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Journal Issue: U.S. Health Care for Children Volume 2 Number 2 Winter 1992

Richard E. Behrman


Although there is considerable disagreement about what should be done and by whom, virtually no one disputes the need for health care reform in this country. As various specific changes in health care are considered, it is critical to assure that these changes result in improvements in the health of children, youth, and pregnant women.1 It is equally important that, in our zeal for reform, we do not make the kinds of changes that would have adverse consequences for these groups.

Our ability to accomplish these objectives depends on an understanding of what good health means for children, youth, and pregnant women, an accurate assessment of what services are now provided to them and the costs of these services, and a recognition of the significant differences in many dimensions of health care for these groups compared with care for the rest of the population. Because to know where we are going, we need to know where we are, this issue of The Future of Children deals primarily with the ways in which existing programs are working in regard to preventive, acute, and chronic medical and surgical services for children, youth, and pregnant women.

A subsequent issue of the journal will be devoted entirely to the system for providing specialized mental health services to children; therefore, this important and complex issue is not separately dealt with here. (It has been estimated in a report prepared by the Institute of Medicine that at least 12% of children have a diagnosable mental illness.2) The oral health of children is encompassed in a limited fashion within discussions of Medicaid, the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program, the Title V Maternal and Child Health Care Block Grant, and the article on expenditures for children's health care.

Dr. Barbara Starfield, a pediatrician who heads the Division of Health Policy and Management at Johns Hopkins University, describes the health status of children from several points of view. She notes important distinctions from measures of adult health and suggests new ways of viewing child health.

Drs. Racine, Joyce, and Grossman of the National Bureau of Economic Research focus attention on the effectiveness of prenatal, obstetrical, and neonatal care in terms of infant morbidity and mortality related to pregnancy. They discuss recent trends, the cost-effectiveness of neonatal intensive care, and new neonatal technologies.

The current spectrum of health care services delivered in the private and public sectors is reviewed in articles by Perrin, Guyer, and Lawrence, and by Janet Perloff. Perrin, Guyer, and Lawrence discuss the need for community integration of certain programs such as immunization, injury prevention, and services for adolescents. In addition, Perloff reviews the supply, distribution, and accessibility of medical and obstetrical services and providers for children and pregnant women.

Drs. Eugene Lewit of the Center staff and Alan Monheit of the Agency for Health Care Policy and Research provide significant new data and analyses on which to base estimates of the annual medical expenditures for children from conception through 18 years of age, including expenditures on pregnancy and delivery. This information is critical to making effective health policy because financial information about the health care system in general may mask important considerations that are applicable to children in particular.

The next three articles address the important issue of insurance coverage for children and pregnant women. John Sheils of Lewin-ICF and Patrice Wolfe of MEDSTAT Systems provide a review of the current role of private health insurance, which is the primary source of coverage for most children and pregnant women. Ian Hill of Health Systems Research, Inc., describes and analyzes the existing coverage of children and pregnant women under Medicaid and other government programs. Drs. Alan Monheit and Peter Cunningham of the Agency for Health Care Policy and Research present new information about children who do not have private or public insurance and the implications of various strategies that might be implemented to deal with this problem.

Finally, Dr. Lorraine Klerman of the University of Alabama discusses the nonfinancial barriers that may prevent families of children and pregnant women from obtaining medical care. This issue needs to be addressed if reform of the health care system is to achieve its goals.

In addition to the foregoing articles, the Center staff provides an analysis of the major issues involved in health care for children, youth, and pregnant women in the United States. This summary and the staff's recommendations are based on a consideration of the views discussed by the preceding authors, a reexamination of the literature, and conversations with leaders in various fields.