Health Care Policies on Childrens Health and Development

sharing child and youth development knowledge
volume 29, number 4
2016
Social Policy Report
The Influence of Health Care Policies on
Childrens Health and Development
James M. Perrin Thomas F. Boat Kelly J. Kelleher
Harvard Medical School University of Cincinnati Ohio State University
ABSTRACT
Rates of health insurance for children have improved significantly
over the past few decades, and more children have insurance than
ever before in U.S. history. Health care does improve child health
and well-being, but growing understanding of social and community influences has led health care practitioners to work toward more
comprehensive and community-integrated child health services to
improve child and family well-being. High rates of poverty affect childrens health
poor children have more acute and chronic illness and higher mortality as well. Children
and youth also have more diagnosed mental health conditions than in years past. This
paper reviews the current state of health insurance for children and youth and contrasts
health services with the needs of children and families. It then describes new models
of health care, including ones that actively connect health care with other community
services, and suggests promising trends in child health care.
Social Policy Report V29 #4 2 The Influence of Health Care Policies on
Children’s Health and Development
Social Policy Report
Volume 29, Number 4 | 2016
ISSN 1075-7031
www.srcd.org/publications/socialpolicy-report
Social Policy Report
is published four times a year by the
Society for Research in
Child Development.
Editorial Team
Samuel L. Odom, Ph.D.
(Lead & Issue editor)
[email protected]
Kelly L. Maxwell, Ph.D. (editor)
[email protected]
Iheoma Iruka, Ph.D. (editor)
[email protected]
Stephanie Ridley (Assistant editor)
[email protected]
Director of SRCD Office for
Policy and Communications
Martha J. Zaslow, Ph.D.
[email protected]
Managing Editor
Amy D. Glaspie
[email protected]
Governing Council
Ronald E. Dahl Mary Gauvain
Lynn S. Liben Kofi Marfo
Marc H. Bornstein Frosso Motti
Natasha Cabrera Seth Pollak
Robert Crosnoe Deborah L. Vandell
Michael Cunningham Natalia Palacios
Kenneth A. Dodge Lonnie Sherrod, ex officio
Andrew J. Fuligni Martha J. Zaslow, ex officio
Anne Perdue, ex officio
Policy and Communications Committee
Brenda Jones Harden Taniesha A. Woods
Rachel C. Cohen Kenneth A. Dodge
Sandra Barrueco Seth Pollak
Kimberly Boller Robey Champine
Rebekah Levine Coley Ellen Wartella, ex officio
Kelly Fisher Lonnie Sherrod, ex officio
Rachel A. Gordon Martha J. Zaslow, ex officio
Tina Malti Nighisti Dawit, staff liaison
Ann Rivera
Publications Committee
Pamela Cole Marc H. Bornstein
Marian Bakersmans-Kranenburg Erin Hillard
Robert J. Coplan Patricia Bauer, ex officio
Diane Hughes Rob Kail, ex officio
Melanie A. Killen Cynthia Garcia Coll, ex officio
Vladimir Sloutsky Ellen Wartella, ex officio
Jeffrey Lockman Angela Lukowski, ex officio
Kenneth Rubin Jonathan B Santo, ex officio
Judith G. Smetana Lonnie R. Sherrod, ex officio
Mary Gauvain Adam Martin
From the Editor
The health of children in America has primary implications for the future of
this country. In this report, the Drs. Perrin, Boat, and Kelleher review the
progress made in providing health care to children, the changes that have
occurred in childrens health conditions, the impact of current policies, and
potential innovative approaches to providing health care. Childrens health
could be seen as a success story of policy and practice. Greater than 90% of
children in the United States have some type of health insurance coverage,
which is the highest it has ever been. Major childhood diseases, epidemics,
and severe malnutrition, previous primary causes of childhood mortality have
largely dissipated. These have been replaced by conditions such as childhood
obesity, asthma, mental health, and neurodevelopmental disorders, which
are the result of interactions between genetics and social and environmental
factors. The overlay of poverty, despite progress in childrens health coverage, still creates health disparities between poor and non-poor children. The
authors describe a range of factors that may address this disparity. These
include new models of health policy, health economics, and funding (e.g., the
Affordable Care Act, social impact bonds), new models of health care (e.g.,
chronic condition management, behavioral health integration), innovations
in health care delivery (e.g., mHealth approaches), and changes in pediatric
training (e.g., emphasis on integration of health and other social services).
In their commentary, two childrens health leaders also focus on the
continued effect of poverty on childrens health. Dr. Dreyer describes the new
policy on poverty and health adopted by the American Academy of Pediatrics,
which emphasizes (as did Perrin et al.) integration of services and engagement
with other sectors of the community. He importantly points out that health
care reform for children is different than for adults, in that it focuses on longterm health outcomes for children that last into adulthood, as contrasted with
the adult care emphasis on cost containment for chronic disease conditions.
Dr. Chaudry, like Dr. Perrin, acknowledges the significant progress made in
promoting childrens health, noting that the proportion of children reported in
excellent health is higher than it has ever been. Again, this positive message
is tempered by disparities that poverty continues to create, but he also states
that at this point in time there may be the opportunity to leverage current
health care policy to address disparate outcomes. He notes the potential for
innovative programs that integrate services, have a two-generation emphasis,
and focus on behavior health in the context of the home.
On a final note: this is the concluding Social Policy Report for the
current editorial team. As lead editor, I want to express my appreciation for
great collaborators who have been issue editors for this reportDonna Bryant,
Kelly Maxwell, and Iheoma Iruka, our outstanding copy editing and production
staff, Stephanie Ridley, Leslie Fox, Gina Harrison, and the support of SRCDs
central office (Amy Glaspie) and the SRCD Office of Communication and Policy
(Marty Zaslow). We leave this report in the skilled hands of Dr. Ellen Wartella
and her editorial team.
Samuel L. Odom (Issue Editor)
Kelly L. Maxwell (Editor)
Iheoma U. Iruka (Editor)
Social Policy Report V29 #4 3 The Influence of Health Care Policies on
Children’s Health and Development
The Influence of Health Care Policies on
Childrens Health and Development
How do current health care policies
influence child health and development in America? The US has recently
achieved the highest rates of child
health insurance coverage in history, in
part due to state Medicaid expansions
and the continued growth of the state Childrens Health
Insurance Program (CHIP). Other health care policies
many in the public health arenainfluence child health,
ranging from infection control programs and policies to
public nutrition programs to prevention of injurious exposures to child abuse and neglect reporting to (generally
ineffective) gun violence prevention programs. For the
most part, these policies provide for basic, not optimal,
health protections and access to health care.
Over the past several decades, many of the scourges of child healthinfectious diseases such as diphtheria
or meningitis, rickets
and severe
malnutrition,
lead poisoning, and early
deaths from
cancerhave
diminished or
even almost
disappeared, in part due to effective federal policy on
sanitation, food, and health care. The decline of many
older diseases has been countered by new epidemics
of obesity, asthma, neurodevelopmental disorders, and
mental health conditions, but federal health policy has
moved slowly to address these new issues. Most of the
health problems that affect children and youth today
reflect social and community influences rather than
infections (although social factors also influence acquisition of infections and their severity). The circumstances
into which a child is born have stronger relationships to
her/his health and development than do genes or direct
health care services, limiting the effectiveness of health
care to improve health. At the same time, greater understanding of the importance of early life experiences,
early education, and family and community influences on
child health and development has highlighted new and
changing needs for child health care. Additionally, there
is clear recognition that improving child health requires
integration across multiple sectors as well as having a
long-term or life course perspective. Two examples document these needs for new policy directions wellthe
effects of poverty on child health and the prominence of
behavioral health issues for children.
Poverty affects essentially all aspects of child
health and developmenthigher mortality from serious
childhood illnesses, higher rates of accidents and injuries, higher rates of common chronic health conditions
and resulting disability, less physical endurance as well as
poorer school
performance
and graduation
rates, more
risky sexual
and substance
abuse behaviors, and
higher rates of
incarceration
as adolescents. From a health perspective, decreasing
poverty will improve health status and response to medical treatments as much or more than improvements in
personal health care services for children. Yet, strategies
to diminish poverty among U.S. families are not straightforward and require a multifaceted approach, including
work to improve household income, housing, nutrition,
jobs, and education among families of young children.
Rates of mental health diagnoses have grown rapidly among U.S. children and youth. Here, too, children
face a highly fragmented system at every level of care
for behavioral and emotional symptoms. Identification
there is clear recognition that improving child
health requires integration across multiple sectors as
well as having a long-term or life course perspective.
Social Policy Report V29 #4 4 The Influence of Health Care Policies on
Children’s Health and Development
of mental health problems can come from community
services (e.g., day care or schools), health services, or
family referral. Much mental health diagnosis and treatment, especially for low-income children, takes place
in the public school system. Health and related service
providers have little incentive currently for early identification and treatment (or referral) of children and families for behavioral health, although recent efforts to (re)
integrate behavioral health with the rest of the health
care sector have promise. Current federal policy in this
area maintains separation of health and behavioral health
services in many situations, from precluding researchers
from accessing behavioral health claims for study to policies that support separation of psychiatric hospitals and
institutions from other services.
How do current policies affect and improve child
outcomesand especially help to promote an effective,
well-trained, healthy, and competent young adult population? This report addresses those questions and offers proposals to build stronger, cross-sector programs to enhance
the health and development of children in America.
