10

Improving the Health and Wellbeing of Children, Youth, Families, Communities, and the Nation

Roughly one hundred years ago, a crisis in child health resulted in a broad social movement to improve outcomes for children (McMillan, Schumacher, & Singh, 2006; Takanishi, 1978). That movement resulted in the development of organizations and agencies that would support and organize efforts to improve health outcomes for children and adolescents, including the American Academy of Pediatrics and the Maternal and Child Health Bureau, among others. That social movement also created child labor laws, nutrition regulations, education reform, and legal protections for children that had been missing previously. Today, another transformational movement is needed, one that addresses the crisis facing America’s children.

U.S. children are not well. Increasing morbidity and mortality threaten their health and wellbeing and that of the coming adult workforce. The crisis comes in the context of decades of policies that disadvantage racially and ethnically diverse and low-income communities and have resulted in inequitable opportunities for children and disparate outcomes that start in childhood and extend into adulthood. National progress to reverse this crisis and improve long-term outcomes for all Americans will come only from a dedicated and ongoing commitment to focus on children, youth, and their families. Previous and ongoing work to improve health care for Americans has had limited focus on the population under age 30. This crisis requires

national recognition of the need to take the health of children and youth seriously, specifically, and differently—including changing the organization and financing of their health care and related services. Children and youth may benefit from the general developments in U.S. health organization and financing, but in many cases, child health care is excluded and children’s unique needs are unmet. Without dedicated and continued focus on younger populations, the nation will continue to lag behind other industrialized countries in most indicators of child and adolescent wellbeing and lead to a young adult population that is less able to participate fully in American industry, military, and society.

Not addressing this crisis has led to serious social consequences. Today, many working-age adults have health burdens that demand public resources and limit workforce participation and military preparedness—a situation that is unlikely to change if the health care system for children is not fixed. Furthermore, with declining birth rates, the growing older population will rely on fewer employed adults for their wellbeing. Growing mortality and disability rates among U.S. working-age adults are ominous indicators of a larger epidemic of poor health in communities, outcomes of failing to provide the care that children and youth need.

The committee recognizes the many important influences on child and family health outside the health care system, especially those around poverty and income support, housing, labor markets and employment, community wellbeing, family leave and child care support, justice and education systems, and financing of these. Our recommendations focus on the health care sector, defined broadly to include public health investments in child and family health and school-based health care. While recognizing the critical role of other public, economic, and social issues on health over the life course and supporting recommendations from several previous reports by the National Academies of Sciences, Engineering, and Medicine (National Academies) on reducing child poverty and addressing the economic and social needs of children and youth, the recommendations emphasize transforming the health care system to advance child, youth, and family wellbeing.

This chapter, drawing on the findings in previous chapters, provides several calls to action for executive and legislative leadership at federal, state, territorial, and local levels. The recommendations here speak to the critical need for the nation to address health trends and the poor state of the wellbeing of America’s children by strengthening policies in ways that expand opportunities for improving the health care system across states and communities. The recommendations, discussed below, focus on governmental levers for change that will allow health care systems and the pediatric workforce the flexibility to change and improve health care for children and youth. While many challenges with the current child health care system are raised in the prior chapters, the committee did not make recommendations

to address all the specific challenges. In the context of implementation goals for an improved health care system, we offer a number of recommendations to establish the leadership, financing, and other resources necessary to address these challenges and support the expansion of promising innovations in health care delivery.

In Chapter 1, the committee articulated its guiding principles and vision for a transformed child and adolescent health care system. These principles were developed from a collective understanding of the challenges in the current health care system and emerging opportunities to improve the delivery of care, informed by the committee’s substantial experience in health care from multiple perspectives and the large body of scientific evidence and traditional knowledge on factors promoting child and adolescent health and wellbeing.

The committee’s vision recognizes the opportunities and imperative to improve population health and wellbeing by focusing health care priorities earlier in the life course. Decades of research and experience show that early life adversity and poor health lead to chronic disease and mortality in adulthood and limit individuals’ capacity to participate fully in community life and the workforce. Further knowledge points to the critical influence of family and community health on child health and subsequent life course wellbeing (see Chapter 2). There is evidence of the persistence of racial inequities and injustice in access to and receipt of care and resulting health outcomes; these disparities are discussed in Chapter 3 and documented in a number of other reports (Institute of Medicine [IOM], 2003b; National Academies, 2017a; 2023c). Advancing science in social, relational, and structural determinants of health, genetics, and artificial intelligence prediction all emphasize the potential and benefits of focusing health care on prevention and earlier identification of disease.

While all of this has been well known for some time, and recognition of major disparities and discrimination in health and health care have grown during the COVID-19 pandemic, several challenges remain to refocus child health care¹ from an emphasis on treatment to an emphasis on prevention. A barrier to this shift is that growing rates of poor physical and mental conditions among children and adults can keep the emphasis on treatment as opposed to prevention. This is made more likely by current funding and financial incentives that center diagnoses and treatments and limit attention to prevention and health promotion and addressing root causes of disparities. Furthermore, there is substantial fragmentation and lack of coordination among health care systems, schools, and other community

___________________

¹ Throughout this report, the committee regards the term “child health care” to encompass maternal, prenatal, child, adolescent, family, and community health care.

resources with clear roles and interest in supporting the health and wellness of children, families, and communities.

Throughout its report, the committee aimed to document increased scientific and traditional knowledge about health and wellbeing in childhood and later adulthood, including persistent and worsening poor health among U.S. children and youth, the uneven health care system for children and youth, racism in health care and disparate outcomes, growing health problems among working-age adults, and the implications of these trends for the nation’s economic productivity and prosperity. All these findings support the urgency of addressing child and adolescent health care transformation now.

In making recommendations for health care system transformation, the committee was tasked with addressing six questions (see Chapter 1, Box 1-2). These questions directed the committee to identify key levers for change that would facilitate health promotion and disease prevention; address systemic inequities and gaps in payment models; incorporate lived experiences into community- and team-based care; and enhance multisystem collaboration for improved health and wellbeing. Early in the study, the committee drew upon the questions in its charge to create a set of principles for an improved health care system (see Box 10-1); these principles guided the committee’s work of developing the program and policy recommendations presented in this chapter. Adhering to these principles will enable changes in policy and practice to improve health care.

