On March 23, 2010, US President Barack Obama signed the Patient Protection and Affordable Care Act of 20101,2 (Pub L. No. 111–148). At his side was Marcelas Owens, an 11-year-old boy whose mother had passed away after she lost her health insurance. Several days later, President Obama signed a companion piece of legislation (Pub L. No. 111–152)3 that created an unprecedented health reform package. The signing of these bills is indeed historic—the United States has finally acknowledged that health care access should be available for every citizen. Health reform puts into place the mechanisms for a transformation of health care delivery to meet the needs of children like Marcelas, his neighbors, and all Americans in the 21st century.
WHAT IS AT STAKE?
In 2008, the United States spent more than $2.3 trillion on health care, which translates to $7681 per capita.4 It was projected that by 2020, 67 million Americans were slated to be uninsured, and the premiums for families were projected to cost $25000 per year.5 Compared with all other developed nations, the United States spends more on health care and has little to show for it.6 The United States has one of the worst life expectancy rates and an unacceptable infant mortality rate.7 In child health, we got a wake-up call in 2007 when the United Nations Children's Fund report card rated the United States last on health and safety measures among 21 developed countries.8
Because of economic pressures, health reform has been needed for years, but what health reform brings us is more than an economic fix. Congress placed substantial emphasis on the power of primary care and the importance of prevention. Because the new law calls for a fundamental revamp of practice, the success or failure of health reform rests on the ability of health care delivery professionals to change. Doctors and nurses are charged to adopt new attitudes (including population-based medicine and evidence-based practice) and to use new tools such as electronic health records and quality-improvement methodology. What is at stake is no less than a transformation of practice.
WHAT IS INCLUDED?
First and foremost, the law includes basic patient protections that address many of the unfair and abusive practices. The law funds the Children's Health Insurance Program through fiscal year 2015 and provides an increased federal funding commitment to states through 2019. Preexisting-condition exclusions for children are banned, and in 2014 the law will prevent children and adults from losing access to health insurance if they become sick.
Starting in 2010, young adults under the age of 26 can stay on their parents' health insurance, preexisting-condition exclusions for children will be banned, and all public and private health plans will be required to provide all Bright Futures9 services without cost-sharing. The significance of these victories for children's health should not be overlooked; we now have a national prioritization of prevention, expansion of coverage to young adults who currently have some of the highest uninsurance rates, and coverage for some of the nation's sickest children who are currently denied care because of chronic conditions. The law also allows for the development of new innovations in health care delivery. Of great interest to the pediatric community are the creation of Medicaid pilots for medical homes and the support of home visiting for young families.
The law also makes incremental changes in the financing of health care. Inadequate payment through Medicaid has been a critical barrier to care for vulnerable children across the United States. On average, Medicaid has paid pediatricians ∼66% of what Medicare would pay internists for primary care services.10 The law substantially improves access to pediatric services for low-income families by investing $8.3 billion in federal funds to bring parity to Medicaid and Medicare payments for primary care doctors. The increase applies to payments for evaluation and management codes recognized by Medicare starting in 2013 and running through 2014 and is available to physicians with a primary specialty designation of internal, family, or pediatric medicine.
Although the signing of health care reform legislation was historic, the real history will be made as implementation of health care reform begins. On balance, the new opportunities for children, families, and pediatricians far outweigh the inevitable challenges that come along with any big change.
Over the weeks and months ahead, those who are interested in ensuring the success of health reform should follow the regulatory process and weigh in when appropriate during the period of public comment. The passage of health reform was contentious at times but was, in the end, a thoroughly democratic exercise. The voices of children, families, and pediatricians were heard and acted on. For health reform to be successful, those who care about child health need to keep speaking up until the job is done.
This research was supported by an Academic Pediatric Association Young Investigator Award and institutional development funds from the Children's Hospital of Philadelphia. In addition, the project described was supported by award K23HD059919 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
We thank Cyndi Ritz and Gary Moore of Social and Scientific Systems, Inc and Dingwei Dai of the Children's Hospital of Philadelphia Research Institute, Healthcare Analytics Unit, for help with data preparation, Katherine Bevans, PhD, for suggestions regarding outcome measurement, Cayce Hughes, MPH, for assistance with manuscript preparation, and Lovlei McKinnie for administrative support.
- Accepted June 1, 2010.
- Address correspondence to Judith S. Palfrey, MD, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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- 2.↵US House of Representatives, Committee on Energy and Commerce. Patient Protection and Affordable Care Act resource page. Available at: http://energycommerce.house.gov/index.php?option=com_content&view=article&id=1931:health-care-reform&catid=169:legislation&Itemid=55. Accessed June 8, 2010
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