Health Insurance for
Children and Families Today
Children and youth obtain health insurance through a
combination of public and private sources (Bureau of
Labor Statistics & the Census Bureau, 2014). The majority
(although diminishing in proportion) of children still receive insurance coverage through a parents employment
benefits. Rates of employer coverage of childrens insurance have slowly dropped over the past quarter century
(from about 75% in 1980 to about 57% in 2014), in part
due to decreasing family coverage for employees (Bureau
of Labor Statistics & the Census Bureau, 2014). In years
past, employee benefits usually included health insurance
for the employees household; increasingly, employers
limit health benefits to the employee alone.
Partly as a result of the decline in employer support for dependents, public health insurance has grown
substantially as the payer for childrens health care.
Medicaid, the major public insurance program for lowincome children, differs from Medicare in several critical
ways (Iglehart & Sommers, 2015). Medicare, a national
health insurance program for all citizens over age 65,
has national payment rates, full funding from the federal government, and common covered services for all
beneficiaries, regardless of where they live. Medicaid,
like Medicare, is an entitlement program, such that
any applicant meeting eligibility requirements must be
enrolled. But Medicaid, unlike Medicare, has joint funding from the federal government and the states, and
states maintain oversight prerogatives regarding the
states Medicaid program. Insofar as Medicaid, too, is an
entitlement program, states are unable to predict their
Medicaid expenditures each year. Furthermore, when the
economy weakens, state revenues fall but more people
meet financial eligibility requirements for Medicaid (and
other public programs). Medicaid, as a joint federal-state
program, has much variation across states in payment
level and services covered. On average, Medicaid payments are about 2/3 the level of Medicare payments
for the same service (Rosenbaum, 2014). New York and
Massachusetts may cover different mental health services
and pay very different rates for those services. States
set eligibility requirements, payment rates, and methods
of payment (e.g., managed care or direct to provider
payment), covered services, and scope of benefits (e.g.,
hospital days or physical therapy may be covered, but
the maximum yearly benefit could be just a few days or
a few treatments). The variations across state Medicaid
programs are dramatic, with little consistency (Kaiser
Commission on Medicaid and the Uninsured, 2013).
Medicaid, initially limited to children on welfare
or with severe disabilities, now includes many children
with household incomes well above the limits required
for public assistance through the Temporary Assistance to
Needy Families (TANF) program, in most states up to 2 or
3 times the Federal Poverty Line (FPL). In the mid-1990s,
Congress passed the Children’s Health Insurance Program
(CHIP), which provides additional insurance coverage for
children in households with incomes too high for Medicaid but not eligible for employer-based programs (Artiga
& Cornachione, 2016). CHIP, unlike Medicaid, is a block
grant to the states rather than an entitlement program;
when a state runs out of its yearly grant, it can refuse to
enroll new, eligible children. Finally, implementation of
the Affordable Care Act (ACA) has helped insure some additional children, both because they may be directly eligible but also because increasing coverage for adults has
led parents to seek different ways to insure their children
(Artiga & Cornachione, 2016). Generally, insured parents
are more likely to try to find insurance for their children
than are uninsured parents, and the process of enrollment for the ACA has helped parents determine whether
their children are eligible for Medicaid or other programs.
While more children than ever before are covered,
insurance coverage does not guarantee access. First,
Social Policy Report V29 #4 5 The Influence of Health Care Policies on
Children’s Health and Development
Some evidence does indicate that
having health insurance improves
child health, although clearly
other factorsfamily, social, and
community characteristicshave
much more influence on a childs
health and well-being than does
health care.
large numbers of dentists and pediatricians in the US
do not accept Medicaid for children in their practices
because of low payment rates. Second, parents with
both private and public insurance have increasing out-ofpocket costs for a variety of health care expenses from
new, high cost treatments to routine visits. Finally, many
children with specialty care needs lack needed services
because of long wait lists for appointments at regional
pediatric specialty centers where the supply of pediatric
specialists remains low.
These insurance expansionsmost in the public
sectorhave led to over 94% of children in the US now
having some form of health care insurance coverage. Poor
children continue to lag behind middle income children,
but the gap has markedly
narrowed (Bureau of Labor
Statistics & the Census
Bureau, 2014). This growth
in public insurance for
children represents substantial growth in public
investment. Given the
major squeeze on discretionary funding in federal
and many state budgets,
however, this growth has
come at the expense of
new funding for other public services in education or
social and community services (Rosenbaum & Blum,
2015; Steuerle, 2014).
What Does Insurance Cover?
U.S. health insurance has long focused on paying for
services providedin general, the more work done (i.e.,
more visits, procedures, treatments), the greater the
payments (i.e., fees for services provided). Providers
(physicians, nurses, hospitals, health centers) must meet
certain requirements for licensure and accreditation but
they then receive payment for an array of services mainly
focused on disorder assessment and treatment. Public
and private payers will pay for a variety of services,
increasingly including some preventive care and health
promotion, although the original intention of insurance
was catastrophic-risk protection against unexpected high
(health care) expenses. Preventive services (e.g., immunizations, screening) still account for only a small percentage of total health expenditures for children.
The incentives in traditional insurance arrangements thus are to increase the number of visits or procedures for which insurance will pay. Yet, the relationship between these services and outcomes that might
be valued for children and adolescents may be limited.
Assessment of quality of care in traditional arrangements
has often focused on assuring performance of certain
services, especially monitoring activities (e.g., routine
height and weight, assessment for obesity) and some preventive services (e.g., immunizations and certain screenings, such as hearing and vision or lead levels) rather
than improvements in outcomes or effectiveness.
Some evidence does indicate that having health
insurance improves child health, although clearly other
factorsfamily, social, and
community characteristics
have much more influence
on a childs health and
well-being than does health
insurance. In general, most
of the evidence is that
health care improves access
to and use of preventive
services, especially routine checkups (Edmunds &
Coye, 1998). Children with
health insurance appear to
have better dental health
as well (Leininger & Levy,
2015). But, as an example,
although the US has high
immunization rates, that
achievement in large part
reflects requirements for adequate vaccination at school
entry rather than the success of health insurance. For
very young children, more evidence supports the value of
non-reimbursed services like home visiting and nutrition
programs (e.g., WIC) than reimbursed routine prenatal
care (Rossin-Slater, 2015). Addressing the family and community issues that have the main impact on childrens
long-term well-being will require major changes in the
application of incentives in health insurancemoving
from a focus on medical care coverage to strategies to
make health care more effective in building healthy communities (Robert Wood Johnson Foundation, 2014).
A sizable number of children experience (individually) relatively rare and complex conditions such as
juvenile arthritis, hemophilia, leukemia, brain tumors,
sickle cell disease, and chromosomal disorders. Although
Social Policy Report V29 #4 6 The Influence of Health Care Policies on
Children’s Health and Development
each condition may be individually rare, adding all approximately 7,000 rare diseases (most of which manifest
in childhood) together leads to a large number of children (3.5 million) with conditions that typically require
much expertise and cost in their diagnosis, management,
assessment for complications, and monitoring over time.
This group of children may get a good deal of care from
community health providers, although most of them
also will need access to care and support from pediatric
subspecialistsmedical and surgical (Perrin, Anderson, &
Van Cleave, 2014). Pediatric subspecialists, unlike many
subspecialties in adult medicine, are relatively few in
number and typically centralized in specialized childrens
hospitals and academic programs, often at some distance
from where their patients with rarer chronic conditions
may live.
Medicaid, as a joint federal-state program, generally serves children within a states borders. A child who
may need to travel to a neighboring or more distant state
for specialized care may find that the insurance coverage does not travel with her and may face difficulty in
accessing needed care. Most childrens hospitals provide
specialized care to children in neighboring states as
well as in their home communities. While these specialized programs may contract with Medicaid agencies in
neighboring states, these contracts may pay less than the
in-state rate for care and can be an obstacle to needed
specialized treatment. Moves to develop regionalized
systems of care, with regionalized Medicaid funding, may
help to improve access (Childrens Hospital Association,
2015).
Support For Children Living In Poverty
and Those with Disabilities
A number of other programs provide some support for
children and families, especially in low-income households. The full range of these programsfrom nutrition
to housing to juvenile justiceis beyond the scope of
this report, although all can influence child health. We
will focus on two programs with direct effects on poverty amelioration and links to health care eligibility: the
Temporary Assistance to Needy Families (TANF) program
and the Supplemental Security Income (SSI) program.
Both programs provide cash assistance to low-income
families but with different purposes. TANF, like Medicaid,
is a joint federal-state program, with states having much
flexibility in determining eligibility and payment rates. In
2012, TANF income eligibility rates varied across the nation, with a national average of about 50% of the FPLor
less than $13,000 for a family of four. Thus, households
must generally be extremely poor to gain TANF eligibility
(Falk, 2013). State payment rates vary similarly, from a
high in New York of $753 per month for a family of three
to a low of $170 in Mississippi. TANF rules, outlined in
the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, also place limits on the number of
years recipients may receive benefits. Furthermore, that
welfare reform act ended any increase in funds, such that
the total state and federal expenditures for TANF have
remained the same for the last two decades, indicating
a loss of about 32% in real dollars from inflation. About
a third of households receiving TANF have children with
disabilities in them, limiting parents work opportunities
and often requiring much parent caretaking over years.
TANF acts as a critical safety net for the few families with
young children who are eligible for benefits in lifting them
out of abject poverty. Although a vital source of income
for the relatively small number of households who are
eligible, TANF fills a relatively small gap in services and
support needed by families raising children with chronic
health conditions and other threats to their health and
development. Poverty is linked to numerous opportunities
for stressful adverse experiences, and persistent adversity can be toxic and contribute to poor behavioral and
physical health across the lifespan. Policy that addresses
poverty, with understanding of the short- and long-term
costs and benefits for individuals and society, should be a
national priority.
