CHAPTER 1
Well Child Care: Components, Benefits, History, and Future Need
William B. Pittard III, MD, PhD, MPH
Introduction
Well child care is designed to promote optimal physical, social, and cognitive development for children birth through twenty years. A broadly accepted manifestation of success for this preventive care in the preschool years is increased time without illness and readiness for first grade learning. Increased wellness time should promote greater opportunity for playing and interacting with other children and adults, facilitating socialization, school readiness, and more long-term life success. Specifically, well child visits in the preschool years include an assessment of physical growth, anticipatory guidance for parents or caregivers, immunizations, and screening procedures for illness and abnormal vision, hearing, and cognitive development.
This chapter presents an overview of well child care, describing its components and anticipated benefits for children. The history of governmental recognition of need for well child care and its funding for low-income children includes the Children's Bureau; the Sheppard-Towner Act; the American Academy of Pediatrics (AAP); Medicaid and the confrontations and controversies surrounding its early and periodic screening, diagnosis, and treatment (EPSDT) benefit for children; and the establishment of the State Children's Health Insurance Program (SCHIP). The chapter concludes with a look at future needs for maternal and child preventive care.
Components and Benefits
Well child visits offer clinicians an opportunity to identify and address problems that might impede optimal growth and development. The AAP recommends frequent well child/EPSDT visits in the preschool years, including six visits in year one, three visits in year two, two in year three, and one visit annually thereafter. An initial visit during the prenatal period provides child health education and anticipatory guidance for soon-to-be parents, and post-delivery visits offer age appropriate immunizations, developmental and sensory evaluations, assessment of nutrition status and oral health, and age-specific parenting education. Parents of children with the recommended number of visits in infancy should receive more information than parents of children with fewer visits about cognitive stimulation for their children and about avoiding risks to cognitive health such as lead exposure, accidents, and under-nutrition. Recommended topics for parental anticipatory guidance include advice regarding physical activity, appropriate use of health care services, parent-child reading, and avoidance of household toxins. Developmental screening includes assessment of height and weight, vision, hearing, language skills, and behavior; the screening is designed to facilitate the early implementation of corrective measures for any abnormality detected with improved health outcomes.
Despite the benefits of well child care, it is not always utilized. Due to cost and lack of information confirming well child care effectiveness, privately insured children have been reported to under-use well child care particularly in the preschool years. In contrast, despite government funding, the Medicaid EPSDT/well child benefit is more likely to be underutilized by low-income children than well child care by privately insured children.
Although providing well child care involves cost, not using well child visits often results in still greater medical cost. Low-income children also more frequently use emergency department and in-hospital, non-primary care provider services for non-urgent ambulatory care sensitive condition (ACSC) diagnoses than higher income children. ACSC diagnoses include asthma; seizure; cellulitis; ear, nose, and throat infections; bacterial pneumonia; kidney and urinary tract infections; and gastrointestinal infections and are illnesses routinely treated in a primary care provider (PCP) office setting. Increased use of ACSC ED visits has been directly associated with both inadequate EPSDT/well child care utilization by Medicaid-insured children and by lack of a regular medical home by low-income children. These characteristics may reflect lack of awareness by low-income parents of the availability of EPSDT and its beneficial effects on the physical, social, and cognitive development of children.
History
The Children's Bureau
The history of well child care in America began with publicly recognizing the need to identify the causes for and methods to prevent maternal and child mortality. With this issue in mind, President Theodore Roosevelt called a conference in Washington DC in 1909, subsequently referred to as the first White House Conference on Children. A significant recommendation from this conference was for the establishment of a federal Children's Bureau. After much debate in Congress, President William Howard Taft approved and signed the Children's Bureau into law on April 9, 1912.
The mission for this bureau was "to investigate and report on all matters pertaining to the welfare of children and child life among all classes of our people". Bureau staff initiated studies to identify the social and economic factors contributing to maternal and child morbidity and mortality in both rural and urban settings. The bureau also initiated the routine registration of all births nationwide and the publication of guidelines regarding appropriate prenatal and infant care; these guidelines were presented at professional meetings and were made available to the public.