LIFE COURSE PERSPECTIVE: THE CRITICAL IMPORTANCE OF CHILD HEALTH

As discussed throughout the report, the committee takes a multigenerational, life course perspective because research has shown the inextricable link of child health to maternal and family health on one end and later adult health on the other. Substantial evidence demonstrates that health early in the life course sets the foundation for health through childhood, adolescence, and young adulthood, and for tomorrow’s workforce. This science points to the importance of early life experiences and close adult relationships and to developmental origins of health and disease. The community and social environments contribute as well and help frame both typical trajectories at given times in history as well as opportunities and threats (Alwin, 2012). Early antecedents discernable in childhood contribute to adult chronic illness. For example, mental illness and substance use and addiction among most adults started with conditions in childhood and adolescence, and children with obesity are more likely than nonobese children to have obesity in adulthood. Chronic stress and allostatic load, social and structural determinants of health (especially poverty, hunger, and

housing insecurity), and persistent racism have oversized roles in driving the health and wellbeing of children, youth, and families. High rates of childhood adversity and poverty are associated with poorer adult physical and mental health, job opportunities, and earning potential. These adversities are most pronounced in historically marginalized communities.

Addressing family health needs and social determinants of health can improve child and family health, with strong empirical evidence linking family socioeconomic status and education level to child health outcomes. The scientific findings on the developmental origins of health and disease and the importance of the community and historical context point to the opportunity and imperative to focus population health strategies early in

the life course. The connection between health and wellbeing for children and the nation’s capabilities and capacity has never been clearer.

FAMILIES, COMMUNITIES, AND HEALTH CARE

Health care experiences for families seeking care vary greatly. Differential treatment, racism, discrimination, and bias are prevalent in health care service provision (see Chapters 2 and 3). The United States is one of a few resource-rich countries in the world that does not entitle young children to health care, with resulting disparities and some of the lowest rates of access to preventive care and routine services among resource-rich countries. As a result of persistent disparities in prevention and health promotion, many U.S. cities and states report high rates of infant mortality, preventable disease outbreaks, and high costs of care for many specialty conditions. Large subsets of U.S. children face barriers to positive mental and physical health and wellbeing as a result of poverty, food insecurity, unsafe or unstable housing, neighborhood segregation, insufficient access to high-quality care, and other adverse childhood experiences (see Chapter 4). This report focuses on the important opportunities the health care sector can leverage to acknowledge community needs, build care practices that better support these needs, and link families to social resources.

While some innovative programs exist, in general, U.S. health care provides only limited attention to the integration of health care for the whole family, health care across the life course, or integration of mental and behavioral health into clinical care. This report argues for collaborative and strengths-based relationships among children, families, communities, and health care professionals and systems as foundational for improving child health. Health care that centers on partnerships, strengths, and equity provides children with the greatest opportunities to receive care and resources to support their lifelong development. Community-driven solutions are necessary to address determinants of health, as families and communities are uniquely positioned to drive priorities and actions tailored to their needs.

HEALTH EQUITY

Health equity needs to be centered across all aspects of health care system transformation. Achieving health equity is an ongoing goal requiring multilevel, evidence-informed strategies and interventions at the policy, program, and system levels to distribute resources where they are needed most. Engagement and building trust in health care systems, particularly with historically marginalized populations, begins with acknowledging existing inequities and pursuing efforts to combat them in communities.

In the current system, health care institutions expose patients and families to interpersonal and structural racism throughout the care process, resulting in more expensive care and poorer patient outcomes. Racism affects which patients are accepted for appointments or how long it takes to get appointments, the location of specialty resources in pediatrics, the types of diagnoses that are offered, and the types of treatments provided (see Chapter 2). Building trust at the provider level will require ensuring that the current and future workforce is able to provide care with cultural humility and empathy and making room for dignity in care.

Child poverty remains the strongest predictor of poor health outcomes in children and youth. Poverty works against healthy living conditions and can limit access to nutritious foods, stable housing, green space, pollution-free environments, safe and nurturing relationships, and health care. Children whose families live in poverty experience worse health early in life than children growing up in higher-income families, and this disparity worsens as they age (see Chapters 2 and 4). A variety of public programs has helped decrease family poverty in several ways, including income support, underscoring the effectiveness of public investments in children (National Academies, 2019a, 2023f). Although the committee does not address the root causes of this critical determinant of health directly, it strongly supports the recommendations of prior reports by the National Academies on reducing child and intergenerational poverty (National Academies, 2019a, 2023f).

This report focuses on ways to advance child health equity through health insurance coverage and direct clinical services support (see Chapter 6) and investment in public health aimed at health promotion and disease prevention (see Chapter 7), including that delivered through schools (see Chapter 8).

SUSTAINABILITY

Sustainability includes consideration of financing, payment, trained workforce, data, and technology that will support an effective health care system. An improved child health care system, emphasizing a whole health approach (National Academies, 2023a), needs to be designed to adapt and evolve to meet the continually evolving needs of the communities and families it serves, to strategize with other sectors that share goals of child wellbeing (e.g., education, social services, justice), and to respond to an ever-changing built and natural environment. Successful health care system transformation relies on partnerships among leaders across sectors, payers, engaged families, and activated communities; such partnerships establish agreements and track performance on shared goals, ensuring transparency and open exploration of performance on population-based outcome indicators (see Chapter 9).

VISION FOR IMPROVING HEALTH AND WELLBEING OF CHILDREN AND YOUTH

The committee envisions a child and adolescent health care system a decade from now that builds from traditional knowledge in communities and empirical evidence on early life experiences, human development, and disease prevention to provide comprehensive, family-engaged, community-integrated, and equitable care focused on optimizing the healthy development and lifelong wellbeing of all children, youth, and their families. This health care system will exist within a broad, cross-sector system, notably expanding the role of schools; the envisioned health care system promotes flourishing equitably, builds on community strengths, and addresses family and community needs to create the safe, stable, and nurturing relationships and environments that all children need to thrive. Critical to a future transformed system is ensuring that the lived experiences and expressed needs of children, youth, and families set the priorities. The committee expects that the primary clinical workforce will continue to transform to a coordinated team-based care model—with physicians and nurses working alongside integrated mental and behavioral health workers, community health workers or navigators, and multisector community partners (see Chapter 5).