The Supplemental Security Income (SSI) program
provides cash assistance to low-income people with severe disabilities, including children. In general, the level
of disability must be quite highthat is, most children
with chronic health conditions will not meet the high
standard of severity that SSI uses (Boat & Wu, 2015).
Approximately 1.3 million U.S. children and youth currently receive SSI benefits, and the associated income (up
to about $8,000 per year) keeps a moderate number of
households with children with disabilities above the FPL.
SSI is mainly a federally-funded program, although many
states supplement the monthly federal benefit. States,
through their Disability Determination Services, determine financial and clinical eligibility for applicants, working under federal rules and supervision. Raising a child
with a severe disability usually increases family expenses
(many needed services and supplies are not covered by
private or public health insurance), along with decreasing household income, as often one or both parents must
limit or quit the workplace to care for a child with a
Social Policy Report V29 #4 7 The Influence of Health Care Policies on
Children’s Health and Development
major disability. Thus, these SSI funds help to replace this
income and allow families to meet some of their additional costs. Moreover, SSI eligibility almost always confers
eligibility for Medicaid enrollment and services.
Both of these programs, like Medicaid, experience
major variations across states. For Medicaid and TANF,
states have much flexibility in determining eligibility and
benefits. A recent report also documented wide variations
in rates of applications, assessments, and determinations of eligibility for SSI across the states, although the
reasons for these variations are not clear (and likely do
not reflect major variations in rates of severe disability
across the states) (Boat & Wu, 2015). Policy that promotes equity in supports and services that improve health
outcomes should have a beneficial impact on the health
of the U.S. population.
Recent Trends In Health Care Payment
The high rates of inflation in health care expenditures have
led to much interest in finding new ways to diminish the
growth of health care costs. The Affordable Care Act, especially as implemented through the Center for Medicaid and
Medicare Services (CMS), has supported experimentation
with new ways to incentivize preventive care for high-risk
older populationsgroups with high rates of hospital and
emergency department care. Based mainly in Medicare
and not Medicaid, these strategies have begun to apply
new notions of prevention and keeping populations healthy
(or healthier). Payment approaches have included sharing
financial risk with providersif providers can cut costs for
populations, for example, by decreasing hospital use, the
provider may share in the savings accrued. Providers have
responded by implementing health care teams, dedicated
case management, new health status monitoring technologies (including extensive use of mHealth), home care, and
others. Payers, with Medicare leading the way, have experimented with new ways to pay for health care, including
incentives to meet newer quality standards, sharing savings
through implementing new programs, and fully capitated
arrangements, where providers get a fixed dollar amount
for providing a full range of services to a defined population over some time period (Burwell, 2015). These strategies have worked relatively well for specific populations
that have traditionally used large amounts of health care
services, achieving lower expenses in a relatively short
period of time (18-36 months) (Powers & Chaguturu, 2016).
Applying a similar short-term savings approach works less
well for children who generate only a small fraction of
total U.S. health care costs, and where the opportunities
for major health care cost savings in a short period of
time are much more limited. Improvement of child health,
however, represents an appealing long-term strategy for
reducing adult health care costs.
What Are the Needs of Children and Families
That Health Care Policies Can Address?
Several characteristics distinguish children from older
populations. They have substantially more racial and
ethnic diversity than any other group, and their development influences what diseases they experience, how
those conditions manifest at different ages, and how children respond to treatment (Forrest, Simpson, & Clancy,
1997; Perrin & Dewitt, 2011). Children depend very much
on adultsinitially, parents and family and later, teachers and othersfor their health care and developmental
needs. Although in general, children are healthier than
other populations, they too experience much chronic
illness, at increasing rates over the past decades. And
finally, they have much higher rates of poverty than any
other age group, and poverty has pervasive influences on
health and wellness and on growth, development, and
educational achievement.
The past few decades have seen much change in
the health conditions that children face. Many serious
infectious diseases have disappeared with effective immunization programs (e.g., measles, diphtheria, tetanus,
meningitis). Tuberculosis affects far fewer children than
in decades past; many conditions that would have led
to early death now have treatments that have greatly
improved life expectancy for those who experience them
(e.g., leukemia, complex congenital heart disease, cystic
fibrosis). Main causes of death today among children and
adolescents are accidents and suicides rather than malnutrition and epidemics (Rosenbaum & Blum, 2015).
These strong improvements in child health have
been accompanied by major growth in four groups of
common health conditions among children: obesity,
asthma, mental health conditions (e.g., depression,
anxiety, attention deficit hyperactivity disorder), and
neurodevelopmental conditions (e.g., autism spectrum
disorders, adverse consequences of prematurity). Diagnoses of these conditions, not typically fatal, have experienced huge growth over the past half century. Parents in
1960 reported less than 2% of children as having a chronic
health condition severe enough to interfere with their
lives on a daily basis. That percent has grown by over
400% to a rate today of over 8% (Field & Jette, 2007).
Social Policy Report V29 #4 8 The Influence of Health Care Policies on
Children’s Health and Development
And rates of less severe chronic conditions (usually in the
same four categories) have also grown such that some
studies indicate that 25-35% of people under age 20 years
will have experienced some chronic health condition in
their first two decades (Van Cleave, Gortmaker, & Perrin, 2010). Some of this growth does represent improved
survival owing to advances in medical and surgical care
that have improved the outcomes of young people with
conditions such as spina bifida and cystic fibrosis, but the
large majority reflects the growth of these four common
condition groups. Recent data also note well the growth
of disability among young Americans of working age,
with increasing numbers having severe obesity, mental
health impairments, or developmental disorders that
limit their ability to pursue
educational opportunities
or employment (Field &
Jette, 2007).
Mental and behavioral health play an
increasing and critical role
in any consideration of
child health and its impact
on long-term health outcomes. For example, most
mental health disorders of
adults have their roots in
childhood or adolescence.
For several decades, child
mental health was treatedand paid foras a set of conditions separate from
and distinct from the other conditions that children experience. Prevention in mental health gained little attention. Community physicians and pediatric subspecialists
had little incentive or support to identify mental health
conditions early or to prevent them through effective
parent counseling or referral to community agencies. As
a result, children with moderate to severe mental health
conditions were not identified until they had quite severe
symptoms, where earlier identification and intervention could have had major benefit. In more recent years,
payers and program leaders, including a number of state
Medicaid programs, have begun to address this separation and are working to reintegrate behavioral health
into general pediatric care.
The effects of persistent mental health problems
on childrens functioning are clear, along with greater
recognition that mental health conditions also generate or complicate many other health conditions. For
adults, the co-occurrence of mental health conditions
with chronic diseases such as heart disease or diabetes is
associated with much higher costs (Melek et al., 2013).
Children with chronic health conditions have higher rates
of mental or behavioral health concerns as well. The
opportunities within the health sector include addressing mental health concerns on all visits, systematic early
identification through screening, building on longer-term
trusting relationships to institute treatment, and providing services directly in the health sector (see below for
co-location of mental health practitioners in pediatric
settings as well as parent training activities carried out
in pediatric practices) (American Academy of Pediatrics
Task Force on Mental Health, 2010; Institute of Medicine & National Research
Council, 2014). Given the
substantial role of public
schools in mental health
care provision, it is also
critical to have effective,
ongoing collaboration between schools and (other)
health providers. Unfortunately, budget constraints
in school districts have
diminished availability of
health care personnel in
schools. Similar attention
to early childhood health
has been even more spotty
in preschool and child care settings.
Families seek responses to their needs in a delivery
system that is a good deal broader than medical care,
incorporating a wide array of community, public health,
education, and other services (Perrin et al., 2007). These
service systems are highly fragmented, and families
access to and use of services depends on many factors,
including financing, physical access, knowledge, and
beliefs. In mental and behavioral health, fragmentation is particularly obvious, with some care from mental
health clinicians and primary care providers, especially
in screening and identification of younger children, but
a good deal more in public schools and for many in the
juvenile justice system. Current incentives for collaboration across sectors are limited, but the opportunities that
could accrue from coordination and collaboration are
substantial (Cuellar, 2015).
Asthma, obesity, mental disorders, and neurodevelopmental conditions all reflect an interaction of genetic
Given the substantial role of public
schools in mental health care
provision, it is also critical to have
effective, ongoing collaboration
between schools and (other)
health providers.
Social Policy Report V29 #4 9 The Influence of Health Care Policies on
Children’s Health and Development
susceptibility with the influences of social and other environmental phenomena. Their prevention and management require a multidisciplinary and multi-institutional
response, not something that the health care sector
alone can manage. It will, nonetheless, be critical to find
ways to prevent the onset and severity of these conditions, or the nation will face larger numbers of citizens
who depend on public institutions and services for their
livelihood, and fewer young people resilient and capable
to participate effectively in the nations economy (Field
& Jette, 2007).
Over the past decade, increasing evidence has
documented the importance of early life experiences for
the well-being of young childreninfluencing their readiness for school and literacy at age 8 and their ability to
succeed in adolescence and young adulthood. Particularly
difficult circumstances lead to toxic stress, where very
young children face persistent adversity with consequent
impact on their neuroanatomy and the functioning of
their brain and other body systems. Toxic stress, much
more prevalent among poorer children (although not limited to children growing up in poverty), can have permanent effects on the developing child (American Academy
of Pediatrics, Committee on Psychosocial Aspects of
Child and Family Health, 2012). Family functioning is a
strong predictor of child developmental outcomes and
health. Child health and development are inextricably
intertwinedhealthy children grow better, develop more
skills, and have better school readiness. Similarly, children whose development has had support from parents
and community services are healthier, pursue less risky
behaviors, and have lower rates of the common chronic
mental health and other health conditions in childhood
and adulthood (Campbell et al., 2014). As addressed
above, policies that promote better family functioning
and support of children can broadly improve childrens
health and development.