The Sheppard-Towner Act and the Academy of Pediatrics
Early Children's Bureau findings led to yet another pivotal Congressional action strongly endorsed by the newly established contingency of women voters. This action was known as the first Maternity and Infancy Act (or the Sheppard-Towner Act) of 1921. The act provided maternal and child health services such as maternal outreach education and support through pregnancy and postpartum, as well as instruction regarding parenting and child health needs. These activities were funded through federal grants-in-aid and matching state funds. With these monies, so-called Sheppard-Towner clinics were established in all but three states (Connecticut, Illinois, and Massachusetts), where opposition was strongest to government-sponsored support for the health of mothers and children. During the Congressional debates preceding approval of the Sheppard-Towner Act, many larger cities launched maternal and child health (MCH) activities on their own. Although with this legislation the concept of public responsibility for child health was established, just as today there was much uneasiness and opposition to the concept of government-sponsored health care. Actual outcome data assessing the effectiveness of these maternal and child clinics were unavailable, but enactment was carried on the "face validity" of their likely benefit. Those opposed to federal grants-in-aid for maternal and child health ultimately won, and in 1929 the Sheppard-Towner Act was not continued.
The physician contingency supporting the Sheppard-Towner Act drove the formation of the American Academy of Pediatrics (AAP). In a section meeting of the 1922 American Medical Association (AMA) in St. Louis on diseases of children, the section recognized that the act promoted the welfare of mothers and children, and it elected to approve the Sheppard-Towner Act. However, at the same AMA meeting, the House of Delegates viewed this act as an infringement on the entrepreneurial boundaries of practicing physicians, declared it to be little more than a "socialistic scheme," and reprimanded the section's action. The discord created by this controversy ultimately resulted in the establishment of the AAP in June 1930, which was primarily composed of physicians in favor of the Sheppard-Towner Act. At its founding, the AAP's stated mission was education, public health, and issues affecting child health.
The Children's Bureau, with increased power from the Sheppard-Towner Act, was able to establish well child clinics throughout rural America and to firmly establish the societal mindset that there is need for government support for the maintenance of good health (preventive care) from birth through the preschool years. Indeed, the benefit of appropriate dietary and sleep habits for child health was established by the bureau as a health care paradigm, as was the need for well child care to facilitate normal development.
Dr. Borden Veeder, author of Preventive Pediatrics (1926) and professor of pediatrics at Washington University, predicted that Sheppard-Towner clinics would be replaced by preventive care physicians (pediatricians). In other words, he predicted that well child care would become the primary component of some future practices. Between 1928 and 1935 it was reported that approximately 40 percent of pediatric office visits were for well child or preventive care rather than acute health care needs. Thus the mindset of physicians (pediatricians) routinely providing preventive care for children was clearly established by 1935.
Medicaid's Role, Historical and Present
Medicaid was enacted in 1965 as an open-ended individual entitlement program for eligible children. Shortly after initiation, it was apparent that to be more effective in improving the health status of children, Medicaid needed to have its scope broadened from predominantly acute medical care to include preventive care. In 1967, two years later, Medicaid added the early and periodic screening, diagnosis, and treatment (EPSDT) benefit for children. The primary goal of this benefit was and continues today to be to prevent disease and detect and correct conditions early so that more serious health problems and costly health care services can be avoided. This preventive care benefit was designed to ensure that children receive not only care for acute and chronic medical problems but also needed well child care, including screening, developmental assessment, and immunizations. Unlike the circumstance in Europe, EPSDT is America's only individual entitlement program for comprehensive health care services for children.
EPSDT is an entitlement, and federal law requires that states provide the services of EPSDT to all eligible children up to age twenty-one. These services include age-appropriate screenings and immunizations, follow-up diagnostic services for conditions identified in the screenings, and any medically necessary treatment services. Specifically, this preventive care program provides physical and developmental examinations, vision and hearing screening, dental referrals and treatment, appropriate laboratory tests, and immunizations.
When established in 1967, EPSDT had several problems with implementation at the federal, state, and local levels. Social science analyses used to evaluate these issues indicated the problems were related to both program design and lack of commitment by state officials to the EPSDT mission. Adjustments were instituted when possible. After this somewhat tumultuous beginning in the 1960s and 1970s, the EPSDT benefit then evolved into a genuine national policy issue between 1985 and 1997. With all but hyperinflationary increases in Medicaid costs, state officials became fixated on Medicaid reform, specifically on changes in the EPSDT benefit that (to them) appeared to represent an unfunded federal mandate placing unnecessary strain on state budgets.