The committee identified five implementation goals in pursuit of this vision:

1. Elevate the importance of child and adolescent health for the nation through continuous public focus on children and youth.
2. Finance health care systems for all children, emphasizing prevention and health promotion.
3. Strengthen community-level health promotion and disease prevention.
4. Ensure co-creation and co-design of programs and structures with youth, family, and community voices and leadership.
5. Implement measurement and accountability to ensure equitable achievement of these goals.

The recommendations that follow for each of these goals attend to the compelling need for the nation to address the poor state of health and wellbeing for large numbers of America’s children and youth and the major concerns regarding the nation’s workforce.

Goal 1: Elevate the Importance of Child and Adolescent Health for the Nation through Continuous Public Focus on Children and Youth

Chapter 1 concludes that the nation needs sustained federal, state, and local leadership for child and family health. While many public and private

organizations provide key support for children, youth, and families, no one group has clear leadership among them. Key federal agencies include the Centers for Medicare & Medicaid Services (CMS; the main health care financing program), several direct service programs, especially the Maternal and Child Health Bureau (the agency in the Health Resources and Services Administration [HRSA] charged with monitoring and improving the health of mothers and children) and the Bureau of Primary Health Care (supporting substantial numbers of community health centers across the nation), as well as the key public health efforts of the Centers for Disease Control and Prevention.

Among professional organizations, the American Academy of Pediatrics represents many but not all of the physicians and other providers who care for U.S. children and youth. Children’s hospitals play an important role, but they provide inpatient services for a relatively small proportion of children. Some states have developed children’s councils or boards at the cabinet level, where health is a major topic. Furthermore, the labor market and health insurers greatly influence health care payment and incentives.

The need for federal leadership on child health arises from evidence that the distinct needs of younger populations often get little attention in development of delivery models, in development of diagnostics and therapeutics, and during public health crises. Since children are not the cost drivers in health care, are only 22% of the U.S. population, and have diseases that are relatively rare, their unique needs often get lost in political and policy debates on health care. There are many examples of how child health has been deprioritized within a health care system that focuses predominantly on adults (see Chapter 1). For example, during the early period of the COVID-19 pandemic, vaccine development and availability for children were slower than for adults, and the work to ensure educational support came late and was based more on the needs of the workforce than on the needs of children and youth.

The unwinding of pandemic-related Medicaid policies provides graphic evidence of the delayed policy attention to children and youth, even despite their prominence among the Medicaid-insured population. With the unwinding, many children and youth lost critical health care coverage through preventable bureaucratic mishaps and mistakes and thus lost access to needed preventive and treatment services for long periods of time (see Chapter 6). Notably, state factors contributed to differences in children’s loss of coverage. For instance, states that combine Medicaid with the Children’s Health Insurance Program (CHIP) have had smooth coverage transitions, reducing loss of coverage. States with less generous CHIP income eligibility limits or with CHIP programs that have copays or premiums (26 states) have seen greater loss in coverage. Limited and late concern for children during the pandemic and other social crises exemplifies the major lapses that occur without sustained federal leadership focused on children.

National leadership must bring about coordination, facilitating communication among agencies serving children, using a child-health-in-all-policies lens, and maintaining robust data collection and review across federal agencies on the health status of all children. Previous efforts at change have floundered in part because of lack of sustained attention. The locus of leadership and coordination needs to be at the highest levels of the federal government, with clear participation across key government agencies, states, communities, and the private sector. Other nations have designated child commissioners and ombudsmen for this purpose. Creating such positions demonstrates a government’s commitment to children; it ensures an entity for oversight, research, and review of public policies, as well as technical assistance for matters impacting child health (James & Wright, 2015; Kim, 2019; UNICEF, 1997). Some U.S. states have already established organizations and programs resembling children’s commissions found in other countries. About half of U.S. states currently have some version of a children’s cabinet, with increasing collaboration among these units (Forum for Youth Investment, 2021).

This report provides an overall guide for the types of ongoing strategy and focus on the wellbeing of children, youth, and families. Reviewing the report and implementing its recommendations would require a high-level national expert panel of families, health care leaders, and key agencies to develop a strategic framework. This prominent convening, led at the federal level, can help with reconceptualizing child health and development across sectors and elevating the importance of specific changes needed. Furthermore, such a convening could examine the strategic plans of federal government departments and agencies impacting child and youth wellbeing, including the U.S. departments of Health and Human Services, Education, Agriculture, Housing and Urban Development, Justice, and Defense, as well as the Food and Drug Administration, and advise how they could be called upon as key federal agencies serving children and families to implement changes discussed in this report. A key outcome would be a framework for change in child health coordination.

Recommendation 1-1: Federal policy makers should convene an expert panel of key stakeholders, families, community partners, and state and federal agencies to develop a framework for promoting health and wellbeing for all children and adolescents and an enduring implementation plan. The framework should strive to integrate health programs among health care, education, labor, child welfare, and justice systems and foster shared goals of improving health and wellbeing throughout the life course and advancing health equity. The framework should present options for (1) financing enhanced services, (2) monitoring coordination over time, and (3) designating key leaders and agency structures that can focus attention on the health care needs of children, youth, and families.

This convening could also identify a federal agency or federal leadership position charged with ensuring the implementation of the framework and that all policies address children and families. The agency would produce an annual report on the status of children, youth, and families, with an enduring interagency structure with key programs included. Expansion of the charge and authority of the current Interagency Working Group on Youth Programs could provide this base. The structure could include participation of adolescents and families; ensure representation from historically marginalized communities; and have advisory, coordinating, and regulatory powers for implementation and ongoing assessment. It could develop performance monitoring and quality improvement focused on whole child and family health and equity through licensing, certification, accreditation bodies, relevant programs, and agencies (see measurement and accountability in Goal 5 and Chapter 9).

Another example, within the legislative branch, might take the form of a congressional committee on life course health and wellbeing, focused on children, youth, and families (similar to the Senate Committee on Aging), to raise visibility on issues of child, youth, and family health and wellbeing and impacts on the nation’s health. The committee could study relevant issues, oversee programs, and advance important causes related to launching lifelong health.