New Models of Health Care
Recognition of the unaddressed and changing needs of
children and families in the presence of changing financial incentives has fostered the development of new
models of care. Most of these include the concept of
medical homes and some elements of interdisciplinary care teamsassociating medical professionals with
other professionals who can expand the work and attention of the health care program (Patient-Centered
Primary Care Collaborative, n.d.). Team functions (not
specific team members) tend to fall into four main areas:
chronic condition management, behavioral health integration, improving early childhood experiences, and
linking households with critical community services. The
growth of common chronic conditions has led to greater
use of nurses or nurse practitioners to monitor care and
progress over time and to help children and families with
adherence to medical treatments. Greater recognition of
mental health needs among children and the interconnection of behavioral issues with health and illness has led
to programs of co-locating or integrating mental health
professionals in pediatric practice (Kolko & Perrin, 2014;
Williams, Shore, & Foy, 2006). Other programs to support
better attention to behavioral health in pediatric care
have included primary care physician backup systems in
over 30 states, where physicians can easily and expeditiously consult a mental health practitioner by phone to
help care for behavioral issues in the practice (Sarvet et
al., 2010). Increasing understanding of the critical importance of early childhood has led practices to include
home visiting and other parent support programs among
their services or to collaborate with home visiting programs in the community. A focus on two generation health
(child and parents) as essential for child well-being has
begun to achieve traction in some pediatric health care
settings. Finally, many practices have incorporated staff
members who are or become knowledgeable about community culture and resources, learn to refer households to
appropriate community services, and follow up to assure
that families receive the services they need (Berkowitz
et al., 2015). In all of these cases, family members (and
children in developmentally appropriate ways) are central
members of the teamteams reflect co-production with
patients and families.
Financial support for these practice innovations has
been limited; private payers rarely reward these innovations in traditional payment schemes because they often
focus on non-professionals, diverse settings, and linkage
of social and educational services with medical care,
areas without a history of health care payment. Equally
challenging, Medicaid (the largest payer for child medical care) has been much less active in child health care
reform than with adults. To date, the development of
federal policy around value-based purchasing has largely
been driven by Medicare policy including the encouragement of both accountable care organizations and bundled
payment initiatives. Primary care clinicians participating
in the transformation to team-based care and related
initiatives complain that they do so at their own financial
risk (Chesluk & Holmboe, 2010).
Social Policy Report V29 #4 10 The Influence of Health Care Policies on
Children’s Health and Development
Nevertheless, many clinicians and a few health
systems have learned the value of these changes and have
worked to obtain external funding or to reorganize the financing of the practice to support the changes. In a number
of states, Medicaid programs have supported innovations,
developing some incentives for practices similar to those in
Medicare (i.e., care coordination, behavioral health integration, and chronic care management) (Centers for Medicare & Medicaid Services, n.d.; Hervey, Summers, & Inama,
2015). The largest of these are the statewide accountable
care organizations (ACOs) undertaken by a handful of states
to enroll all Medicaid managed care children and adults
into provider networks that take both clinical and financial
risk for the patients. Anecdotal experience to date suggests
that cost growth in these ACOs has been lower than overall
Medicaid cost growth in the respective states (Lloyd, Houston, & McGinnis, 2015). CMS has fostered both the start and
expansion of some of these and related experiments in care
transformation.
With innovation grants and
systems improvement awards
from CMS, states
have experimented with a variety
of programs,
some focused on
specific chronic
conditions (obesity, asthma), others on behavioral
health integration
in primary care,
and still others
with bundled payments for episodes of care, an intermediate payment state between fee
for service and capitation.
The statewide ACO initiatives have not had specific
measurement or quality incentives for care focused on
children, but fourteen pediatric health systems around the
country have engaged in exclusive pediatric risk contracts
while many more have plans to do so (Makni, Rothenburger, & Kelleher, 2015). These efforts have had dedicated pediatric networks and child specific goals for care
improvement. Two have published evaluations suggesting
modest quality improvements and significant cost savings
(Christensen & Payne, 2016; Kelleher et al., 2015).
The use of ACO contracting to transform care is
shifting incentives markedly in some places, but a larger
effect in practice transformation will likely come from
the bundled payment initiatives undertaken by Arkansas (Chernew et al., 2015), Ohio, and other states. The
provision of incentives for providers that meet minimum
quality standards and save money, with corresponding
penalties for high cost providers for specific diagnoses
and procedures, results in tight referral networks of low
cost providers and careful followup of high cost patients.
Notably, these efforts include partnerships among Medicaid and the largest private insurers so that all providers
are affected.
Together, these efforts have started a movement
to better use newer measures of quality (Anglin & Hossain, 2015; Blumenthal & McGinnis, 2015). What should
indicate value in child health care? What outcomes should
health care payers (public and private) use to assess care?
Where do patient
and parent experience of care and
partnership appear in measures?
Would school
readiness at age
5, literacy at age
8, and high school
graduation serve
as good measures? Quality of
life, functioning
at a high level,
and freedom from
health symptoms
and conditions
are potentially
important considerations. In behavioral health, increasing evidence
indicates the greater importance of improving functioning
and academic performance than controlling symptoms
(Cuellar, 2015).
Training the Pediatric Workforce
While pediatric training has evolved in response to
emerging needs of children over the last several decades,
several gaps remain for residency and fellowship training
that deserve attention. These include health promotion
and prevention in general, parent and family health and
With innovation grants and systems improvement
awards from CMS, states have experimented with
a variety of programs, some focused on specific
chronic conditions (obesity, asthma), others on
behavioral health integration in primary care, and
still others with bundled payments for episodes of
care, an intermediate payment state between fee
for service and capitation.
Social Policy Report V29 #4 11 The Influence of Health Care Policies on
Children’s Health and Development
functioning assessment and support as it influences child
health, and behavioral health, along with skills in epidemiology, behavior change, and clinical management.
Although training content is not legislated, several important programs and organizations have responsibility to
consider and set expectations for pediatric training that
can respond more to the overall health needs of children.
These include individual training programs, the Pediatric
Residency Review Committee (RRC), and the American
Board of Pediatrics (ABP). The latter two influence training outcomes by defining criteria for accreditation of
training curriculum and experiences (RRC) and expected
competencies for post-training certification (ABP). These
regulatory bodies de facto set expectations for pediatric
training and its outcomes and thereby set national training policy. The organizations must embrace greater attention to health promotion and prevention, family function,
and behavioral health of children, and how to embed
these elements of care widely into pediatric practice.
Physicians should also have facility and familiarity with
digital monitoring and communications devices, basic
epidemiology and population health skills to lead community health efforts, and basic business skills to operate in
large corporate enterprises across multiple settings.
A further need for pediatric training is experience
in creating and working effectively within interdisciplinary teams. Currently, medical trainees rarely work with
trainees and practitioners in other relevant health professions such as nurses and nurse practitioners, psychologists
and social workers, and community health workers. The
needs of children and families call for planning, integration, and delivery of care that is transdisciplinary, a term
that has come to define partners who go beyond working
in the same place to those who adopt integrated planning
and delivery of comprehensive care. An example arises
from the creation of integrated behavioral and traditional
medical care, where pediatricians should develop competencies in sharing responsibility for behavioral health
outcomes of children.
Integration Across Sectors
Beyond Health Care to the Health of
Communities Where Children Live
What are potential solutions to the long-standing disconnect between traditional child health services, the
growing population of children with chronic conditions including behavioral health, and the social and community
determinants of childrens health and development?
One innovative solution to expanding funding for
health promotion and disease prevention for children
and families is the expansion of social financing broadly
and social equity or impact bonds (SIBs) in particular.
This class of investments uses innovative finance tools to
engage private capital and oversight in addressing social
needs and to create shared value (Porter, 2010). SIBs
also are known as and are not classical bonds in that they have elements of both bonds and
stocks. Private investors enter into fixed period investments with return contingent on savings generated by the
public agency for successful improvements. In the original
Rockefeller Foundation bond at Petersborough prison in
London, investors were returned funds based on the effectiveness of the recidivism prevention programs supervised by social agencies and investors. SIBs have been
established to prevent teen pregnancy in Washington,
DC, special education among young children in Utah, and
asthma exacerbations among children in Fresno, CA, and
South Carolina. For specific social problems, they show
promise, but across broader social issues, inability to
project a clear return on SIB investments will be a barrier
to their attractiveness.
Two more general approaches for intervention have
been suggested to address the multifactorial nature of
health and mental health risk and resilience for children,
especially the large number of children living in poverty.
First, early childhood support programs that connect
center-based child activities with family support can have
lasting effects. Two carefully-designed and implemented
long-term studies have shown that providing comprehensive child and family support during early childhood can
have long-lasting payoffs for children and the community.
Both the Abecedarian Project (in rural North Carolina) and
the Perry Preschool Project (in more urban Michigan) randomized low-income households, predominantly AfricanAmerican, to intervention and control groups and have
now followed the children for over four decades (Campbell et al., 2014). Among the results have been higher
high school and college graduation rates for the intervention groups; as well as later first pregnancies, lower rates
of obesity, diabetes and hypertension, higher incomes and
job retention, and substantially lower rates of incarceration among males (Campbell et al., 2014). Although both
of these programs had health components, they mainly
represent coordination of family support and early education with other community services.
