low.11,12 Many young people were steering away from science as a career, and many senior investigators were losing grant support. It is even more discouraging to see the same problem happen all over again.
More important for pediatrics is that even during, and now after, the NIH budget doubling, pediatric research funding is losing ground. Pediatric research funding increased only 82% compared with the 98% increase in the overall NIH budget, falling from 13.1% of the NIH budget in 1993 to 10.1% this year (Fig 1). 9,10 This situation is not likely to change, given the even more restrictive 2009 NIH budget from the president, the competing research interests of senior citizens, and the NIH interest in developing broad themes for research rather than age-specific approaches.* Unfortunately, therefore, children and their research needs are being left behind, and "left behind" is where no child is supposed to be.
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We need to take a different tack. Elias A. Zerhouni, MD, Director of the NIH, clearly pointed out that research that solves problems at their beginning and prevents their future effects on well-being and exponentially increasing financial costs are fundamentally what the NIH and Congress should be spending their money on (Fig 2). Dr Zerhouni called this "The Future Paradigm: Preempt Disease" (fiscal year 2008 budget request witness appearance before the House and Senate Subcommittees on Labor, Health and Human Services, Education Appropriations, Elias A. Zerhouni, MD, Director, NIH, March 6 and 19, 2007). More important for us to recognize as pediatricians is the related concept that research into the causes, preventions, and treatments of diseases that begin very early in life will have a profound impact on disease burden and financial costs, not just for the duration of the disease but over the entire life span.
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As just one example, preterm birth remains the leading cause of later-life developmental disabilities, yet its causes remain largely unknown and unpreventable and its incidence is increasing; as a result, the burden of lifelong problems and their financial costs that stem from preterm birth are growing exponentially. The total 2007 NIH annual budget equaled the costs of only 1 year's worth of preterm births.13 Even a modest increase in solving the causes of preterm birth and reducing its many burdens would provide a huge and positive impact on enriching the quality of life of preterm infants and their capacity to contribute beneficially to our society.
What should be done about this shortage of research funding in pediatrics? We might be more successful if we focused on increasing support for already established and proven pediatric research initiatives. Good examples might include new money to fully support the Pediatric Research Initiative of the Children's Health Act of 2000 and the National Children's Study; NIH research and career development awards to provide research opportunities to help determine the basic mechanisms of disease and treatments and the training necessary to produce new investigators to carry out the research; addition of pediatric components with dedicated funding to all NIH roadmap initiatives; and specific funds for child and maternal clinical-translational research in the Clinical Translational Science Award Program, surely better than simply shifting funds internally at each center, all of which already have constrained budgets. Development of new programs, such as the Pediatric Research Consortia program recently introduced into the Senate and House, also has great promise to enhance our lagging pediatric institutional research infrastructure.
New research funding should indeed increase the fraction of research support for pediatrics, because that is where the biggest gains can be made. We should adapt Dr Zerhouni's "prevention-preemption" paradigm to support research into the causes, preventions, and treatments of diseases that begin very early in life.14 It is imperative that our national leaders put pediatric research support on their national agenda and work to increase the research support in the United States that is directed to children. Such research has the greatest promise of reducing the tremendous burden of illness and huge financial costs that these diseases bring to children during their childhood and over their entire life span. The United States cannot afford to do less.
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THE PEDIATRIC WORKFORCE AND WOMEN IN PEDIATRICS |
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Bonita Stanton, MD, President-Elect Association of Medical School Pediatric Department Chairs
Children need and deserve highly skilled providers, but training these providers requires specific targeted support. The field of pediatrics must be able to maximize the benefit derived from those receiving such training. Two significant workforce issues are potentially threatening the field of pediatrics: (1) the threat to continued funding of the Children's Hospital Graduate Medical Education (CHGME) program and (2) the field's inability to support and therefore maximize the contributions from women in pediatrics.
The CHGME program was established by Congress in 1999 to address a disparity in federal graduate medical education support for programs at adult teaching hospitals, which receive Medicare support, and independent children's teaching hospitals. Medicaid graduate medical education payments, which are optional for states to provide, remain well below costs, and the current administration has proposed that these be eliminated. Since its inception, Congress has appropriated more than $2 billion to support pediatric training in 
60 eligible hospitals.15
The CHGME program helps provide training for >4700 full-time residents each year. Children's hospitals train one third of all pediatric residents, one half of pediatric specialty residents, almost all pediatric researchers, and many other physicians who require pediatric training. Although the eligible freestanding children's hospitals receiving graduate medical education funds represent <1% of all hospitals, they provide half of all hospital care to children with serious conditions, and more than half of the patients they serve are covered by Medicaid. Finally, the world's leading pediatric research centers are in these hospitals.
Congress reauthorized the CHGME program in 2006, providing authorization for up to $330 million annually. In fiscal year 2008, Congress appropriated $301.7 million for the program. Although the president's 2009 budget proposal eliminated all funding for the CHGME program, funding was restored and actually increased to $310 million in fiscal year 2009 appropriations bills by both the House and Senate Appropriations Committees in June 2008. These measures await action by the full Congress, however, and signature by the president.
