Many children’s health issues—such as regular checkups, continuity of care, and immunizations—boil down to inadequate access. One in seven children do not have insurance, and when they don’t have coverage, kids are less likely to get medical attention when they need it.

Heather Bennett McCabe, PhD, speaks for many. "Change is absolutely needed, she said." "I can think of nothing worse than a family who needs health care who, for whatever reason, but largely because they don’t have money, can’t get health care for that child." As executive director for the Association for the Care of Children’s Health in Bethesda, Maryland, McCabe views the money the federal government has allotted for children’s care as a boon the states "need to spend wisely."

"The greatest benefit to providing healthcare coverage for children is their health status," McCabe said. "It gives families access to providers, nurses in particular, who can give them anticipatory guidance in the health and wellness of their children." She says nurses’ training as communicators means they can help families interpret what’s happening

But money alone doesn’t improve children’s health, and some experts worry that the increased funding won’t be used for health care. Ruth E. K. Stein, MD, professor and vice chairperson of the department of pediatrics at Albert Einstein College of Medicine at Yeshiva University in Bronx, New York, worries that the federal money may go to bureaucracy rather than care.

The United States spends more money on health care than many other countries, yet when the state of children’s health is compared internationally by a few "good measures," such as low birth weight or infant mortality, children in this country "aren’t doing so well," Stein said. The book she edited, Health Care for Children: What’s Right, What’s Wrong, What’s Next (United Hospital Fund, 1997), examines why that is.

One of her conclusions is that the nation needs "a system of health care for kids that’s organized, that has a well-articulated package of benefits, that is uniform as children move in and out of insurance status." She points to a lack of continuity in insurance—and in care providers—as adding to the unstable care. While there is much talk about 10 million uninsured children in the United States, if all children without insurance over a two-year period are taken into account, as many as 35 million are uninsured at some point, she said.

Even with those drawbacks, a recent study by the Rand Corp. bolsters the managed care solution. The study concluded that children in HMOs were 40 percent more likely to receive preventive care and their overall rate of visits to providers was 50 percent higher than their counterparts in fee-for-service plans.

To truly upgrade care for children, a public health infrastructure needs to be maintained, Stein said. She advocates establishing "centers of excellence" to study child health that would continue to develop new knowledge. In early September, the Department of Health and Human Services and the Environmental Protection Agency announced plans to establish six federal research centers dedicated to children’s health that could be up and running a year from now.

an infant mortality rate of 8 per 100,000 live births, which is almost half what it was in 1993, but still higher than 20 other countries;

a suicide rate for children age 10 to 14 that has almost tripled from 1987-92; and

an immunization rate that has improved but still leaves 25 percent of the young not immunized.

Dull said that it’s often wrongly assumed that those without coverage are children of the poor, when many actually are the offspring of working parents. "With the pressure on employers to cut costs, family coverage is dropped most frequently, and that is on the rise," she said. Welfare reform also is likely to have an impact on the equation; once their parents leave the Medicaid rolls, possibly for jobs that don’t offer healthcare coverage, the children’s coverage will be extended for only a year.

With 14 percent of the nation’s children uninsured, school-based care has been growing "by leaps and bounds," says Genie L. Wessel, MS, RN, president of the American School Health Association and coordinator of school-based clinical services at the University of Maryland School of Nursing. School-based clinics, first established in the 1980s, now number about 400 across the United States.

"We are able to meet a very specific need," Wessel said. Because children are treated more quickly and can be given a prescription on-site, absenteeism goes down and overall health improves. The school and clinic nurses meet the need to teach children about healthcare consumerism. "Unless they know how to advocate for themselves, they aren’t going to get all the care they need," Wessel said.

The childhood problems at clinics include mental health problems from living in a violent society, abuse, and chronic illnesses, especially asthma, Wessel said. These and the mainstreaming of children with life-threatening illnesses has made the role of the school nurse more important once again. The number of nurses practicing in schools is on the rise across the country, she said.

Community outreach in general will be an important part of the plans the states come up with, experts agree. "Whether you are in the health profession or not, we need to do a better job of meeting the needs of children," Stein said. "We haven’t had a policy of a nation of doing that. I think that’s a failure of society, not to be good caretakers of our children."

Illustration Credits:
Table 1 by Malcolm Garris
Table 2 by C. Sponselli