In March 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. Designed to reform the health insurance market in the United States and thereby improve access to care for more than 30 million uninsured Americans, its provisions were structured to become effective by 2014. Along with broadening access to care, improving quality, and placing a new emphasis on care coordination, the act was celebrated by its champions for its focus on clinical preventive services, health screenings, and surveillance of well patients.
The Affordable Care Act stands to transform children’s health care delivery. Not only does it promise to provide greater stability to poor families with children by reducing the numbers of uninsured parents, for example, the law makes it impossible for private insurers to deny coverage to children because of preexisting conditions. However, many of the other concepts embedded in the PPACA are not new at all. More than a century before its passage, physicians, nurses, and other health care reformers had begun building a care delivery model for children that broadly emphasized health promotion and disease prevention for well children, in addition to caring for them when they were ill.
Those ideas would later become the conceptual underpinnings of well-child care, and were considered important enough to be codified in publicly funded initiatives such as the 1920s Sheppard–Towner Act and the Early and Periodic Screening Diagnostic and Treatment (EPSDT) program, created in the 1960s to ensure that indigent youngsters received needed comprehensive developmental services, and, in the 1990s, the Children’s Health Insurance Program (CHIP), which provided insurance coverage for poor and near-poor children. Now those principles would extend beyond pediatric practice into adult health care delivery.
One central feature of the Affordable Care Act is an expanded focus on measuring the quality and outcomes of care, a landmark change that was strongly influenced by the most recent reauthorization of CHIP. The 2009 Children’s Health Insurance Reauthorization Act (CHIPRA) not only provided states with significant new monies, programmatic options, and incentives, it also mandated the use of a core set of quality measures for all pediatric care covered by Medicaid and CHIPRA programs.
Among the measures chosen by the federal Centers for Medicaid and Medicare Services (CMS) was one that required “[s]creening using standardized screening tools for potential delays in social and emotional development.” In order to be chosen for inclusion, each measure needed a sturdy body of evidence attesting to its importance and feasibility. The CMS had been convinced of the need for this measure based on the evidence presented by the Assuring Better Child Health and Development (ABCD) Screening Academy, a major initiative of The Commonwealth Fund.
Why did The Commonwealth Fund create this initiative? What did the ABCD program discover about well-child care and providing developmental services to indigent infants and young children that helped it shape a major piece of legislation? This monograph traces the history of the ABCD initiative and of the program in which it was nested, The Commonwealth Fund’s Child Development and Preventive Care (CDPC) program. Specifically, it considers how the CDPC worked successfully to convince parents, payers, health care providers, and policymakers of the importance of developmental screening in well-child care.
The emphasis of this monograph is on The Commonwealth Fund’s recent efforts to improve the delivery of well-child care in the first years of the 21st century. However, these recent efforts should first be placed in the context of the foundation’s involvement in pediatric health care and well-child care over the past century. Only in this way is it possible to fully appreciate the Fund’s successes, the challenges it faced, and its development of the platform on which it mounted the program.
Part I explores the development of well-child care in the United States in the 20th century, focusing on turning points and emphasizing Commonwealth Fund initiatives and their contributions to child health care, from those of the 1920s through Healthy Steps for Young Children, in the 1990s. Part II traces the creation of ABCD and the CDPC program, and provides an intellectual history of the theories and philosophies informing them. Part III examines how the CDPC program built momentum for change, engaged stakeholders, generated evidence, and, by so doing, was poised to capitalize on a particular policy window to effect sustainable change in well-child care in the United States. Finally, Part IV analyzes the lessons learned from ABCD and the CDPC program and considers them in the context of enduring issues in American society, children’s health care delivery, and 21st-century challenges to effecting policy change.