Health outcomes are highly influenced by policies, programs, and practices that shape, for example, the quality and location of health care, availability and accessibility of public transportation, land use and street connectivity, and agricultural practices (National Research Council [NRC], 2011). Health in all policies is a promising (but not novel) approach to identifying and examining a policy’s health and equity impacts. The approach builds on early principles of health promotion developed in the late 1970s and 1980s, centered on concepts such as legitimacy, accountability, transparency, accessibility, participation, sustainability, and multisectoral collaboration (Pan American Health Organization, 2015; United Kingdom Department of Health and Social Care, 2020; Wernham, 2011; WHO, 1986; WHO & United Nation’s Children’s Fund, 1978).

A health impact assessment is a process used to support a health-in-all-policies approach to decision making (Georgia Health Policy Center, n.d.; NRC, 2011). Such a process

Given that social, relational, and environmental factors have strong influence on the health and wellbeing of children and youth (see Chapters 2 and 4), the committee encourages policy makers to view child health holistically and weigh a broad set of policy decisions against the consequences they will have on family and community health.

Recommendation 1-2: Federal policy makers should enact child health and health equity impact statements that include impact and cost/benefit over longer time horizons for (1) Office of Management and Budget regulations in the federal register; (2) Congressional Budget Office (CBO) scoring of legislation; and (3) all major federal programmatic and research actions involving the U.S. departments of Health and Human Services, Education, Housing and Urban Development, Agriculture, Labor, and Justice. The CBO should expand its scoring of health programs to address longer-term outcomes (including Medicare and other public health expenditures) and impacts on federal sectors beyond health care. The president’s annual budget line items should also report on inclusion of children and child health and health equity impact.

Recommendation 1-3: State legislatures and agencies should implement scoring of legislation and major programmatic initiatives to inform decisions based on their impact on the health and wellbeing of children and families and on health equity.

Foundations and child and youth wellbeing advocacy organizations can play a role in elevating the importance of child health through public awareness campaigns. Activated communities and constituents can be supported and grown to hold accountable their elected representatives, other government officials, and agencies, ensuring that policies promote rather than harm the health of children, youth, families, and communities.

Recommendation 1-4: Foundations and child and youth wellbeing advocacy organizations should fund and implement a long-term, multifaceted public awareness campaign that highlights issues of child and adolescent health and describes the importance of children and adolescents for the nation’s future wellbeing and economic and national security.

Several agencies carry out research programs that have greatly improved the health and wellbeing of populations of all ages; yet, here too, children and youth have been relatively neglected in the breadth and scope of this work. As part of the broader plans suggested in this report, the nation should commit to strengthen and coordinate research related to

children, youth, and families, in areas of inclusion, longitudinal research addressing key transitions, and increased study of the whole family.

Recommendation 1-5: The U.S. Department of Health and Human Services—through the Agency for Healthcare Research and Quality, the Advanced Research Projects Agency for Health, the National Institutes of Health, and other research and technology funders and developers—should continue and accelerate investment in research on whole child and family health, including mothers, children, adolescents, and families. Key elements of this research follow:

• Inclusion of children, as well as child health and equity impact evaluations, in major research and technology initiatives.
• Longitudinal research early and throughout the life course, assessing long-term return on investment in health and developmental/educational outcomes and across sectors.
• Research that includes individuals’ family and community context.
• Research on developmental transitions and care, such as from the prenatal period to infancy and from adolescence to adulthood.
• Clinical trials and dissemination and implementation research, especially related to incorporating scientific and technological advances in practice and policy.
• Engagement of youth, families, and community in the co-creation and co-design of research.

Goal 2: Finance Health Care Systems for All Children, Emphasizing Disease Prevention and Health Promotion

This goal and its recommendations focus on Medicaid and CHIP reform and on changing payment incentives to drive the system toward prevention and health promotion. Medicaid and CHIP, the dominant payers for health care for children and youth, ensure a major safety net for large numbers of American children who would otherwise have no insurance. Yet persistent inequities in Medicaid leave many children and youth without adequate coverage for basic services, including key preventive services. States vary in their implementation of federal Medicaid laws, which creates barriers to enrollment and differences in program eligibility and accessibility, widening the gap in insurance coverage and access to care. These barriers affect racially and ethnically marginalized populations disproportionately, contributing to place-based racial/ethnic health inequities.

The major Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit in Medicaid provides a strong statutory requirement for the range of services that children and youth need. A central part of Medicaid,

EPSDT has lacked updated regulations for 40 years, and the program has had little monitoring or enforcement of statutory requirements. Medicaid and CHIP reform need to strengthen an already critical program and advance it to one that invests in the best future for U.S. children and youth. See Chapter 6 for more background on Medicaid and CHIP.

A health care system that supports the health and wellbeing of all children, families, and communities—recognizing the diverse set of strengths and needs among them—requires expanded focus on disease prevention and health promotion, along with ensuring adequate insurance coverage for individuals and families and support for a range of care providers for their health care needs. The health care system needs to advance toward continuous and comprehensive health care coverage for every child and family in every community. Gaps in children’s insurance coverage must be addressed so that care is uninterrupted, comprehensive, and health promoting for both children and their families.

Recommendation 2-1: Federal and state policy makers and the Centers for Medicare & Medicaid Services (CMS) should reform Medicaid and the Children’s Health Insurance Program (CHIP) to ensure coverage and services for every child and parent under age 65 who lacks other insurance. Specific actions to ensure insurance coverage include

• Providing presumptive continuous eligibility for all children through their 6th birthday and universal access to Medicaid for all those under age 26 years who lack other health insurance.
• Enrolling all newborns at birth in Medicaid/CHIP if not covered by another plan.
• Allowing undocumented children and their parents access to Medicaid/CHIP, the Health Insurance Marketplace, and other federally funded health care services.
• Ensuring continuous Medicaid coverage for low-income parents.
• Aligning the financing of child coverage in the territories with that of states through Medicaid and CHIP.

Specific actions to improve benefits and payment include

• Reducing state and territory variability in eligibility, enrollment, quality, and payment by raising minimum federal standards.
• Ensuring a national base of high-quality services by modernizing Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits and rules. CMS and Congress should update EPSDT regulations, and CMS and the states should implement ongoing strategies for ensuring statutory compliance.

