A History of Child Health Equity Legislation in the United States
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A History of Child Health Equity Legislation in the United States
Peter C. van Dyck, MD, MPH, FAAP
ABSTRACT. The Issue. The mission of the Maternal tion in the United States provides perspective as to
and Child Health Bureau (MCHB) is comprehensive in the genesis of current MCHB goals and insight into
scope and establishes the capacity, structure, and func- future goals and objectives of the MCHB.
tion for the MCHB to continually improve the health and During the 19th century, states and private agen-
well-being of pregnant women and children. The MCHB cies assumed responsibility for the health and social
works in partnership with states and has broad authority
to improve access to care and ensure the provision of
well-being of special groups of children. However,
quality preventive and primary care services. Specific the concept of a partnership between the states and
provisions of legislation establish the framework for ac- the federal government to improve the health of
complishing this mission. With the increasing recogni- mothers and children did not appear until 1912,
tion of the social, economic, and environmental determi- when the federal government established the Chil-
nants of child health and the inequities that exist in dren’s Bureau to promote the welfare of children
access and quality of care for children, the Maternal and with special needs.
Child Health Bureau (MCHB) has set the following 3 In 1921, the Maternity and Infancy (Sheppard-
goals for year 2003: 1) To eliminate disparities in health Towner) Act (PL 67-97) was passed and adminis-
status outcomes through the removal of economic, social,
tered by the Children’s Bureau (1921–1929). Shepp-
and cultural barriers to receiving comprehensive, timely,
and appropriate health care; 2) To ensure the highest ard-Towner was the first federal grant-in-aid
quality of care through the development of practice guid- program to states for health, establishing the princi-
ance and data monitoring and evaluation tools; the use of ple of public responsibility for child health. The act
evidence-based research; and the availability of a well- was controversial and was labeled as radical and
trained, culturally diverse workforce; and 3) To facilitate socialistic by its critics. The American Medical Asso-
access to care through the development and improve- ciation, Catholic Church, and Public Health Service
ment of the maternal and child health infrastructure and were instrumental in having it repealed 8 years after
systems of care to enhance the provision of necessary, enactment. Because of a disagreement within the
coordinated, quality health care. Priority MCHB strate- American Medical Association over its opposition to
gies to accomplish these goals include improving and
expanding 1) the cultural competence of providers (in
this legislation, the American Academy of Pediatrics
particular to decrease sudden infant death syndrome (AAP) was formed in 1930.1
[SIDS] among minorities), 2) emergency medical services It took the Great Depression to demonstrate how
for children, 3) health and safety in child care, 4) quality dependent children are on protection against eco-
of primary pediatric care, and 5) the providing of every nomic hazards and to produce the rich harvest of
child with a medical home. Pediatrics 2003;112:727–730; children’s programs that came with the Social Secu-
history, child health programs. rity Act in 1935 (Vince Hutchins, MD) and other
legislation thereafter. Several key legislative actions
ABBREVIATIONS. MCHB, Maternal and Child Health Bureau; highlight the subsequent evolution of maternal and
SIDS, sudden infant death syndrome; AAP, American Academy of child health programs in the United States.
Pediatrics; EMSC, Emergency Medical Services for Children; • The 1930s: Title V of the Social Security Act autho-
HCCA, Healthy Child Care America.
rized grants-in-aid to states for maternal and child
HISTORY OF CHILD HEALTH POLICY
health programs (Title V, Part 1), including ser-
vices for children who are crippled (Title V, Part 2)
H
ealth policy in the United States is charac- and child welfare services (Title V, Part 3). The
terized by incremental change leading to pe- Crippled Children’s Services program was the
riodic paradigm shifts in the focus and di- first US program of medical care. It was based on
rection of public- and private-sector activities. the principle of continuing federal grants-in-aid to
Elimination of health disparities, as presented in the the states.
first of the 3 current Maternal and Child Health • The 1940s: The Emergency Maternity Infant Care
Bureau (MCHB) goals, is an example of such a shift. program established a service delivery system to
Understanding the evolution of child health legisla- provide free and complete maternity and infant
health care for the wives and infants of the 4
From the Maternal and Child Health Bureau, Washington, DC. lowest grades of servicemen.