The second approach is a more recent and rapidly
growing attention to place-based or geographically
Social Policy Report V29 #4 12 The Influence of Health Care Policies on
Children’s Health and Development
circumscribed, community development interventions
that share common principles for neighborhood and child
development. These include locally developed coalitions
with community residents as leaders and members, assetbased development with local strengths assessments,
support from anchor institutions such as medical centers
or universities, and a comprehensive service package to
include at a minimum housing, jobs and education reform
linked to health care services. Such initiatives presume
that long-term sustainability requires neighborhood commitment and involvement, and the health of children
and families will always be vulnerable unless underlying
risks like homelessness and unemployment are addressed
(Fryer & Katz, 2013; U.S. Department of Health and
Human Services, n.d.). National foundations have been
leaders in this effort including the Casey Foundation Two
Generation Approach, the Robert Wood Johnson Foundation Culture of Health initiatives, and the Kellogg Healthy
Communities. The federal Promise Neighborhoods are
similar. Independent of these efforts, several neighborhood initiatives are being spearheaded by pediatricians
and childrens hospitals oftentimes connected with
Medicaid financial risk contracts. For example, the Lower
Price Hill initiative in Cincinnati, the Southern Orchards
initiative in Columbus, and the East Milwaukee initiative
in Wisconsin all are linked to organizations with Medicaid
capitation contracts. Here, the organizations have recognized that investment in non-traditional programs such as
housing may lead to decreased health care costs. While
many of these initiatives across the country begin with
extended provision of health care services in community
settings, Medicaid and other payers are often recognizing
the importance of the other components, often with the
maxim, Housing First. In fact, Medicaid waivers like the
one in New York now allow Medicaid dollars to be used in
focused populations for rent support in recognition of the
critical role of housing in maintaining health.
A number of promising programs have focused on
the integration of public and private efforts to link multiple services at the community level. Much of this work
has focused on early childhood, recognizing that interventions must address both child issues and the needs of
parents. These programs recognize that parent health
and well-beingand meeting the needs of parentsis
critical to improving the health of children. Care must
address two generations and not focus only on children.
Examples include the major commitment of the business
community to improving early childhood education (see
http://www.americaspromise.org; http://toosmall.org),
public efforts to integrate services so that households find
a seamless set of programs to help them meet their needs
(Fryer & Katz, 2013; U.S. Department of Health and Human Services, n.d.), and the inclusion of early childhood
and community investment in a number of state budgets.
Governors recognize that one of the major expenses in
state budgets involves maintaining or financing prisons
for (mainly) young malesan investment with very little
return for the state or community. They also have recognized that prevention of the need for incarceration can
be a wiser investment. A recent report from the Robert
Wood Johnson Foundation calls for greater investment in
children and communities and for making the communities where we work and live and raise children healthy
communities (Robert Wood Johnson Foundation, 2014).
Experiences reflecting this approach also have integrated
a variety of services at the community levelincluding
health careto support health and child growth. The
Federal Reserve Banks, which invest large amounts of
resources each year in communities, have recognized the
importance of community development and coalitions to
achieve the kinds of communities that will strengthen the
local economy and the lives and preparation of workers.
Below, we will consider ways that the health care sector
can support and engage with these community efforts and
how health care policies could aid that integration.
Federal policy is also influential in the link between
the education sector and health care. Health insurance
and access to a usual source of care can improve academic outcomes (Institute of Medicine, 2009). Specifically,
Medicaid access for children results in better grades, fewer missed days, greater graduation rates, and higher long
term earnings (Cohodes, Grossman, Kleiner, & Lovenheim,
2014). When schools aid in insurance enrollment during
school registration or other events, they are promoting
better performance in school. The Patient Protection and
Affordable Care Act (ACA) also recognized the link between health and schools. More than $200M was authorized for expansion of school health clinics, purchase of
new equipment for school clinics, and modernization of
the same. CMS also modified its free care policy allowing
Medicaid reimbursement as first payer for school-based
services (U.S. Department of Health and Human Services,
2014). Finally, schools, in partnership with health care
agencies, can provide wrap around case management to
high risk children who are chronically absent, homeless,
or at risk of falling behind (Suter & Bruns, 2009).
Social Policy Report V29 #4 13 The Influence of Health Care Policies on
Children’s Health and Development
New Strategies in Health Care
Whats Most Promising
New ventures in health care financing and organization
could assist the broader attention to prevention, health
promotion, and community integration. Health care payment approaches that pay for value rather than services
provided, with value defined as outcomes indicative of
child and adolescent wellness and development, should
be considered (e.g., readiness for next developmental
steps, such as school entry). Such
incentives move well beyond fee
for service to payment for achieving
specified goals or potentially global
budgeting (payment for all health services over a specified period of time).
These payment arrangements provide
incentives for health care providers to
account for social and community influences on the health status of their
patients and to engage community
partners to improve those outcomes.
Doing this will require incentives for
coordination and new measures to
assess outcomes related to functioning and performance. CMS recently
announced a new program to support
healthy neighborhoodsexperimenting
with payment to enhance health care
connections with the community and
recognize the multiple community
players that influence health (Centers
for Medicare & Medicaid Services,
n.d.). The neighborhood for a child includes the multiple service programs,
including of course schools, that
impact a child (Perrin et al., 2007),
and for children with more complex
chronic conditions, the subspecialists
(often not in the same geographic neighborhood) that the
child needs.
New information technologies can enhance these
systems of community care. Mobile health (mHealth)
developments include the ability to monitor a child with
a chronic condition (e.g., asthma) at a distance but in
real time; to assess the middle ear status of a child with
fever and earache while she stays in school; to communicate with children and families about the value of
certain health behaviors (including immunizations, safe
sex, adequate sleep, physical activity); and to examine
growing premature infants for retinopathy at a distance.
While these and additional forms of mHealth development
hold great promise, their yield and implementation will
be determined more by federal policy than by technical
limitations because investment and growth are affected
by a myriad of federal issues at the moment.
Oversight of mHealth technologies at the federal
level is distributed among several agencies. The Food
and Drug Administration issued guidance in 2012 that it would regulate
some devices and forms of mHealth as
medical devices and modified that
guidance in 2013 to include mobile
medical apps (U.S. Food and Drug
Administration, 2013). For items classified as medical devices, registration,
pre-release testing and post-release
safety monitoring are all required,
considerably raising the costs and
stakes for development and sales of
mHealth devices. The Federal Trade
Commission also plays an important
role in assessing whether mHealth
advertising claims are met or fair
and has the lead federal role in data
breaches due to device malfunction
or negligence. When data breaches do
occur, the Office of Civil Rights within
the U.S. Department of Health and
Human Services supervises penalties
which may amount to $50,000 per
individual patients data loss. Finally,
the Federal Communications Commission regulates all mHealth tools
that use part of the electromagnetic
spectrum or transmit personal data as
communications devices (Center for
Connected Health Policy, n.d.). They specifically set aside
part of the electromagnetic spectrum for transmission of
personal medical information in 2012 and monitor the use
of public airwaves (Office of the National Coordinator for
Health Information Technology, n.d.).
Perhaps most importantly, licensing restrictions
and outdated federal telemedicine restrictions discourage innovation and spread of telehealth generally. Telehealth offers many opportunities in health care, including
decentralizing subspecialty care to communities through
distance evaluation and treatment, providing mental
CMS recently
announced a
new program to
support healthy
neighborhoods
experimenting
with payment to
enhance health care
connections with
the community
and recognize the
multiple community
players that
influence health
Social Policy Report V29 #4 14 The Influence of Health Care Policies on
Children’s Health and Development
health services in homes and community settings, and
providing new skills to community practitioners (Burke &
Hall, 2015). Licensing of physical therapists, nurses, and
physicians, among others, precludes cross-state interactions requiring clinicians from the originating site to seek
multiple state licenses. While interstate compacts are
being pursued in some places, short-term solutions are
not in sight. Similarly, older legislation prevents Medicare
and Veterans Administration patients from receiving telemedicine services in urban areas, at home, in community
health centers, and in some other locations. The widereaching nature of these exclusions strongly discourages
investment in mHealth and telemedicine (American Telemedicine Association, n.d.). A variety of bills have been
introduced in Congress aimed at individual pieces of the
logjam, but progress has been slow.
Finally, the growing collection of biologic data
phenotypic and genomicwill help guide more targeted
therapies and support better health surveillance and
prediction of health outcomes. Greater understanding
of environmental influencestoxic exposures, social and
community interactionswill also improve prediction of
critical health outcomes, as well as help target useful
interventions to improve health.
As the focus sharpens on understanding child and
family health risks and orienting medical care to reduce
these risks, identifying individual risks will be increasingly possible and important. Risks are not only socially
but biologically determined. Children are born with genetic health risks and resilience, and are both born with
and acquire epigenetic health risk and resilience traits.
National research funding priorities should acknowledge
and promote studies aimed at identifying these risk and
resilience factors and using that information along with
socioeconomic risk and resilience factors to individualize or be selective in efforts to mitigate health risks in
early life. A partnership of biological and socioeconomic
research has potential to advance the promotion of child
health to levels not achievable by either alone.
Social Policy Report V29 #4 15 The Influence of Health Care Policies on
Children’s Health and Development
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Perrin, J. M., Anderson, L. E., & Van Cleave, J. (2014). The rise in chronic conditions among infants, children, and youth can be met with continued health system innovations. Health Affairs, 33, 2099-2105.