• Enforcing managed care organization contracts and implementation to ensure meeting all Medicaid/CHIP standards and requirements. States should ensure transparency in managed care organization contracts and public accountability.
• Designing and requiring integration of Medicaid and CHIP into a single program, making CHIP permanent, establishing the same provisions as Medicaid, and eliminating differences in eligibility and benefits.
• Increasing transparency in provider payment rates and direct provider subsidies and raising provider payments to levels that ensure that children and adolescents have equitable access to comprehensive, team-based primary and specialty care without discrimination based on payer.
• CMS and the Medicaid and CHIP Payment and Access Commission should collect and analyze data that speak to the adequacy of payment for child health care services.
• CMS should implement a Medicaid Beneficiary Survey, modeled after the Medicare Current Beneficiary Survey, that captures beneficiaries’ health and functioning; satisfaction with health care; usual source of care; and access to care, including primary care and specialty care for new and established patients.

Although the current child health care system generally promotes wellbeing and prevention, it is hampered because of its continuing focus on disease identification and treatment reinforced by a fee-for-service payment model that pays mainly for visits and procedures. Strategies for improving population health include team-based care and community-engaged programs, combined with specific efforts at prevention and health promotion and decreasing inequities.

Current fee-for-service payment models do not allow clinicians the flexibility to work with families and communities to address health and developmental goals for children. They do not support the many well-evidenced advances in enhanced pediatric primary and subspecialty care. Furthermore, most recent efforts to change payment methods have focused on short-term cost savings among older populations with high medical expenses. Child health care offers few opportunities for major cost savings in the short term; rather, improvements are seen in long-term outcomes beyond childhood, often in education and other sectors outside of health care, as well as long-term savings in Medicare and other public health outlays. Current insurance mechanisms have not kept pace with changing demographics; environmental influences on health; major new clinical strategies; scientific breakthroughs; and technological advances, such as increased use of telehealth.

As discussed in Chapter 5, a growing literature documents the value of multidisciplinary team-based care, including nonphysician personnel, in effectively addressing the needs of children, families, and communities. The roles of nurses and community health workers have become more prominent in clinical teams, as they provide support for families in several ways—including, for example, assistance in managing chronic conditions, navigating the health care system, and accessing community resources to improve healthy living.

Chapter 2 describes the strong scientific foundation on the importance of early life experiences and how safe, stable, and nurturing relationships support health promotion and set the trajectory for lifelong health outcomes. The dramatic prominence of mental health issues among children, youth, and parents particularly calls for integrated mental and behavioral health care systems (see Chapters 4 and 5).

Taking a life course approach and reaping the benefits of improving child health requires a system-wide focus on prevention of health problems and promotion of healthy experiences, from preconception to adulthood. Achieving this goal will require implementing payment models for child health care that incentivize population health efforts in prevention and promotion, especially bringing to scale the many successful advances in pediatric care. Doing so necessitates financing for all team members; incentivizing practice transformation; and providing continuous, consistent, and comprehensive health care coverage for every child and family in every community.

Recommendation 2-2: Public and commercial payers should transition from relying predominantly on fee-for-service arrangements and explore payment incentives that emphasize prevention and health promotion services, team-based and cross-sector care, health equity, health outcomes, and longer-term return on investment. While enhancements in fee-for-service models can support needed change, related payment strategies, including direct incentives, various withholding mechanisms, and alternative payment methods, should support this transition. The Centers for Medicare & Medicaid Services (CMS) and commercial payers should use payment methods that provide direct incentives toward population health, health equity, and the health of communities. Strategies for incentivizing practice change could include tiered payments that reward high-performing pediatric care. Current payment innovations, including numerous state efforts such as per member per month or population payments, serve as key experimental steps for covering health care services for children, youth, and families.

• CMS and commercial payers should test and implement episodic and bundled payment models that are designed for the service needs of children, youth, and families, especially those with more complex conditions.

• CMS, through its Center for Medicare and Medicaid Innovation (CMMI), should innovate in pediatric payment strategies and ensure inclusion of children in their programs. For example, as CMMI implements state total-cost-of-care models in the States Advancing All-Payer Health Equity Approaches and Development Model, children should be included and child health and health equity impact statements addressed.
• Payment should support team-based and cross-sector care, including high-performing medical homes, mental and behavioral health integration, and other innovations that support development of safe, stable, and nurturing relationships between caregivers and children; improve health equity; and build community health.

Because of their prominence in the lives of most children and families, schools offer unique opportunities to advance child health, without parallel among institutions for adult populations (see Chapter 8). Schools can assist in outreach and enrollment of eligible children in public health insurance programs and income support programs, offer direct care through school-based health centers, and reduce food insecurity and improve dietary quality through school meals programs. Direct school health services vary widely, as do their funding sources, including some funding from Medicaid and other federal sources and local school funds. These variations can exacerbate racial and other health disparities arising from the impact of structural racism on the makeup of neighborhoods and communities and on the financing of schools. The committee calls for strengthening direct school health efforts, including efforts to grow and support school-based health centers.

Recommendation 2-3: State legislatures and Medicaid programs should adopt and enforce policies that promote equitable payment for services delivered in school-based health centers (SBHCs) and by other school providers. Policies that have been effective in several states include those that (1) define SBHCs as a specific provider type; (2) waive prior approval or authorization from primary care providers for all SBHC billing; (3) allow Medicaid managed care organization payment for “self-referred” children seen in SBHCs; and (4) incorporate clarification of laws related to data sharing, including the Health Insurance Portability and Accountability Act and the Family Educational Rights and Privacy Act. Such policies should be implemented with intent to prioritize communities that face the largest health inequities, including gaps in access to pediatric health care services, and to encourage school-based programs to leverage, support, and enhance collaborations between schools and community health centers and health care systems.