Received for publication Mar 14, 2003; accepted Mar 14, 2003. • The 1980s: The Maternal and Child Health Ser-
Address correspondence to Thomas Tonniges, MD, FAAP, American Acad- vices Block Grant (1981) consolidated 7 categorical
emy of Pediatrics, Department of Community Pediatrics, 141 Northwest
Point Blvd, Elk Grove Village, IL 60007. E-mail: ttonniges@aap.org
child health programs into a single program of
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- formula grants to states supported by a federal
emy of Pediatrics. special projects authority. In addition, states
PEDIATRICS Vol. 112 No. 3 September 2003
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727adopted injury prevention as a public health is- Newborn Screening
sue—the Emergency Medical Services for Chil- The MCHB has supported the development of
dren (EMSC) program. newborn metabolic screening and newborn hearing
• The 1990s: The 1990s ushered in an era focused on screening. However, the array of screening tests per-
assessing unmet service needs, improving ac- formed by each state varies and changes periodi-
countability in program performance, and cally. These inconsistencies reflect differences in
strengthening federal-state partnerships, eg, the community values, state political and economic en-
Healthy Start program (1991) and the Child Health vironments, and public health technical capabilities.
Improvement Act (1997). These programs targeted In response to these inequities, the MCHB has
long-standing national concerns about infant mor- funded a number of initiatives, including the follow-
tality and children who are uninsured ing:
• The National Newborn Screening and Genetic Re-
CURRENT PROGRAMS
source Center to provide technical assistance to
Current programs of the MCHB respond to the the states
contemporary understanding of the priority issues • The development of standards for conditions to be
confronting children and families and the social de- screened, national guidelines for informed con-
terminants of the well-being of children. The pro- sent, and retention of residual blood spots and
grams acknowledge and respond to the disparities their storage
and inequities confronting children’s health. • States to facilitate the integration of newborn
screening programs and data systems with other
Cultural Competence points of early identification of children with ge-
netic conditions and other special health needs
Improving cultural competence has become a ma-
• Public health agencies and the private sector to
jor priority of the MCHB and is considered a prereq-
ensure coordination of screening efforts
uisite to achieving equity in health systems. There is
• The Consumer Network for Genetic Resource and
a compelling need to consider cultural competence
Service Information to develop culturally appro-
to:
priate communication strategies
• Research and demonstration programs on imple-
• Respond to current and projected demographic menting newborn hearing screening technologies
changes in the United States
• Eliminate long-standing disparities in the health Bright Futures Guidelines
status of people with diverse racial, ethnic, and
Bright Futures is a vision, philosophy, set of expert
cultural backgrounds
guidelines, and a practical developmental approach
• Improve the quality of services and health out-
to providing health supervision for children of all
comes
ages. Bright Futures is dedicated to the principle that
every child deserves to be healthy and to have a
States are required, through their block grant per-
trusting relationship among health professionals, the
formance measures, to report on their progress to-
child, the family, and the community as partners in
ward achieving cultural competence in their pro-
health practice. The mission is to promote and im-
grams. Similar measures are being instituted for
prove the health, education, and well-being of chil-
programs supported through MCHB discretionary
dren, adolescents, families, and communities.
grant programs. States, organizations, programs, and
After the publication of the Bright Futures guide-
individuals who receive MCHB funds are mandated
lines, the implementation phase of Building Bright
to have the ability to:
Futures was initiated to 1) foster partnerships be-
tween families and professionals; 2) establish links
• Value diversity and similarities among all people among health professionals and between profession-
• Understand and effectively respond to cultural als and communities; 3) enhance health professional
differences practices; and 4) increase family knowledge, skills,
• Engage in cultural self-assessment at the individ- and participation in health education and prevention
ual and organizational levels activities. Bright Futures implementation tools in-
• Make adaptations to the delivery of services and clude Bright Futures in Practice: Oral Health, Bright
enabling supports Futures in Practice: Nutrition, Bright Futures Pocket
• Institutionalize cultural knowledge Guide, Bright Futures Encounter Forms for Health Pro-
fessionals, Bright Futures Encounter Forms for Families,
Improving Cultural Competence in Reducing SIDS and Bright Futures for Families material: Bright Fu-
The Back to Sleep campaign has shown dramatic tures in Practice: Mental Health and Bright Futures in
success by reducing the incidence of SIDS by 42.3% Practice: Physical Activity.