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Perrin, J. M., & Dewitt, T. G. (2011). Future of academic general pediatrics: Areas of opportunity. Academic
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Social Policy Report V29 #4 17 The Influence of Health Care Policies on
Children’s Health and Development
Powers, B. W., & Chaguturu, S. K. (2016). ACOs and high-cost patients. New England Journal of Medicine,
374, 203-205. doi:10.1056/NEJMp1511131
Robert Wood Johnson Foundation Commission to Build a Healthier America. (2014). Time to act:
Investing in the health of our children and communities. Princeton, NJ: Author. Retrieved from
http://www.rwjf.org/en/library/research/2014/01/recommendations-from-the-rwjf-commission-tobuild-a-healthier-am.html
Rosenbaum, S. (2014). Medicaid payments and access to care. New England Journal of Medicine, 371, 2345-
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Rosenbaum, S., & Blum, R. (2015). How healthy are our children? Future of Children, 25, 11-34.
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Social Policy Report V29 #4 18 The Influence of Health Care Policies on
Children’s Health and Development
Commentary
Poverty and Child Health in the United States:
Addressing the Social Determinants of Health in the Medical Home
Benard P. Dreyer, MD
New York University School of Medicine
P
errin, Boat, and
Kelleher (2016) in
this issue give us an
erudite discussion of
health care policies
and their impact on
childrens health and development.
Their discussion ranges from health
insurance, the new or millennial
morbidities facing children, newer
models of health care payment and
delivery, integration across sectors
beyond health care, and promising
new developments. I will comment
on and expand on some of the important points made in their report.
Poverty is the elephant in the
room. The authors rightly point out
that poverty affects essentially all
aspects of child health and development and that family, social, and
community influences are more
strongly related to child health and
developmental outcomes than either
genes or direct health care services.
The truth, as the authors recognize,
is that direct health care has a real
but limited ability to improve child
health and well-being. Perrin and his
co-authors also stress the importance
of early childhood experiences and
the long-term impact, for better or
worse, which these experiences have
on children. They describe new models of health care which include support for parenting, two-generation
approaches, and inclusion of staff
who are knowledgeable about community resources and can refer families to obtain community resources
as well as make sure the families get
the services they need.
The American Academy of Pediatrics (AAP) has recently released a
new policy, Poverty and Child Health
in the United States, which focuses
on what the health care delivery
system can do to impact the health
problems of poor children (AAP
Council on Community Pediatrics,
2016). The recommendations in this
policy statement regarding improvements in health care practice
address many of the issues brought
up in the report by Perrin and his
co-authors.
The AAP recommends that
pediatricians and other health care
providers caring for children in poor
or low-income families screen for
risk factors within the social determinants of health in order to assist
families in meeting their basic needs
(e.g., food, housing, heating, child
care). The point of screening of
course is to connect families with
community resources that help them
meet these basic needs.
The AAP also recommends that
practices and health care systems
serving poor or low-income children
consider integrating programs in the
medical home that address parenting
as well as behavioral health. There
are a number of evidence-based programs that could be adopted. Early
literacy promotion can be addressed
with Reach Out and Read, a widely
adopted intervention that reaches 4
million children each year and has
been shown to improve language
development in preschool children,
as well as encourage parents to read
to their children and engage in interactive play (Diener, Hobson-Rohrer,
& Byington, 2012; Mendelsohn et
al., 2001). VIP, or the Video Interaction Project, which combines early
literacy with guided parent-child
interactions, enhances responsive
parenting, and has also been shown
to improve cognitive, language, and
social-emotional development of
children (Mendelsohn, Dreyer, Brockmeyer, Berkule-Silberman, & Morrow, 2011). Healthy Steps for Young
Children, a manual-based primary
care strategy, and programs such as
Incredible Years and Triple P, which
Social Policy Report V29 #4 19 The Influence of Health Care Policies on
Children’s Health and Development
integrate behavioral health into primary care, have been shown to promote parenting and address common
behavioral problems in early childhood (Bauer & Webster-Stratton,
2006; Minkovitz et al., 2007; Perrin,
Sheldrick, McMenamy, Henson, &
Carter, 2014). These interventions in
primary care have an important positive impact on early brain and child
development and ameliorate the
toxic stress of poverty on families
and children.
Pediatricians are also encouraged by the AAP to engage with
other sectors in the community,
especially education, child care,
home visiting, local and state
health departments, and community
development programs. This recommendation is consistent with Perrin
and his co-authors call for integration across sectorsbeyond health
care to the health of communities
where the children live (Perrin et
al., 2016). Furthermore, echoing
the concerns of the authors of this
report about the impact of mental
and behavioral health on the long
term health outcomes of children,
the AAP asks pediatricians to develop strategies to address family and
child mental health issues, including
screening and referral for maternal
depression.
Health care reform in the U.S.
is very different for children than for
adults. For adults, the primary aim
is cost-saving, and therefore quality
measures and financial incentives
have focused on high cost chronic
conditions of adults. For children,
short-term cost-saving is not usually applicable. Improving long-term
child outcomes, although potentially
saving billions of dollars, is far in the
future. Even those future savings,
while to some degree in the health
care system, are often in other sectors, including education and criminal justice. The difficulty, as the authors describe, is encouraging public
health insurance and private insurers
to incentivize the changes in health
care delivery that they and the AAP
are recommending for children in
view of the pressures to focus on
decreasing health care expenditures
for expensive adult health care.
Alternatively, other sectors that will
benefit from the health and wellbeing of children, adolescents, and
young adults might be involved in
financing these improvements. The
authors rightly stress the need to develop newer measures of quality to
indicate value in child health care.
Perhaps, as they ask, measures of
school readiness and academic success are the correct ones to indicate
child health outcomes in todays and
tomorrows world.
Advocacy will be required
by all of us who care for and care
about children in order to affect a
change in this value proposition. As
the AAP recommends in its new policy on poverty and child health (AAP
Council on Community Pediatrics,
2016), our society needs to invest in
young children, to create incentives
to improve population health with
the goal of reducing health disparities, to enhance health care financing to support comprehensive care
for at-risk families, and to support
integrated models of care in the
medical home that promote effective parenting and school readiness,
such as Healthy Steps, Reach Out
and Read, Video Interaction Project,
Incredible Years, and Triple P Positive Parenting Program.
As Perrin and co-authors stress,
health care payment must be targeted to address value based on child
and adolescent wellness and development, with measures that track
the childs readiness to be successful in the next developmental step.
In order to do this, we will need to
collaborate across sectors and reach
out to our community partners, and
government will need to support
families meeting their basic needs,
support and expand strategies that
promote employment and that increase parental income, and improve
the communities in which children
are living so that they may thrive
and not just survive.
References
AAP Council on Community Pediatrics.
(2016). Poverty and child health in
the United States. Pediatrics, 137(4),
1-14. doi:10.1542/peds.2016-0339
Bauer, N. S., & Webster-Stratton, C.
(2006). Prevention of behavioral
disorders in primary care. Current
Opinion in Pediatrics, 18, 654-660.
doi:10.1097/MOP.0b013e3280106239
Diener, M. L., Hobson-Rohrer, W., &
Byington, C. L. (2012). Kindergarten
readiness and performance of Latino
children participating in Reach Out
and Read. Journal of Community
Medicine & Health Education, 2:133.
doi:10.4172/jcmhe.1000133.
Mendelsohn, A. L., Dreyer, B. P., Brockmeyer, C. A., Berkule-Silberman, S. B., &
Morrow, L. M. (2011). Fostering early
development and school readiness in
pediatric settings. In D. Dickinson & S.
Neuman (Eds.), Handbook of early literacy research (Vol. 3, pp. 279-294).
New York, NY: Guilford.
Mendelsohn, A. L., Mogilner, L. N., Dreyer,
B. P. Forman, J. A., Weinstein, S.
C., Broderick, M., Napier, C.
(2001). The impact of a clinic-based
literacy intervention on language
development in inner-city preschool
children. Pediatrics, 107, 130-134.
doi:10.1542/peds.107.1.130
Minkovitz, C. S., Strobino, D., Mistry, K. B.,
Scharfstein, D. O., Grason, H., Hou,
W., . . . Guyer, B. (2007). Healthy
Steps for young children: Sustained
results at 5.5 years. Pediatrics,
120(3), e658-e668.
doi:10.1542/peds.2006-1205
Social Policy Report V29 #4 20 The Influence of Health Care Policies on
Children’s Health and Development
Perrin, E. C., Sheldrick, R. C., McMenamy, J. M., Henson, B. S., & Carter,
A. S. (2014). Improving parenting
skills for families of young children
in pediatric settings: A randomized
clinical trial. JAMA Pediatrics, 168,
16-24. doi:10.1001/jamapediatrics.2013.2919
Perrin, J. M., Boat, T. F., & Kelleher, K.
J. (2016). The influence of health
care policies on childrens health and
development. Social Policy Report,
29(4).
Commentary
The Opportunity for Health Care Policies to Advance
Child Health and Development
Ajay Chaudry
New York University
T he Influences
of Health
Care Policies
on Childrens
Health and
Development, by Drs. Perrin, Boat, and
Kelleher provides a cogent and
timely summary of recent progress,
current challenges, and pending opportunities for policy to effect child
health and development. In this brief
commentary, I echo and emphasize
a few key points in the report and
argue that the current moment
presents some unique, but complex
opportunities to better integrate
health and human services for lowincome families with children and to
not treat childrens health in isolation of their parents health and
community contexts.