Goal 3: Strengthen Community-Level Health Promotion and Disease Prevention

While the health care system focuses on identifying and treating health conditions in individuals, public health focuses on population-level actions to promote health and prevent disease (Wiley, 2016). In the United States, far more of the investment in health flows through the health care system for medical care than through public health for primary prevention, with particular loss of benefit for the health and wellbeing of younger populations. The United Nations Children’s Fund Innocenti Report Card #16 (UNICEF, 2020) found that in 2015 the United States spent just 1.3% of its gross domestic product (GDP) on families with a significant proportion of that coming through tax breaks. This is compared with an average of 2.4% GDP across wealthy nations and an average of 2.9% GDP among the three highest-ranked countries for overall child wellbeing (Netherlands, Denmark, and Norway). In a ranking of nations’ child wellbeing policies, the United States ranked 28th for health care policies and last (41st) in social policies.

As discussed throughout the report, efforts to advance primary prevention are especially salient for children and youth, since childhood presents a critical window for influencing health outcomes over the life course. Public health investment focused on child populations and community-level primary prevention can protect the nation from future high costs of health care and other services to address preventable health conditions.

The committee views expansion and intensification of the nation’s investment in public health as essential for strengthening population-level health promotion and disease prevention and launching lifelong health for children. Public health investment can take several forms and requires a diverse group of public and private stakeholders, including the health care system and government public health agencies, working together to contribute to the health of a community. Investment needs to extend beyond immunizations, screenings, and the like to truly address community needs. Public health efforts can be funded through and implemented in a variety of community settings: local hospitals, community health clinics, schools, and local public health departments are some discussed in this report. The key is having an entity capable of serving as a catalyst for engaging multiple stakeholders in tackling community health problems.

Effective programs shown to improve the health and wellbeing of children (see Chapter 7 for review of federal programs aimed at improving population health) need to be expanded to reach the communities most in need and reduce long-standing health disparities. The committee highlights the Child Opportunity Index or Social Vulnerability Index as a measure of geographic advantage or disadvantage to guide federal and state funding. Using these or other measures will ensure that neighborhood factors and needs drive a more equitable allocation of funding or block grants that communities receive for health and wellness services.

Furthermore, financing for the public health infrastructure, including local public health departments, needs to be strengthened. Because public health spending is highly uneven across communities,² the committee calls for assessing and strengthening local health departments to ensure that each has a minimum standard of core, foundational capabilities, and a strong emphasis on the health of children, families, and communities. Expanding on the notion of primary prevention as a form of insurance (Newhouse, 2021), new spending on public health initiatives for improving child health can be seen as a form of insurance for the nation against high future health care and non–health care costs attributable to preventable conditions.

Recommendation 3-1: Federal policy makers and agencies should expand funding for population-level whole child and family health promotion and disease prevention resource investments in ways that (1) provide greater and equitable support for children and families in need; (2) integrate community-level resources with child health care systems; and (3) ensure that all eligible children and families receive the highest-quality services in current public health programs. Federal programs that have particular relevance to younger populations and should be expanded to build core services for communities include

• The Administration for Children and Families Head Start and Early Head Start programs.
• The U.S. Department of Agriculture Special Supplemental Nutrition Program for Women, Infants, and Children and the Supplemental Nutrition Assistance Program.
• The Prevention and Public Health Fund, administered through the Centers for Disease Control and Prevention, with elevated focus on younger populations.
• Investments in early childhood health and prevention administered through the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration. Within HRSA, the Maternal and Child Health Bureau Title V block grant and targeted funding for maternal health, child health, and child development particularly merit expansion.

___________________

² In its synthesis, IOM (2012b) finds that “the health departments in the poorest communities and communities that have the poorest health outcomes are among the least-well-funded” (p. 56). Mays and Smith (2009) found a more than 13-fold difference between communities with high versus low public health spending. The National Association of County and City Health Officials (NACCHO, 2020) shows a threefold difference between the 25th and 75th percentile values of annual per capita expenditures across local health departments. And Owsley, Hamer, and Mays (2020) point to the widening gap between urban and rural public health delivery systems.

Recommendation 3-2: Federal, state, and local agencies should reduce inequities in local public health department capacity and improve execution of current evidence-based support programs aimed at children to reap long-term benefits of improving child health and wellbeing.

• Federal policy makers should create a permanent Public Health Infrastructure Fund to ensure that each local health department has basic, core capabilities and technology support and to ameliorate existing inequities in public health resource availability.
• State and local agencies should evaluate existing public health capacity across communities and support coordination with other local health departments and health care systems.
• Federal and state agencies should evaluate how competitive grant-in-aid mechanisms may exacerbate resource inequities across local health departments and test alternative approaches to allocating limited resources.
• Federal and state agencies should coordinate and streamline processes and systems for ensuring strong execution of current evidence-based programs that support child health, in order to reach all who are eligible for services, using multiple points of access.

In addition to providing direct clinical services, schools engage in health promotion and disease prevention in multiple ways, including through formal and informal curriculum—which may include socioemotional learning, physical education, health class, and reproductive health education (family-life education). Teachers, counselors, and school nurses, among others, deliver these services, with a wide variety of school-based programs for improving mental health, reducing obesity, and managing chronic conditions. Many children receive meals through schools, making school meal programs a natural lever for influencing nutrition (see Chapter 8). Furthermore, teachers are present in children’s day-to-day lives and, if supported, can provide safe, stable relationships for children and youth, which are essential to children’s health and wellbeing (see Chapter 2). The committee identifies great promise in leveraging schools to support children’s wellbeing and calls for strengthening schools’ capacity around health promotion and disease prevention.

Recommendation 3-3: Federal, state, and local policy makers and agencies—in collaboration with health care systems, schools, foundations, employers, and other community partners—should expand

investment, through blended and braided funding, to support the infrastructure and resources to enhance school-based health promotion and disease prevention. Key actions include

• Funding expansion of the Centers for Disease Control and Prevention Healthy Schools program to meet community needs.
• Expanding resources to meet community needs and provide nutritious meals to all eligible students through the National School Lunch Program and the School Breakfast Program.
• Expanding the School-Based Mental Health Services Grant Program distributed through the Bipartisan Safer Communities Act to improve the ability of communities and schools to reach all children in need.

