There are three Viewpoints worth your time this month in JAMA Pediatrics. The first is by Charles Horner and Kavita Patel, and discusses ACOs and children. Pediatric care accounts for a relatively small part of national health care expenditures, and almost none of it comes from Medicare. So how much do ACOs matter for kids? “Accountable Care Organizations in Pediatrics: Irrelevant or a Game Changer for Children?”
The term accountable care organization (ACO) is the new buzzword in health care. Enshrined in the Affordable Care Act as well as being advanced by private payers, ACOs are becoming real in adult health care systems and are starting to appear in pediatrics. (Indeed, the Affordable Care Act calls for the establishment of a pediatric demonstration project, although the specified starting time for the project [June 2012] has passed without any guidance from the US Department of Health and Human Services.) But, what is an ACO? What does it intend to accomplish? Is it relevant for child health and health care? What concerns need to be addressed for ACOs to benefit children?
The second is by Lisa Simpson, and discusses the state of children’s health services research. I’m biased here, but it’s a must-read. “The Adolescence of Child Health Services Research“:
It has been 15 years since child health services research (CHSR) began emerging as a distinct field, living at the intersection of the greater health services research (HSR) community and the pediatric research world.1 In 1999, an invitational conference explored the state of the science in CHSR, including public and private funding opportunities, networks for conducting research, and uses of research in policy and practice. Since that time, CHSR has become listed as a distinct topic in the National Library of Medicine’s HSR resource center, and child health is an annual theme at the Annual Research Meeting of AcademyHealth. We have also learned much about the care that children and adolescents receive—its safety, quality, and effectiveness—and about which children are most at risk for poor health outcomes. Health policy has been successfully informed by CHSR, most notably in the reauthorization of the Children’s Health Insurance Program. Finally, a decade of quality efforts is resulting in care improvements, albeit modest ones and not for all children.
The third is by health care policy wonks Aaron Carroll and Austin Frakt. “Medicaid Expansion: Good for Children, Their Parents, and Providers“. Obviously, I’m even more biased with this one:
Public insurance makes a real difference in the health of children. Those who are covered are significantly more likely to have a usual source of care than those who are uninsured, which is strongly associated with better outcomes. Insurance also makes care more affordable, and insured children are significantly less likely to forego care because of cost. Public insurance has reduced disparities in health care related to race, ethnicity, and unmet health care needs.
But things are far from optimal. Many of the still uninsured are parents. Although Medicaid and SCHIP do a reasonably good job of covering children and pregnant women, the programs have not been nearly as universal when it comes to adults. This is important because the insurance status of a parent can significantly effect the health of his or her child. Children with uninsured parents are significantly less likely to receive recommended health services, even if they themselves are covered.
The Medicaid expansion is intended to reduce the percentage of uninsured in the adult population. At the moment, Medicaid is a universal program for children in families making less than 100% of the federal poverty line; its coverage of parents is far less robust. The Affordable Care Act (ACA) changes Medicaid into a universal program for all people, children and adults alike, in families with incomes below 138% of the federal poverty line. This is not an insignificant change. About half of the more than 30 million currently uninsured who are expected to get coverage under the ACA will do so through the Medicaid expansion. Many of the people who will get coverage are parents.