REVIEWED BY RICHARD S. WAYNE, MD
Ruth E. K. Stein, ed., United Hospital Fund, New York City, 1997, 416 pp, $40
The United States is the only nation in the Western world that fails to guarantee universal health coverage to its children and adolescents. In this ambitious book, experts in pediatrics, public health and health policy analyze current U.S. practices and policies in children's healthcare and conclude that significant changes are required to ensure children receive the care they need.
In the first chapter, the book's editor highlights the following: 10 million, almost 14 percent, of U.S. children are uninsured; 35 percent are uninsured for at least part of the year; almost two thirds of uninsured children live in families in which the head of the household is employed all year; and 23.5 percent of children are covered by Medicaid, but 4 percent lose their eligibility each month.
Health Care for Children is organized into four sections. The first discusses how healthy U.S. children are under our current healthcare delivery system. Research demonstrates that a strong relationship exists between income and child health and that poor, minority, and uninsured children fare consistently worse than nonpoor, white, and insured children in access to primary care.
The organization of children's health services is the topic of section two, which reviews the historical development of the public sector, dealing with the health of populations, and the private sector, focusing on the individual patient or family base. Case histories highlight the complexities, frustrations, and difficulties in utilizing the patchwork of services and programs currently available.
The third section focuses on managed care as a rapidly growing, potent force in children's healthcare. Although an estimated 16.7 million children, 22 percent of Americans under age 20, were enrolled in HMOs in 1994, little is known about managed care's impact on children, especially adolescents, children living in poverty, and those with chronic conditions whose consumption of resources (dollars) is higher. Two controversial issues involve the lack of incentives for managed care plans (1) to enroll children with costly or special healthcare needs or (2) to invest in programs with no promise of financial return (e.g., assisting children with learning disabilities). Children's needs will continue to be incompletely met as long as incentives among all stakeholders are misaligned.
The final section evaluates possibilities available in systems of care for children in the future, citing examples of successes with redesign in Oregon, Massachusetts, Maine, Illinois, New Hampshire, Wisconsin, Minnesota, Rhode Island, Ohio, and Arizona.
In the concluding chapter, Stein articulates and supports her clear agenda on behalf of children. This agenda is built on five principles: a child-specific standard of care; the appropriate alignment of incentives for healthcare providers; universal coverage; strengthened community health functions; and investments in appropriate research, education, and data systems. She acknowledges that one cannot escape political reality in the United States. However, she says, "even a portion of the child health agenda articulated in this book will make a tangible difference in the lives of millions of children throughout the country."
This book can be a valuable resource for a large audience, especially legislators, advocates, healthcare providers, and employees of government agencies and managed care organizations. Parents of children with special needs and educators will benefit from the authors' insights. Those concerned about our society's commitment to our children's health need to understand current issues. This book helps address this need in a thorough, comprehensible manner.
Reviewed by Richard S. Wayne, MD, CEO and Medical Director, Santa Rosa Children's Hospital, San Antonio, TX