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Now What?

A Message from Charlie Homer, MD, MPH
NICHQ's President and CEO

November 2012

The election is now behind us. The most immediate impact is clear: no more ads or debates (thank heaven!). Beyond that, the results of this election are likely to have far reaching implications for NICHQ and our mission.

NICHQ is a non-partisan, nonprofit organization. We are not affiliated with a party, do not make contributions to campaigns, and do not lobby Congress or advocate for specific legislation. Our agenda is to ensure that all children achieve optimal health. And we achieve that vision by improving children’s health and healthcare through quality improvement.

Although we are non-partisan, we admit to having a bias. Quoting what one of the leading pediatricians of our era, T. Berry Brazelton, wrote just before the election, “our bias is that children matter—to our future and to our present.” And quoting what another pediatrician long active in public service, Woodie Kessel, also wrote before the election on the history of child health in the US, “leadership matters.” In light of these perspectives, what are the implications of the election results for the pursuit of optimal health for all children?

Some things are clear while others remain uncertain. One undeniable outcome of the 2012 election is the enhanced role of young people, Latinos and other minorities (who are more likely to have young children) in the political process. I hope this demographic shift in the electorate will result in a greater focus on investments in our children and families.

The other near certainty is that the Affordable Care Act (ACA) will remain in place and move rapidly into implementation. For children, this will mean the expansion in coverage for poor and near poor children that began with SCHIP and was renewed with the CHIPRA legislation will continue. My observation over the past twenty five years of working on healthcare quality is that when access to care is uncertain, concerns about quality (safety, timeliness, effectiveness, efficiency, equity, patient and family centeredness) become secondary at best. Indeed the focus on quality typically falls off the table despite arguments that enhancing quality will save money and ultimately enhance access. So now I hope as a nation we can focus more deliberately on quality.

Children’s health will also be aided by the expansion in access for young families who are poor and near poor. The health of young women—beyond what can be addressed during prenatal and intrapartum care—strongly influences the health of an infant. Similarly parental health concerns (such as maternal depression) and health-related behaviors (such as tobacco use, physical activity and diet) have direct and indirect effects on child health and development. Moreover, healthcare expenses contribute substantial to a family’s financial status, itself a strong determinant of child health and well being. From a scientific, health services research perspective, the question of whether health insurance enhances health—or conversely, whether being uninsured is harmful to health—is settled science, so the expansion in coverage for young families should have a positive effect on child health (as well as on the health of adults).

One part of the ACA expands access while the other seeks to reform and re-orient the health system so that healthcare is more effective in advancing health and more efficient in its use of resources. This redesign is manifest through two broad strategies, both of which have the potential to enhance child health. One is the innovation in healthcare payment and delivery, such as medical and health home initiatives, bundled payment models, accountable care organizations, the partnership for patients (patient safety oriented) and the like. The other encompasses broader public health oriented approaches such as the home visiting program and, through the Prevention and Public Health Trust Fund, initiatives such as Community Transformation Grants, Collaborate for Healthy Weight (our HRSA supported program to apply quality improvement methods to address obesity across multiple sectors), and Best Fed Beginnings (our CDC supported program to improve maternity care practices that support exclusive breastfeeding). The predominant—but not exclusive—focus on the health system redesign efforts to date has been on Medicare populations while many of the public health activities have been more immediately oriented to affect child health.

While the election outcome means the ACA will remain in place, even a casual observer of the political scene knows that much remains uncertain right now. The economy continues to be sluggish and many believe that, over the long term, there is an imbalance between government revenues and expenditures. In the short term, however, unless something changes, automatic cuts will be implemented in many federal programs that directly benefit children. I hope that any actions to address this fiscal cliff will not only “hold children harmless”—the mantra of the child advocacy community in the last budget crisis—but rather recognize that strengthening services and systems for children and families is always a wise investment for the productivity, long-term health and well being of our society.

- Charlie

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