since the campaign’s start in 1992. However, wide
variation exists among some racial and ethnic Child Care
groups— black and Native American infants are 2.4 The development of child health policy addressing
and 2.8 times more likely than white infants to die the health and safety of young children in child care
from SIDS. The MCHB has several initiatives to ad- settings has been a priority of the MCHB and its
dress racial disparities in SIDS. partners. Caring for Our Children: National Health and
728 SUPPLEMENT Downloaded from www.aappublications.org/news by guest on October 12, 2021Safety Performance Standards: Guidelines for Out-of- to the emergency care of children. Fewer than half of
Home Child Care Programs and the Healthy Child all hospitals (46%) with emergency departments
Care America (HCCA) program are the result of have the necessary equipment for the stabilization of
national collaborations to generate and disseminate children who are ill or injured. Only 5 states cur-
new knowledge related to child care. In addition to rently require that advanced life support ambulances
health professionals, states are encouraged to use carry all EMSC-recommended equipment needed to
these publications as guidance in their development stabilize a child. Only 24% of hospitals in the United
of standards and licensing regulations. States have mental health services for children and
Although health professionals within public adolescents.
health departments are readily identified as appro-
priate resources to control the spread of infectious Medical Home
diseases, they are not as readily seen as potential
The Medical Home Initiative is an endeavor to
partners to promote the health and safety of children
ensure equity in access to care for children with
in child care settings. The same situation holds true
special health care needs. Children with special
for private-sector health providers. Although pedia-
needs are those who have a chronic physical, devel-
tricians and family practitioners are accepted as vital
opmental, behavioral, and/or emotional condition. It
community resources to provide a medical home for
is an approach to pediatric health care in which a
every child, the need to build partnerships that in-
well-trained and trusted physician partners with the
crease their availability and accessibility as health
family to establish regular ongoing health care. Al-
consultants to child care programs in their commu-
though this care is available to most families of typ-
nities often is unrecognized.
ically developing children, it has not been routinely
In response to the need to create healthy and safe
available to many children with special health care
environments for children in child care settings, the
needs, particularly those with complex medical con-
HCCA program, a federal initiative to foster collab-
ditions.2 As many as 12.6 million children, represent-
oration between health and child care providers, was ing 18% of the total child population, have a chronic
established on the principle that families, child care physical, developmental, behavioral, and/or emo-
providers, and health care professionals in partner- tional condition that requires health and related ser-
ship can promote the healthy development of young vices beyond that required by children generally.3 If
children in child care, increase access to preventive children at risk are included, as many as one third of
health services, and ensure a safe physical environ- the total child population may be impacted.
ment for children. Linking health care professionals, The MCHB implemented the national Medical
child care providers, and families maximizes re- Home Initiative in 1994 in collaboration with the
sources for developing comprehensive and coordi- AAP. As part of this initiative, a medical home for
nated services for children in child care. every child with special health care needs was estab-
The partnership assisted in developing the HCCA lished as 1 of 6 critical outcomes for a comprehensive
Blueprint for Action. The blueprint provides commu- system of care. The initiative has several purposes,
nities with steps that they can take to expand existing including:
public and private services and resources or to create
new services that link families, health, and child care. • To establish partnerships with families in the plan-
The AAP administers the HCCA program, which ning, development, and oversight of the medical
continues to serve as a successful model for creating home
partnerships between health and child care provid- • To develop national models for providing medical
ers. homes to children with special health care needs
• To develop effective support systems for primary
Emergency Medical Services for Children
care physicians who serve these children
The EMSC program was initiated to improve the • To develop improved strategies for integrating
capacity of existing emergency medical services sys- health and medical services
tems to treat serious childhood illness and trauma. • To improve families’ access to medical homes
The 3 areas of focus—properly trained personnel,
equipped ambulances and emergency departments, The Medical Home Initiative has been a catalyst to
and organized response systems—are meant to en- ensure inclusion of all children with special health
sure equity in the emergency care received by chil- care needs in the health care system. It has:
dren.