From 1985 through 1997, the congressional debate over the value of EPSDT as a Medicaid benefit for children spun around two groups of powerful policymakers of different thinking regarding this child health policy. The first group consisted of child advocates, and the second was made up of conservative governors. Though there were additional stakeholders in the issue such as the White House, Congress, and Medicaid advocates, these two groups were the key participants during two decades of EPSDT political turmoil.
Between 1984 and 1989, increases in Medicaid eligibility for women and children were enacted yearly. Child advocacy groups such as the Children's Defense Fund, the House Select Committee on Children, the National Committee on Infant Mortality, and Youth and Families supported these enactments. The acts were also supported by organizations such as the Institute of Medicine and had bipartisan congressional support.
Confrontation and Controversies
The first major EPSDT congressional confrontation occurred in 1989. Despite strong objections from the National Governors Association (NGA), the Omnibus Budget Reconciliation Act of 1989 (OBRA '89) was enacted, making the EPSDT benefit and its preventive care services federal requirements for all states. The OBRA '89 measures were designed to correct four well-documented weaknesses in the benefit present since its initiation:
1. State establishment of "reasonable standards" for periodicity of well child examinations
2. State coverage of all medically necessary treatment identified in EPSDT screening
3. State removal of all limitations on participation by any qualified health care provider
4. State establishment of guidelines to facilitate counting and monitoring all EPSDT patient and provider encounters
States were not enthusiastic about compliance with these OBRA '89 mandates. Discussions of child health benefits to be included in the design of a national health care reform bill failed to include stakeholders from several conservative states. This was particularly disturbing for several Republican governors between 1989 and 1994 because they perceived the costs for EPSDT benefits as representing federal infringements on state autonomy.
In designing the Clinton Health Security Plan, EPSDT and other Medicaid benefits for children rapidly became intensely debated policy issues. From 1991-1996, Medicaid reform was the primary thrust for the NGA as Medicaid costs consumed larger and larger amounts of state budget dollars. The 1994 congressional elections experienced a shift in congressional control to the Republican Party, which was taken as an opportunity to initiate policy change by the NGA. With the primary goal of balancing the budget, entitlement spending such as Medicaid was a congressional focus. A Medicaid reform bill combining reduced spending with a Republican governors' proposal to reduce federal Medicaid requirements was generated in Congress under the heading "Medicaid Block Grant." This proposal was designed to cap federal Medicaid spending and to give states the power to modify Medicaid regulations.
As an entitlement, Medicaid, like Medicare, guarantees coverage of all eligible individuals. Each state sets its eligibility requirements, but all individuals meeting these requirements are eligible for services. However, each state must pay its share of the federal/state matching funds to receive the federal share. In contrast, federal block grant funding means there is a cap or limit to the federal funds provided each year; under capped funding, a state receives the federal allotment regardless of the level of need or cost. The lack of a guarantee or entitlement to eligible individuals means that with block grant funding, each state can limit the number of people served by using priority lists or even by shutting down programs. Thus, although the use of block grant funding offers states much better predictability of costs for prospective budget planning, it simultaneously allows limitation of service provision to eligible individuals.
All stakeholders advocating for Medicaid as an entitlement program did not have an equal desire to preserve benefits such as EPSDT. In fact, the common element among EPSDT advocates was opposition to the creation of Medicaid as a block grant program. The primary member in this group included Families USA, but the coalition included religious groups, senior citizen organizations, and nursing home and hospital associations. Thus the opposition to the Medicaid block grant proposal was broad and included individuals of all ages that would or could be adversely affected by ending Medicaid as an individual entitlement. The primary goal of this group was to counter the block grant proposal, and the drive to maintain federal guarantees for comprehensive preventive care services for children was important only to certain groups in the coalition, such as the National Association of Children's Hospitals.
After much wrangling, Congress generated and passed a pure block grant proposal to replace the Medicaid entitlement program. This called for a reversal of coverage for many children, and the proposal actually did away with the EPSDT Medicaid benefit. On December 6, 1995, President Clinton vetoed this legislation.