The links between childhood
poverty and childrens
health and well-being
A key theme the authors effectively
support and develop is that poverty affects essentially all aspects
of child health and development.
The strength and consistency of the
relationship between poverty and the
health conditions and outcomes in the
United States can be found in findings
from a whole host of nationally representative surveys and observational
studies. Table 1 summarizes several
health and development indicators
from the National Health Interview
Survey for 1997 and 2014.
At least three things stand out
in this data. First, there has been very
significant progress for all children,
both poor and non-poor children on
some important measures. Great
progress has been made in children
having health insurance coverage,
which declined more than 70 percent
for children in poor families from 21
percent to 6 percent and for children
in non-poor families from 6 percent
to 3.5 percent. We also see significant
increases in children reported to be in
excellent health from 40 percent to 49
percent among children in poor families and from 63 percent to 69 percent
in non-poor families.
Second, children in poverty
continue to have worse health conditions and have greater health needs.
They continue to be four times as
likely to be reported to be in fair or
poor health, nearly twice as likely to
be uninsured, 30 percent more likely
to have ever been diagnosed with
asthma or determined to be obese,
almost twice as likely to have needed
to visit an emergency room in the last
year, and twice as likely to have been
found to have a learning disability.
Social Policy Report V29 #4 21 The Influence of Health Care Policies on
Children’s Health and Development
Leveraging
Medicaids expansions
Improvements in childrens health
insurance coverage have been due
to the significant expansions over
the last 20 years in Medicaid and
creation of the Child Health Insurance Program (CHIP). In fact, as the
authors note, during this same time
employer-sponsored health insurance for children through parents
employers declined from 66 percent to 55 percent between 1997
and 2014, public health insurance
coverage doubled from 21 percent to
42 percent of all children, and this
accounted for the entire increase in
childrens health insurance coverage (Martinez, Cohen, & Zammitti,
2016). With more than 90 percent of
children now having insurance coverage across all income groups for the
first time ever and the majority of
poor and near-poor children covered
by public insurance, the opportunity
to leverage health care to address
the determinants of childrens
health, development, and well-being
are unprecedented (Iglehart & Sommers, 2015). The Medicaid expanThird, as the authors note,
there are child health conditions
that have remained persistent or
growing challenges, particularly
childhood obesity and asthma, and
these afflict the children of the poor
disproportionately. More than one
in five children in poor families was
found to be obese and one in nine
had been diagnosed with asthma.
These conditions remain particularly
troubling because of their lifelong
consequences for individuals and
long-term costs for health care in
the United States.
Table 1Selected Population-Based Indicators of Well-Being for Poor and Non-poor Children in the United
States, 1997 & 2014
Indicator
1997
(unless noted)
2014
(unless noted)
% of Poor
Children
% of Non-poor
Children
% of Poor
Children
% of Non-poor
Children
Health Conditions/Outcomes (for children between 0 and 17 years, unless noted)
Reported to be in excellent health 39.5%a 63.2%a 48.9%b 66.9%b
Reported to be in fair to poor health 4.4%a 1.0%a 3.2%b 0.8%b
Uninsured for health care 21.3%a 5.9%a 6.2%b 3.5%b
Ever told has asthma 12.9%a 11.7%a 11.0%b 8.2%b
Obesity (age 2-19) (2009-2012) 11.9%c (1988-1994) 7.8%c (1988-1994) 21.2%d (2009-2012) 15.7%d (2009-2012)
Made one or more emergency room visits
in past 12 months 25.1%a 18.0%a 24.4%b 12.7%b
Missed 11 or more school days
in past 12 months because of illness or injury
(ages 5-17)
9.5%a 4.9%a 4.8%b 2.9%b
Developmental Conditions/Outcomes
Learning Disability (ages 3-17) 10.2%a 6.6%a 10.1%b 5.3%b
a Summary health statistics for U.S. children: National Health Interview Survey, 1997.
b Summary health statistics for U.S. children: National Health Interview Survey, 2014.
c Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and socioeconomic status in children and adolescents: United States, 2005-2008
(NCHS Data Brief No. 51). Atlanta, GA: CDC/National Center for Health Statistics.
d Bloom, B., Jones, L. I., & Freeman, G. (2013). Summary health statistics for U.S. children: National Health Interview Survey, 2012. National Center for
Health Statistics. Vital and Health Statistics Series 10(258).
Social Policy Report V29 #4 22 The Influence of Health Care Policies on
Children’s Health and Development
sions in the Affordable Care Act
(ACA) for adults, including childrens
parents, represent their own important opportunity to support childrens health and development.
The expansions in coverage
represent a necessary condition
for greater integration to support
childrens development, particularly for children from economically
disadvantaged families, but will
not by itself directly translate into
improvements in care or be sufficient to significantly reduce the
health disparities for poor children.
This will require concerted efforts at innovation and adaptation,
particularly in how Medicaid policies
get implemented in states. As the
authors note Medicaid coverage has
some disadvantages in that it often
provides lower reimbursement rates,
is not accepted as a form of payment
from a significant number of health
care providers, and can vary greatly
across the states (Rosenbaum, 2014).
These challenges need to be considered when state administrators
also seek to strategically build on
some inherent strengths that Medicaid offers for improving childrens
health. Under the basic law, Medicaid provides a most comprehensive
and strong benefit package with
an affirmative obligation to screen
and treat children for a wide range
of health needs including asthma,
mental health, and others (Paradise,
2015). In addition, Medicaid offers
flexibility in its provisions and for
states to seek waivers for designing
and demonstrating innovations. For
example, Medicaid managed care
programs have been able to provide
air conditioners for asthmatic children as a very cost-effective component of a service plan, and states
have used broad waiver authority to
innovate by supporting housing coordination services for patients that
have shown to reduce health costs
(Barta, 2006). States will have to
think creatively to experiment and
develop policies to leverage the possibilities that Medicaid expansions
offer to advance childrens health
and development.
Besides the expansion of
Medicaid and opportunities it offers for improving childrens and
parents health, the Affordable Care
Act provides many opportunities to
potentially improve child health and
development in addition to expanding insurance coverage. Among
these, mental health parity and the
opportunities to integrate medical
and behavioral health services, the
incentives and support in Medicaid
for states to establish health homes,
and the creation of the federal Maternal, Infant, and Early Childhood
Home Visiting (MIECHV) program are
all important avenues, but all of
them require significant work at the
state, community, and programmatic
levels to lead to widespread improvements in childrens well-being
(Glied & Oellerich, 2014).
Child health and development
are two-generational
The health problems of parents and
children are highly correlated, and
a mothers own health is a strong
predictor of a childs health status (Glied & Oellerich, 2014). For
children, parents health conditions can significantly effect their
own development and well-being. A
prevalent example is the effects that
untreated maternal depression can
have on young childrens development (Schmit, Golden, & Beardslee,
2014). Despite the high incidence of
depression and the effectiveness of
treatments and interventions, there
remains limited diagnosis and treatment with the Institute of Medicine
task force finding only 35 percent of
those with depression receiving treatment (Institute of Medicine, 2009). In
the health care system, children and
adult parents see different doctors
in very different provider systems
(Glied & Oellerich, 2014). Mothers
often regularly attend their childrens
pediatric care visits because of the
frequency and families compliance
with well-child visits, even when they
are not going to see their own primary care provider (Howell, Golden,
& Beardslee, 2013). Given this, an
important direction for policy would
be to have pediatricians systematically screen mothers with depression
and offer referrals for care and treatment, and to seek serving families in
two-generational programs such as
home visitation programs (Ammerman et al., 2013). Moving beyond the
profound challenges for children of
one particularly prevalent health condition like maternal depression that
affects health development, we need
to begin developing approaches to
deal with the health of family members as one. In addition, health care
systems must evolve to more comprehensively address childrens health
and related needs and coordinate
more closely with the human services
systems for children and families
(Weil, Regmi, & Hanlon, 2014).
Ultimately, the opportunity
for health care policies to have a
greater and lasting influence on
childrens health and development
will depend on evaluating, learning
from and adapting concerted activities that emanate across states to
better integrate service systems
and program areas to improve child
outcomes.
Social Policy Report V29 #4 23 The Influence of Health Care Policies on
Children’s Health and Development
References
Ammerman, R. T., Putnam, F. W.,
Altaye, M., Stevens, J., Teeters,
A. R., & Van Ginkel, J. B. (2013).
A clinical trial of in-home CBT for
depressed mothers in home visitation. Behavior Therapy, 44, 359-372.
doi:10.1016/j.beth.2013.01.002
Barta, P. J. (2006). Improving asthma
care for children: Best practices in
Medicaid managed care. Hamilton,
NJ: Center for Health Care Strategies. Retrieved from http://www.
chcs.org/media/IACC_Toolkit.pdf
Glied, S., & Oellerich, D. (2014). Twogeneration programs and health.
Helping parents, helping children:
Two-generation mechanisms, 24(1).
Retrieved from http://www.princeton.edu/futureofchildren/publications/docs/24_01_04.pdf
Howell, E. M., Golden, O., & Beardslee,
W. (2013). Emerging opportunities
for addressing maternal depression under Medicaid. Washington,
DC: Urban Institute. Retrieved from
http://www.urban.org/research/
publication/emerging-opportunitiesaddressing-maternal-depressionunder-medicaid
Iglehart, J. K., & Sommers, B. D. (2015).