Since its establishment in 1984, the EMSC effort • Provided the framework to provide comprehen-
has improved the availability of child-oriented sive systems of continuity of care that are geo-
equipment in ambulances and emergency depart- graphically and financially accessible to all fami-
ments. It has initiated hundreds of programs to pre- lies
vent injuries and has provided thousands of hours of • Articulated a strategy to 1) identify the special
training to emergency medical care providers. EMSC needs of children, 2) establish collaboration among
efforts have led to legislation mandating programs in primary care and subspecialty physicians to meet
13 states and to educational materials covering every those needs, 3) refer families to the right specialists
aspect of pediatric emergency care. However, al- at the time, and 4) form effective working relation-
though EMSC has made great progress over the ships between primary care and subspecialty phy-
years, inequities and disparities remain with respect sicians to coordinate and help families sort
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SUPPLEMENT 729through and interpret the recommendations of children. Pediatricians must redefine the dynamic of
specialists their relationships with families who 1) have an im-
• Established a mechanism to provide early referrals portant role to play in educating health care profes-
for families to a broad array of community ser- sionals about the changes in attitudes, behaviors,
vices and to ensure that primary care physicians practices, and procedures that are needed to truly
participate in the development of Individual Edu- implement medical homes; 2) are most effective in
cation Program and Individualized Family Service advocating for the needs of their children; and 3) are
Plans key to promoting medical homes at the practice,
• Ensured inclusion by addressing the health and policy, and political levels.
medical needs of the child to allow children to live
at home, attend their neighborhood school, and CONCLUSIONS
participate in all community activities like their The challenge of responding to the social, political,
peers and environmental determinants impacting health
disparities in the United States has required new and
The Functional Outcomes Study reported that care evolving strategies and partnerships on the part of
that is coordinated, comprehensive, accessible, and the MCHB. The history of US maternal and child
family centered is associated with improved out- health policy has established a platform on which to
comes in health, behavior, and cognitive develop- build these new approaches to the challenges facing
ment.4 Especially for children who are poor, it has children and families. Partnerships among families,
been demonstrated that long-term personal relation- providers, and communities will play an increas-
ships with primary care physicians who coordinate ingly important role in our response to these social
their care provide important benefits.5 Implementa- determinants of health. The AAP and the Royal Col-
tion of a medical home can lead to a decrease in rates lege of Pediatrics and Child Health should use the
of hospitalization, as well as lengths of stay. How- historical and current experiences of the MCHB as a
ever, there is a cost to equity. David Hirsch, MD, has platform for research as to the effectiveness of pro-
estimated the cost of providing a comprehensive grams to meet the needs of marginalized children
medical home to a child with special health care and deal with health disparities in our respective
needs to be $81 per month, as compared with $16 countries and a template for future programs.
per month for a typically developing child (David
Hirsch, MD, personal communication, December 2000). REFERENCES
The Medical Home Initiative also has begun to 1. Hutchins VL. Maternal and Child Health at the Millenium. Monograph.
document the expanded interdisciplinary knowledge Maternal and Child Health Bureau: Rockville, MD; 2001
2. McPherson M, Arango P, Fox H, et al. A new definition of children with
and skills required by primary care pediatricians to special health care needs. Pediatrics. 1998;102:137–140
respond to the challenges facing children with spe- 3. Newacheck PW, Strickland B, Shonkoff JP, et al. An epidemiologic
cial needs. This knowledge and these skills go well profile of children with special health care needs. Pediatrics. 1998;102:
beyond the traditional perimeter of pediatric practice 117–123
and require pediatricians to be willing to explore all 4. Sandler AD, Casar S. The Functional Outcomes Study. Asheville, NC: The
Olson Huff Center for Child Department, Thomas Rehabilitation
health care options with families and wise and hum- Hospital; 1999. In press
ble enough to acknowledge and nurture the exper- 5. Starfield B. Evaluating the State Children’s Health Insurance Program:
tise and involvement of parents in caring for their critical considerations. Annu Rev Public Health. 2000;21:569 –585
730 SUPPLEMENT Downloaded from www.aappublications.org/news by guest on October 12, 2021A History of Child Health Equity Legislation in the United States
Peter C. van Dyck
Pediatrics 2003;112;727
Updated Information & including high resolution figures, can be found at:
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Downloaded from www.aappublications.org/news by guest on October 12, 2021A History of Child Health Equity Legislation in the United States
Peter C. van Dyck
Pediatrics 2003;112;727
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/112/Supplement_3/727
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2003
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