The second manpower issue facing pediatrics concerns the increasing proportion of women in academic pediatrics. Unfortunately, the demands of a career in academic medicine were established at a time when the overwhelming majority of physicians were male and most of their spouses did not have full-time employment outside of the house.
The report of the first Federation of Pediatric Organizations Task Force on Women in Pediatrics opened with this observation:
"There are many reasons for addressing issues of family balance in the lives of pediatricians during training and practice, including concerns regarding productivity, career advancement and individual fulfillment. The most compelling reason derives from the central responsibility of our profession. The commitment of pediatrics to the health and well being of children and youths should encompass the families of those who choose to pursue careers in pediatrics."16
Currently, 50% of medical students, 70% of pediatricians in training, and 50% of all practicing pediatricians are women. The percentage of women in medicine quadrupled in the past 30 years, but women are only 14% of tenured faculty and 12% of full professors. Approximately 10% of the members of the Association of Medical School Pediatric Department Chairs currently are women. The traditional explanation for these small numbers had been that the pool of qualified women to be considered for such positions was too small because of an inadequate pipeline. However, the "pipeline" theory is no longer applicable; the pipeline has been primed for well over a decade. Determining how to retain and promote women in academic pediatrics is critical both for equity and for improving the quality of our profession by engaging and nurturing the best talent available.17
There are at least 4 areas that need to be addressed for our profession to attract and promote women: (1) the option to train and work part-time at specific career stages; (2) the need for flexibility in the career paths of physician-scientists; (3) a desire to draw more women into leadership positions; and (4) attention to available high-quality child care. A reconstituted second Federation of Pediatric Organizations Task Force on Women in Pediatrics continues to search for effective solutions to these issues (see http://fopo.org/taskforce.html).
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ACCESS TO APPROPRIATE HEALTH CARE |
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Peter G. Szilagyi, MD, MPH, President, 2007–2008 Academic Pediatric Association
A large body of literature has shown that better access to health care for children results in higher quality of care and improved health outcomes.18 Access to appropriate health care for children requires a series of steps that are summarized by Eisenberg's depiction of the cascade of voltage drops from insurance to quality health care19 (Fig 3). For children to receive optimal health care, they must have appropriate health insurance available, they must be enrolled in health insurance, health care providers and services must be available and covered by health insurance, informed choices must be present for parents or adolescents to participate in their care through selection of best options, a consistent source of primary care must be present, referral services must be accessible, and high-quality care must actually be delivered. Although health insurance is an important component of access, it is not sufficient for high-quality care; all 7 steps are needed.
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The most visible and politically debated aspect of access to care is health insurance. A large body of evidence demonstrates the importance of health insurance for children, based on rigorous studies over decades about the problems encountered when children lack insurance, and the effects of Medicaid, commercial insurance, and, most recently, the State Children's Health Insurance Program (SCHIP). Table 1 summarizes findings about the impact of SCHIP on children's health. Numerous studies have demonstrated that provision of SCHIP to uninsured children improves access to care, quality of care, and some outcome measures and even reduces preexisting disparities in care among white, black, and Hispanic children.20–24 It is notable that pediatric organizations are united in calling for universal health insurance for children, including adequate health care coverage for services required by children.25
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Under our current health care system, many children who are eligible for health insurance, particularly low-income children, are not enrolled.26,27 Among uninsured children living below 200% of the federal poverty level, 84% are eligible for either Medicaid or SCHIP,28 yet they are uninsured. Multiple barriers prevent both low- and higher-income families from enrolling children in public or private health insurance, and 8.7 million US children remain uninsured.29 Clearly, enrollment is needed for insurance to be able to facilitate access to care for children.30
Although all 7 steps to optimal health care depicted in Fig 3 are important, a consistent source of primary care is particularly relevant and has been broadened into the importance of a medical home,31 which is an approach to providing health care services within a primary care setting in a high-quality, comprehensive, and cost-effective manner.32 A medical home is a true partnership among primary care professionals, families, and specialists or other professionals, with a shared goal of achieving the optimal potential of children and families.33 Although medial homes are often discussed with respect to children with special health care needs,34–36 it is critical for all children to have a medical home. Medical homes provide added value to prevention as well as the care of acute and chronic conditions. The 7 key attributes of a medical home are that they should be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally competent. Table 2 shows the benefits to children from having a medical home.37
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In summary, it is critical for our evolving health care system to provide a series of essential steps in the cascade of events that lead to optimal health outcomes for children. Two critical steps that are particularly relevant to access to health care and to the current US political climate38,39 are provision of adequate health insurance and a medical home for all children and adolescents.
