showed that children with special health care needs had difficulties obtaining access to inpatient hospitalization and to specialty pediatric providers in managed care organizations (Cartland and Yudkowsky, 1992; Halfon et al., 1995; Hughes et al., 1995; Newacheck et al., 1994). In recent years, health plans have begun to implement programs specifically for children with special health care needs, often in partnership with public health clinics (AAHP, 1997). It will be important to evaluate the impact of these newer disease management programs in improving access to care.

Access to What? Defining Necessary Health Services

As a matter of principle, the committee believes that all children should have appropriate access to coordinated, effective, and child-appropriate care, including the following health care services:

  • generally accepted preventive services for health promotion and disease prevention (anticipatory guidance, health supervision, or maintenance);
  • acute care for immediate short-term illnesses and injuries;
  • ongoing care for children with chronic medical conditions (e.g., diabetes mellitus, cerebral palsy, and muscular dystrophy);
  • rehabilitative care, including allied health services, for children with disabilities; and
  • care for children with special needs (e.g., speech disorders).

As shown in Figure 3.6 and Table 3.3, the cost of preventive or "well care" visits is a small proportion of all money spent on health care. The committee believes that a comprehensive scope of benefits with an increased emphasis on prevention is especially important for children because of their developmental needs.

However, scientific evidence and professional consensus do not give clear indications for specific diagnostic tests, treatments, procedures, drugs, specialists, and other services to which children should have access. This is true for all of medical care, but especially for children, in the committee's view. Professional organizations, parents, and purchasers of care have different attitudes and positions about which services are essential for children, and there are many areas of disagreement and uncertainty. Parents, insurers, and policymakers also may have different views on whether a given expenditure is reasonable, but some priorities must be set if payers and policymakers are to be able to make reasoned and equitable decisions in the face of limited resources (Klein et al., 1996).

A complete analysis or comparison of benefit structures for comprehensive care for children would be beyond the scope of this study. However, Boxes 3.1 to 3.3 summarize three approaches to defining recommended services for children. These are the recommendations of a previous Institute of Medicine committee, the National Forum on the Future of Children and Families; the U.S. Preventive Services Task Force guidelines; and the health care services recommendations of the American Academy of Pediatrics. Box 3.4 summarizes the health care benefits allowed under SCHIP.

Preventive care is important. Immunizations are important. The health of our children is just as important as the education of our children. It is something we value.

Charles LaVallee

Western Pennsylvania Caring Foundation for Children, Pittsburgh, PA

Public Workshop, June 2, 1997

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