Several changes in tax and regulatory policy can provide substantial financing for these recommended investments. An important opportunity comes from strengthening community benefits requirements. Nonprofit hospitals benefit financially from tax exemptions at the federal, state, and local levels when they invest in community benefit activities (i.e., initiatives, activities, and investments undertaken to improve health in the communities they serve; Government Accountability Office, 2023c; The Hilltop Institute, n.d.). Of approximately 6,000 hospitals in the United States, about half are identified as nongovernment, nonprofit community hospitals, which qualify for tax-exempt status (American Hospital Association, 2024). As discussed in Chapter 7, the Internal Revenue Service requires nonprofit hospitals to assess community needs and document their community benefit activities. Efforts to strengthen this existing policy need to include retaining flexibility for hospitals to tailor their programs and practices to address the specific needs and concerns of their communities (Lucas-Judy, 2023); strengthening of these policies also needs to ensure accountability for improved health outcomes.

Beyond hospitals, community benefit strategies can be applied to nonprofit health plans with similar requirements for accountability to address local community needs. Other sources of funds for community benefit include mandating prevention investments by for-profit health plans (as California currently does) and reclassifying community prevention services as part of the medical loss ratio rather than as administrative costs (see Chapter 7). Health care for children provides substantial income for for-profit entities, especially those managed care organizations providing most Medicaid and CHIP services through state contracts. Taxation of these profits could provide substantial resources to strengthen several components of child and adolescent health care.

Recommendation 3-4: To expand investment in community-based prevention and health promotion for children, federal agencies should strengthen existing community benefit requirements and accounting mechanisms to support and incentivize health care system initiatives to advance community health.

• The Internal Revenue Service (IRS) should strengthen community benefit requirements for tax-exempt hospitals and create similar requirements for tax-exempt health plans. Reporting under the IRS Community Benefit Standards should require that nonprofit hospitals and health plans (1) use best-practice community needs assessment and improvement protocols and coordinate with existing community partnerships—or establish such partnerships—to create and implement action plans for addressing findings of community health needs assessments; (2) ensure community representation, accountability measures, and enforcement mechanisms in action plans; and (3) publicly report on progress for community-defined, cross-sector outcomes and measures for child and community health.
• The Centers for Medicare & Medicaid Services should reclassify community-based prevention programs as an allowable service, as part of the medical loss ratio.

Recommendation 3-5: State legislatures should mandate investment in community health from for-profit health care providers and managed care organizations. Such mandates should ensure that for-profit providers employ best practices for assessing community needs, engaging community representation, developing initiatives, and publicly reporting on progress for community-defined, cross-sector outcomes and measures for child and community health and health equity.

Goal 4: Ensure Co-Creation and Co-Design of Programs and Structures with Youth, Family, and Community Voices and Leadership

The perspectives of youth, family, and communities, and their lived experiences around health and the health care system, can have a critical and central role in health care and can improve outcomes (see Chapter 3). However, the impact of their voices on system change has not yet been fully realized. Health disparities and structural racism remain prominent concerns. For many families and communities in the United States, the health care system is untrustworthy. Youth, families, and communities bring critical expertise and must be partners in the co-creation and co-design of programs that will address their health and wellbeing, including health care transformation efforts, policy making, and care decisions.

The current health care system has been characterized as industry and provider centric; it needs to transform to become child, family, and community centered. Vital contributions from youth, families, and communities enables diverse voices in decision making at patient and population health levels and can inform the training of health care professionals, research activities, and quality improvement efforts (see Chapter 3). Future community partnerships will need to be supported appropriately and participants compensated.

To ensure the health and wellbeing of children and youth, engaging families of children and youth needs to be top priority. Integrating them, their perspectives, their collaboration, and their leadership, and supporting their time, are crucial at all levels, including decision making within health care systems, planning through public health agencies, and policy making and guidance at the federal and state levels.

Recommendation 4-1: Health care systems should partner with community members and leaders from historically marginalized backgrounds to co-design policies and build programs that support a more child-, family-, and community-centered health care system, supporting quality improvement, patient safety, and health equity initiatives. Such partnerships should

• Ensure the active involvement of patients, youth, and families in the development and implementation of new science and technologies (e.g., genome sequencing, prediction models that use artificial intelligence) and models of care.
• Strengthen the role and diversity of patient and youth family advisory councils that reflect the communities served and address community needs.
• Provide education and training opportunities as well as compensation to patient, youth, and family advisors that engage in child health care system transformation initiatives and efforts.
• Create pathways with local community programs to involve high school and college students from marginalized communities in early mentorship and job programs, in order to promote community engagement and develop a sustained and diverse health care workforce.
• Provide and encourage training and volunteer opportunities for health care system employees to partner with the community to co-design, build, implement, and evaluate programs, in order to achieve excellent and equitable child health outcomes.

Recommendation 4-2: Federal research agencies, state governments, and foundations should eliminate barriers that make it challenging

for health care entities to financially compensate patients and families for their participation in efforts to improve services or programs; they should also eliminate barriers that limit collaboration among health care, child health–related public health programs, and family- and community-based services.

Recommendation 4-3: Accrediting and certifying bodies for the training and certification of physicians, nurses, nurse practitioners, physician assistants, mental and dental health providers, and other health care workers should require training to ensure that the health care workforce is competent, diverse, team oriented, and antiracist, and able to promote relational health.

Recommendation 4-4: Hospital or health care system accrediting bodies (e.g., The Joint Commission) and recognition programs (e.g., U.S. News & World Report Hospital Rankings, American Nurses Association Magnet Recognition Program) should continue efforts to assess and recognize activities related to patient and family experience; diversity, equity, and inclusion; and achievement of excellent and equitable health outcomes.

Recommendation 4-5: Federal and state agencies should mandate and utilize the expertise of youth, families, and communities by generating and sustaining community representation and advisory practices that are integrated with accountability measures and enforcement mechanisms.

• Federal agencies should incorporate requirements in grants to states and territories for greater youth, family, and community engagement, including those from historically marginalized communities.
• State agencies should instruct community advisory boards to make proceedings and minutes of meetings public to ensure strong engagement.
• Federal and state agencies should support quality improvement efforts and learning health networks—with a specific focus on co-design with patients, children, youth, families, and communities—to improve outcomes tied to decreasing health disparities and quality measures that align with communities’ needs.
• The Centers for Medicare & Medicaid Services should reinvigorate its Partnership for Patients program by funding capacity and capability building for children, youth, families, and community leaders to fully engage and co-lead quality improvement efforts within hospital and community innovation networks and quality improvement organizations.