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THE ACADEMY'S ACCESS PRINCIPLES AND HOW THE CANDIDATES MATCH |
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Renée R. Jenkins, MD, President, 2007–2008 American Academy of Pediatrics
To make an informed decision during the 2008 election, it is important to learn both local and federal political candidates' positions on access to health care as they affect children and adolescents. The presidential candidates’ stated health care proposals were compared to the AAP's principles on access.40 Although there are 9 AAP principles, there are 5 major areas of comparison that were identified for this discussion: (1) health insurance for every child; (2) adequate payment levels; (3) comprehensive and age-appropriate benefits; (4) a choice of pediatric clinicians; and (5) portability of insurance and continuous coverage.
The Access Subcommittee of the AAP Committee on Federal Government Affairs made a recommendation for and the AAP Board of Directors adopted the AAP endorsed principles on access as AAP policy.40 These principles are the gold standard that the AAP uses to evaluate expanded access proposals at the federal level as well as the presidential candidates' positions. These principles are:
- Every child must have quality health insurance.
- Health insurance should be a right, regardless of income, for all children, pregnant women, their families, and, ultimately, all individuals.
- All health insurance plans should have a comprehensive, age-appropriate benefits package such as that of the AAP.
- All children should have access to primary care pediatricians, pediatric medical subspecialists, pediatric surgical specialists, pediatric mental and dental professionals, and hospitals with appropriate pediatric expertise.
- All health plans should have payment rates that ensure that children receive all recommended and needed services.
- Health insurance should be fully portable and provide continuous coverage.
- Administrative aspects should be streamlined and simplified.
- Families should have a choice of clinician(s).
- Health plans should complement and coordinate with existing maternal and child health programs to ensure maximum health benefits to families.
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SUMMARY OF PRESIDENTIAL CANDIDATES' HEALTH CARE PROPOSALS |
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Senator John McCain (R-AZ)
Senator John McCain's health care coverage proposal does not guarantee coverage for children or adults, and health insurance would not be a guaranteed right. His plan does not guarantee payment rates that ensure access to care. The McCain health care plan also does not guarantee an age-appropriate benefits package, and it does not give families a choice of clinicians. The McCain proposal, however, does provide some assurance for portability and continuity, allowing individuals to carry insurance from job to job and to purchase it across state lines. Additional information on the McCain health care proposal can be found at www.johnmccain.com/Informing/Issues/19ba2f1c-c03f-4ac2-8cd5-5cf2edb527cf.htm.
Senator Barack Obama (D-IL)
Although it is not a constitutional guarantee, Senator Barack Obama's health care plan would mandate insurance coverage for children. It would give families a choice of clinicians. Although Obama's plan does not guarantee payment rates that ensure access to care, the plan states that primary care providers would see "improved reimbursement." He proposes a federal employee health benefit plan–style benefit program and expansion of the SCHIP program, which do not necessarily provide age-appropriate benefit packages for children. The Obama health care proposal guarantees portable and continuous coverage by giving all Americans access to a "national health exchange" in which they could enroll at any time regardless of illness or job status. For additional information on the Obama health care proposal, visit www.barackobama.com/issues/healthcare.
Neither presidential candidate's health care proposals completely measure up to the AAP's access principles. Each is lacking in some aspect. Therefore, it is critical that pediatricians mobilize in their communities to emphasize child and adolescent health issues in the 2008 campaign at all levels of government.
To learn more about the candidates' positions on children's issues and to access other information about the upcoming elections, pediatricians are urged to visit the AAP's 2008 election center, "Healthy Kids, Healthy Country," at www.aap.org/moc.
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ACKNOWLEDGMENTS |
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We thank Dr William Keenan (chair, 2008 Pediatric Academic Societies Planning Committee) and Debbie Anagnostelis (executive director, American Pediatric Society/Society for Pediatric Research) for cooperation and assistance in the planning of this symposium. Members of the Public Policy Council (Drs Jon Abramson, Russell Chesney, Jimmy Simon, Elena Fuentes-Afflick, and Thomas Green), Drs Lisa Simpson and Lolita McDavid (Academic Pediatric Association's Public Policy and Advocacy Committee), and Dr Ted Sectish (executive director, Federation of Pediatric Organizations) provided critical advice and continuing support over a 9-month gestation. Ms Becky Fowler (AAP Office of Federal Affairs) provided timely logistic support, and Ms Ellie Miller aided immeasurably in assembling the manuscript.
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FOOTNOTES |
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Accepted Jul 15, 2008.
Address correspondence to Myron Genel, MD, Public Policy Council, Yale Child Health Research Center, PO Box 208081, New Haven, CT 06520-8081. E-mail: myron.genel{at}yale.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
* The NIH categorizes its spending in a variety of manners to satisfy diverse reporting requirements. Spending is tracked for specific diseases (Alzheimer disease, breast cancer, etc), various conditions (infertility, obesity, etc), and specific areas of research (genetics, substance abuse, etc) (see www.nih.gov/news/fundingresearchareas.htm). 
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[Free Full Text] - AAP Endorsed Principles on Access. Available at: www.aap.org/advocacy/washing/principles_access.htm. Accessed August 3, 2008
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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