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Research Brief

The U.S. health care system is at its best when responding to acute health crises, such as heart attacks. But the system falls short when it comes to providing the kind of protective, preventive care children need: care that helps parents anticipate future needs, monitors problems as they arise, and coordinates needed services.

A new study by RAND researchers identifies six areas in the pediatric health care system where major barriers—termed "voltage drops" by several leading health services researchers—lead to a breakdown in delivery of adequate quality care. The study also provides a framework for establishing distinct, achievable objectives to improve health care for children.

The table below describes these voltage drops and summarizes policy recommendations. The authors emphasize that the benefits of expanding access to care will be realized only if the quality of care is addressed.

Voltage Drop Implications Recommendations
1. Many children lack access to insurance coverage: 25 percent may be without coverage for some part of the year. Children's coverage depends largely on parents' ability to obtain employer-based insurance. Public insurance funding is vulnerable, and many children are ineligible. Shore up and protect Medicaid/SCHIP.
Uninsured children are less likely to have well-child visits, other office visits, hospitalizations; they disproportionately visit emergency departments. Widen eligibility.
Improve market-based approaches to increasing access to private insurance.
2. Many barriers prevent enrollment in available insurance plans. Barriers to enrollment include lack of parental awareness of public programs and eligibility; lack of perceived value of insurance; administrative obstacles; and cost of private insurance, when available. Increase federal funding and mandate limited state cost-sharing.
Increase outreach efforts and family coverage.
Help with purchase of private family coverage; strengthen safety net system.
3. Access to insurance does not guarantee access to needed services and providers. Some children are underinsured; cost-sharing may be substantial; not all plans provide same benefits, especially for well-child care. Assess extent of underinsurance; incentivize insurance plans to limit cost-sharing for well-child visits and other preventive care.
4. Children often lack access to a consistent source of primary care. Frequency and continuity of well-child care help ensure adequate well-child care but vary widely; affected by parental race/ethnicity, language barriers, education, income, employment stability, type of insurance plan. Strengthen coordination of community health care systems, organizations and providers.
Fund pilot programs to identify most effective methods for achieving this coordination.
5. Many primary care physicians lack systematic ties with providers of specialty services to whom they can refer patients when needed. Most children, particularly those with special needs, require referrals to specialists at some point. Needs for such services often exceed use of and access to those services. Implement more "medical home programs" that consolidate primary care and specialty referral services with a seamless, comprehensive care model.
6. Quality of health care delivered to children varies widely. Access to services is beneficial only if quality is high. Adoption of evidence-based practice guidelines lags, resulting in quality gaps that threaten safety and effectiveness of care (too little, too much, or inappropriate care). Build and enforce quality standards through economic incentives, report cards, and accreditation mechanisms.
Educate providers in quality improvement techniques and provide measures and feedback systems.
Develop a child health services infrastructure that supports quality

This report is part of the RAND Corporation research brief series. RAND research briefs present policy-oriented summaries of individual published, peer-reviewed documents or of a body of published work.

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