Medicaid at 50 From welfare
program to nations largest health
insurer. New England Journal of
Medicine, 372, 2152-2159.
doi:10.1056/NEJMhpr1500791
Institute of Medicine & National Research Council. (2009). Depression
in parents, parenting, and children:
Opportunities to improve identification, treatment, and prevention.
Washington, DC: The National Academies Press. doi:10.17226/12565
Martinez, M. E., Cohen, R. A, & Zammitti, E. P. (2016). Health insurance
coverage: Early release of quarterly
estimates from the National Health
Interview Survey, January 2010September 2015. Atlanta, GA: CDC/National Center for Health Statistics.
Retrieved from http://www.cdc.
gov/nchs/data/nhis/earlyrelease/
quarterly_estimates_2010_2015_
q123.pdf
Paradise, J. (2015). Medicaid moving
forward. Menlo Park, CA: The Kaiser
Commission on Medicaid and the
Uninsured. Retrieved from
http://files.kff.org/attachment/
issue-brief-medicaid-moving-forward
Rosenbaum, S. (2014). Medicaid payments and access to care. New England Journal of Medicine, 371, 2345-
2347. doi:10.1056/NEJMp1412488
Schmit, S., Golden, O., & Beardslee, W.
(2014). Maternal depression: Why it
matters to an anti-poverty agenda
for parents and children. Washington, DC: Center for Law and Social
Policy (CLASP). Retrieved from
http://www.clasp.org/resourcesand-publications/publication-1/
Maternal-Depression-and-PovertyBrief-1.pdf
Weil, A., Regmi, S., & Hanlon, C. (2014).
The Affordable Care Act: Affording two-generation approaches to
health. Washington, DC: The Aspen
Institute and National Academy for
State Health Policy. Retrieved from
http://www.aspeninstitute.org/
sites/default/files/content/docs/
pubs/ACA_Report_8Sept2014.pdf
Social Policy Report V29 #4 24 The Influence of Health Care Policies on
Children’s Health and Development
About the Authors
James M. Perrin, MD, is professor of pediatrics at Harvard Medical School and former director of the Division
of General Pediatrics at the MassGeneral Hospital for
Children, having previously headed a similar division at
Vanderbilt. He holds the John C. Robinson Chair in Pediatrics at the MGH. He was president (2014) of the American
Academy of Pediatrics, chair of its Committee on Children with Disabilities, and past president of the Ambulatory (Academic) Pediatric Association. He co-chaired an
AAP committee to develop practice guidelines for ADHD.
He directed the Autism Intervention Research Network
on Physical Health for seven years. Dr. Perrin was founding editor of Academic Pediatrics. He spent two years in
Washington working on rural primary care and migrant
health. After fellowship at Rochester, he ran a rural community health center in upstate New York. He received
a Robert Wood Johnson Foundation Investigator Award in
Health Policy Research and also served as a member of
the National Advisory Council for the Agency for Healthcare Research and Quality. A graduate of Harvard College
and Case Western Reserve School of Medicine, he had
residency and fellowship training at the University of
Rochester and held faculty appointments at Rochester
and Vanderbilt.
Thomas F. Boat, MD, trained in pediatrics and pulmonary
medicine at the University of Minnesota, the National
Institutes of Health, and Case Western Reserve University.
His first faculty appointment at CWRU (19721982) focused on Cystic Fibrosis lung dysfunction research related
to abnormal mucus in airways and to improving CF care.
Dr. Boat next assumed the chair of the Department of
Pediatrics at the University of North Carolina (19821993)
followed by appointment as chair of pediatrics and
research foundation director at Cincinnati Childrens
Hospital (19932007). He served as chair or president of
the American Board of Pediatrics, the Society for Pediatric Research, and the American Pediatric Society. After
serving as dean of the UC College of Medicine, Dr. Boat
returned to Childrens Hospital in 2015 as director of
CF WELL, a learning and education center to promote
wellness, quality of life and better health for CF patients
and their families. Dr. Boat is a member of the Board of
Children, Youth and Families of the Institute of Medicine
and has authored 5 IOM reports addressing physical and
behavioral dimensions of child health. In these roles he
has championed pediatric medicines promotion of safe
and nurturing families as important for lifetime health
and wellness.
Kelly J. Kelleher, MD, is professor of pediatrics, psychiatry and public health in the Colleges of Medicine and Public Health at The Ohio State University, Vice President of
Community Health and Services Research at Nationwide
Childrens Hospital, and center director in the Center for
Innovation in Pediatric Practice at The Research Institute
at Nationwide Childrens Hospital in Columbus, Ohio. He
is a pediatrician and health services researcher focused
on improving policy for, and the practice of, pediatric
care for high risk children adversely affected by poverty,
violence, neglect, alcohol, drug use or mental disorders.
He serves or has served on several committees for the
National Academy of Medicine and the American Academy
of Pediatrics. His research has been continuously funded
by NIH for decades, and he is now the principal investigator on projects from NIMH, AHRQ, and CMS/CMMI. He
is involved in strategy development for the Nationwide
Childrens Healthy Neighborhood, Healthy Family zone
focusing on collaborative efforts with neighborhood
leaders, community agencies and related partnerships to
improve housing, employment, schools and safety on the
Near South Side of Columbus.
Social Policy Report V29 #4 25 The Influence of Health Care Policies on
Children’s Health and Development
Ajay Chaudry, PhD, is currently a senior fellow and visiting scholar at New York University and visiting researcher
at the Russell Sage Foundation. He previously served in
the Obama administration as the Deputy Assistant Secretary for Human Services Policy in the Office of the
Assistant Secretary for Planning and Evaluation at the
U.S. Department of Health and Human Services. Prior to
that, he was a senior fellow and director of the Center on
Labor, Human Services, and Population at the Urban Institute in Washington, DC. He has led public policy research
focused on child poverty, child well-being and development, human service programs in the social safety net,
and the early childhood care system for young children.
From 2004 to 2006, Dr. Chaudry served as the Deputy
Commissioner for Child Care and Head Start at the New
York City Administration for Childrens Services, where he
oversaw the citys early childhood development programs
serving 150,000 children in low-income families. He is the
author of Putting Children First: How Low-wage Working
Mothers Manage Child Care, and many articles related to
child poverty, children of immigrant families, and U.S. social policies. Dr. Chaudry graduated with an AB from Columbia University, MPP from the Harvard Kennedy School
of Government, and PhD from Harvard University.
Benard P. Dreyer, MD, is a general and developmentbehavioral pediatrician who has spent his professional
lifetime serving poor children and families. Professor
of Pediatrics at NYU, he leads the Division of Developmental-Behavioral Pediatrics, is Director of Pediatrics
at Bellevue Hospital, and also works as a hospitalist. He
was interim chair of the Department of Pediatrics at NYU
from 20042005 and from 20072008. He is now president of the American Academy of Pediatrics (AAP). For
over 30 years he led a primary care program at Bellevue,
including co-located mental and oral health services and
clinics in homeless shelters. His research is focused on
interventions in primary care to improve early childhood
outcomes, including early brain development and obesity.
Dr. Dreyer has been AAP NY Chapter 3 president, and a
member of the Committee on Pediatric Research and the
Executive Committee of the Council on Communications
and Media. He co-chaired the AAP Health Literacy Project
Advisory Committee, including editing the AAP publication
Plain Language Pediatrics. He has served as a member of
the Executive Committee of the Section on LGBT Health
and Wellness. As president, he is taking a leadership
role in the AAPs Strategic Priority on Poverty and Child
Health. Dr. Dreyer was president of the Academic Pediatric Association (APA), and founded and chairs the APA Task
Force on Childhood Poverty and the APA Research Scholars
Program. He also hosts a weekly radio show on the Sirius
XM Doctor Radio Channel, On Call for Kids.
Social Policy Report is a quarterly publication of the Society for Research
in Child Development. The Report provides a forum for scholarly reviews
and discussions of developmental research and its implications for the
policies affecting children. Copyright of the articles published in the SPR is
maintained by SRCD. Statements appearing in the SPR are the views of the
author(s) and do not imply endorsement by the Editors or by SRCD.
Purpose
Social Policy Report (ISSN 1075-7031) is published four times a year by
the Society for Research in Child Development. Its purpose is twofold:
(1) to provide policymakers with objective reviews of research findings
on topics of current national interest, and (2) to inform the SRCD membership about current policy issues relating to children and about the
state of relevant research.
Content
The Report provides a forum for scholarly reviews and discussions of developmental research and its implications for policies affecting children. The
Society recognizes that few policy issues are noncontroversial, that authors
may well have a point of view, but the Report is not intended to be a vehicle for authors to advocate particular positions on issues. Presentations
should be balanced, accurate, and inclusive. The publication nonetheless
includes the disclaimer that the views expressed do not necessarily reflect
those of the Society or the editors.
Procedures for Submission and Manuscript Preparation
Articles originate from a variety of sources. Some are solicited, but authors
interested in submitting a manuscript are urged to propose timely topics
to the lead editor ([email protected]). Manuscripts vary in
length ranging from 20 to 30 pages of double-spaced text (approximately
8,000 to 14,000 words) plus references. Authors are asked to submit manuscripts electronically, if possible, but hard copy may be submitted with
disk. Manuscripts should adhere to APA style and include text, references,
and a brief biographical statement limited to the authors current position
and special activities related to the topic.
Reviews are typically obtained from academic or policy specialists with
relevant expertise and different perspectives. Authors then make revisions
based on these reviews and the editors queries, working closely with the
editors to arrive at the final form for publication.
The Committee on Policy & Communications, which founded the Social
Policy Report, serves as an advisory body to all activities related to its
publication.

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