Recommendation 4-6: Federal and state agencies, foundations, and other funders should provide financial support for youth-led services in local communities. This support could include

• Research funding directed at strengthening scientific understanding of the efficacy, effectiveness, and implementation of youth-led services.
• Funding of youth-led services, through AmeriCorps’ Healthy Futures focus area, to include training and credentialing, which should be deployed locally. The proposed expansion of funding for this program should target young people in delivering peer-led services, to massively expand their access to health promotion and mental health supports.
• Funding to co-create and co-design a national credential for peer-support specialists with youth-led organizations, graduate student–led national organizations, and the credentialing bodies for allied health care professionals, to expand the workforce of youth leaders. This is pivotal to providing consistency in delivery of youth-led services and to sustaining the development of the future health care workforce.

Goal 5: Implement Measurement and Accountability to Ensure Equitable Achievement of These Goals

A transformed health care system needs to emphasize accountability for equitable, whole child, family, and community health outcomes. In Chapter 9, the committee identifies seven priority areas for implementing an accountability measurement strategy that supports improved outcomes for all children and youth: (1) commitment to child and youth population outcomes and equity measures; (2) applied research on best practices for real-world use of essential child and youth wellbeing measures; (3) shared accountability measures and improved digital health integration and data interoperability across systems and sectors; (4) reduced number of universal quality measures services to improve and track priority outcomes; (5) stronger incentives to accelerate accountability improvements; (6) engagement and transparency with patients, families, and communities on an accountability measurement framework and system performance; and (7) a national data dashboard for tracking progress on goals and recommendations for a transformed child health care system that prioritizes improving child and youth health and wellbeing.

Ongoing innovations in measurement, payment, and cross-sector services integration suggest that a child health care system that is accountable for improved child wellbeing outcomes is possible. Prior National Academies reports and other publications clearly outline the importance

of community and cross-sector accountability, focused on a small set of outcome measures that are meaningful to families and communities, such as rates of infant mortality, school readiness, positive mental health, and high school graduation. Some state Medicaid programs are introducing financial incentives to managed care organizations and their provider partners to improve long-term child health. These incentives use outcome measures that capture information on not just the immediate patients of a health care system but also all children in a geographic area. Related advances include proposals for building equity into accountability metrics and forming federal agency collaborations to address federal barriers to shared accountability measures across health care, public health, and social services systems. The committee’s recommendations build on this renewed commitment to greater accountability for child and adolescent health.

Recommendation 5-1: The Centers for Medicare & Medicaid Services, in collaboration with other federal agencies, should support health care systems’ implementation of new and evolved accountability measurement systems that minimize overall measurement burden, have meaning for families and communities, and highlight equity. Measures should address population health, disparities, and the functioning of children, and they should promote integrated, cross-sector child health care systems of care. Key efforts include

• Providing technical support for state demonstrations on the application of an outcome-based, shared, cross-system measurement and accountability framework focused on a narrowed and integrated set of measures aimed at population health and equity using a whole child and family health approach. Such support could be coordinated with the Administration for Children and Families, the Health Resources and Services Administration, and the U.S. Department of Education.
• Partnering with other federal agencies to support state and local child health accountability-related programs, and working with the Interagency Working Group on Youth Programs and private-sector partners and experts, to develop a toolkit for best practices in engaging families, youth, and communities in the co-design and effective use of accountability measurement systems.

Recommendation 5-2: Federal research agencies tasked with improving the health and wellbeing of children and youth should continue to advance the data resources and research necessary to evolve accountability measurement systems in ways that produce robust state and local area estimates from national surveys and existing federal data

systems, support digital tools for local data collection and reporting to allow for comparable health care, public health, and policy studies, and fill key knowledge gaps in the practice of designing and using population health measures aligned with communities’ needs for better health outcomes for children.

Recommendation 5-3: Federal and state governments should coordinate cross-agency efforts to monitor system performance and eliminate barriers to shared accountability across child health programs, in areas such as health care, education, child welfare, home- and community-based services, and juvenile justice. These efforts should support the development of interoperable cross-sector portals, including patient- and family-facing portals.

Recommendation 5-4: The Office of the National Coordinator for Health Information Technology should partner with the Centers for Medicare & Medicaid Services and a national committee comprising both public- and private-sector members, in order to develop a transparent reporting protocol for data submission that all payers and child-serving health care systems can use to monitor a small set of agreed-upon measures amenable to real-time (daily, weekly, monthly) electronic record submissions that include family- or patient-reported outcomes data.

CONCLUSION

This report comes at a point of national crisis in the health and wellbeing of U.S. children and youth—with graphic evidence of the effects of this crisis on the U.S. workforce, military preparedness, and burgeoning costs of adult ill health. The committee and its report take a broad view of the health care system, while recognizing the many other influences, outside of health care, that heavily affect both children and youth today and, notably, their prospects for the next decade. If child health is not elevated and efforts to improve the child health care system are not expanded, current trends point to a worsening state of health for the nation and deficits in the capacity of working-age adults.

Transforming child and adolescent health care requires an ambitious agenda. This report provides the guide and framework for that transformation. It acknowledges the national imperative for change, if the nation hopes to reverse troubling trends in the health of America’s children, in racial and geographic health inequities experienced by communities, and in the current and future workforce—where rates of mortality and disability are rising, along with a growing population of older adults who will need increased support.

The nation has seen many advancements in new models of care, growing science of early childhood, new research into early identification and prevention of disease, and institutions able to support the care and system needed. The report emphasizes the strong evidence that arises from this research and how to implement needed change. Previous studies have highlighted many of these advances and opportunities, yet their implementation shows the limits of short-term changes and improvements. Few have had lasting impact, in part because of the lack of an ongoing focus on children and youth.

This report calls a national convening to consider the evidence provided and implement the blueprint the recommendations provide. This convening could help form an ongoing framework and structure for maintaining focus and progress. The report recommendations include strategies for maintaining focus on children and youth and their health care, including better assessment of the child health impact of public policies, ways to reform health care financing for children, strategies to improve public health and school health, methods of including children and families and historically marginalized communities in all aspects of program and policy, and ways to measure and ensure accountability and equity for change and outcomes. Such changes will require strong leadership and incentives at the federal and state levels.