In the Literature
Are the health needs of poor children a medical problem or a social welfare issue, and are such needs the responsibility of the states or the federal government? These questions have sparked much debate among policymakers, physicians, and children's advocates. It is the failure to resolve these issues, say the authors of this article in Pediatrics, that has led to the current failure in providing optimal health care to every child in the United States.
In "Successes and Missed Opportunities in Protecting Our Children's Health: Critical Junctures in the History of Children's Health Policy in the United States," (Pediatrics, April 2005), Howard Markel, M.D., Ph.D., director of the Center for the History of Medicine at University of Michigan, and Janet Golden, Ph.D., of Rutgers University, revisit several turning points in the history of child health policy. They conclude that while much changed over the course of the 20th century, "many child health needs still are systematically neglected." In particular, the authors find a wide divide between underfunded, needs-based maternal and child health programs, like Medicaid, and general entitlement programs administered at the federal level, like Medicare and Social Security.
When the practice of pediatrics was first established in the late 19th and early 20th centuries, child health was linked with social issues like poverty and child labor. Goals were similarly aligned: increasing wages, providing aid for widows, improving tenement housing. In particular, the high infant mortality rate united public health officials, philanthropists, health care professionals, and social workers. These efforts led to the signing of the Sheppard-Towner Maternity and Infancy Act in 1921. The act authorized the federal government to grant $1.25 million annually to states for child health and prenatal centers, instructional home visits by nurses, and distribution of educational materials.
While most pediatricians supported the law, it angered many in the medical establishment, including the American Medical Association. Some opponents felt it had Communist undertones, while others thought it would harm the public and intrude on states' rights. Although the law had some positive effects, including making pediatrician checkups for infants a routine practice, the bill was not renewed. "In its absence," say the authors, "a system emerged that decidedly separated the provision of medical care for needy children from children whose parents were working or had financial resources."
In 1935, Title V of the Social Security Act (SSA) more firmly established the division between medical care and social welfare. While SSA created improvements in the health and welfare for elderly Americans, it did not lead to similar gains for children, who remain "a social group without political muscle," say the authors. Because programs for children, like welfare and Medicaid, are needs-based and not guaranteed to all children, they are politically unpopular and often threatened.
Despite additional programs designed to aid children, like the Special Supplemental Nutrition Program for Woman, Infants, and Children and the State Children's Health Insurance Program, children remain vulnerable, with 12 percent under age 19 uninsured in 2002. Improving access to care for a specific age group, is possible—as evidenced by the efforts on behalf of the elderly—but will require the political resolve of pediatricians and other child advocates.