Summary

Ensuring that every child is on an optimal trajectory to a healthy and productive adulthood is imperative for the nation’s future. Investment in children and families improves not only child health but also population health, health equity, education outcomes, workforce productivity, and cost-effectiveness in public spending. The foundations of lifelong health are established early in the life course. Longitudinal studies show clearly that major causes of adult morbidity and mortality and aging have their roots in childhood. Emerging scientific and technological advances in genomics, artificial intelligence, relational health, and social determinants highlight the promise of early identification, health promotion, and prevention to optimize the health of children, adults, and society.

Innovations in health care delivery have been implemented over the past few decades in various locations to expand the reach of pediatric primary care and enhance disease prevention and health promotion through strengthened connections with other community resources. In addition, scientific advancements and quality improvement approaches have increased life expectancy for children and youth with special health care needs. The health care system is positioned to play a fundamental role in advancing these innovations and promoting the early and lifelong wellbeing of children and youth. Yet, the main sources of financing for health care have not transformed to support broad implementation of key innovations.

Meanwhile, in the context of this tremendous advancement and opportunity, the birth rate is declining and children’s health, wellbeing, and survival rates have all worsened. The nation faces the consequences of this poor state of health in rising mortality, chronic disease, and mental

health problems among working-age adults, a less capable workforce, and too few healthy young people to ensure military preparedness and economic stability.

Despite calls to improve the child and adolescent health care system that have been made for more than 20 years, the nation today faces a crisis with serious consequences for the coming decade. Without change, the next 10 years will see larger numbers of young people enter adulthood with chronic illness and disability and worse mental health, leaving fewer adults capable of productive work. This report underscores earlier calls to action on the need to advance health equity, strengthen accountability, promote cost-effectiveness, ensure quality, and engage patients and families through health care transformation. National progress on improving long-term outcomes for all Americans will come only from a dedicated and ongoing commitment to improving the wellbeing of children, youth, and families.

THE STUDY CONTEXT AND CHARGE

In response to rising concerns about the adequacy of pediatric health care to meet evolving challenges and societal needs, the National Academies of Sciences, Engineering, and Medicine (National Academies) assembled the Committee on Improving the Health and Wellbeing of Children and Youth through Health Care System Transformation to provide advice on key levers of change to facilitate health promotion, resilience, disease prevention, and equitable treatment. Committee members included physicians, nurses, hospital system leaders, Medicaid experts, youth and family advocates, community health center providers, economists and health care financing experts, and experts in mental health and school-based health care.

In its charge, the committee was tasked with addressing six questions. The first question asked the committee to identify key levers of change to guide innovation and transformation within the child and adolescent health care system. The second asked for promising policies and programs for achieving transformation. Other questions focused on systemic inequities and disparities, and the gaps and barriers in current payment models. The committee was also asked to examine ways to improve family engagement and community-centered care; team-based care; and integration of major programs serving children and adolescents.

The focus of this report is on the health care sector, defined broadly to include public health investments in child and family health and school-based efforts in health care. However, the committee recognizes the many other important policies and programs that influence child and family health, especially those around poverty and income support, housing, labor markets and employment, community wellbeing, family leave and child care support, juvenile justice, education, and financing of these.

“Child health,” as described in this report, includes preconception, maternal, prenatal, child, adolescent, family, and community health and wellbeing. Throughout the report, the committee takes a multigenerational and life course perspective because research has shown that all health and developmental stages are inextricably linked. To develop a plan to address its charge, the committee ascribed to a set of principles to guide its work and the development of program and policy recommendations: (1) employ a life course perspective; (2) partner with families and communities, which are central to child health and wellbeing; (3) prioritize and drive equitable outcomes through resources and accountability; and (4) make it sustainable over time. The committee views the present time as a clear opportunity for the nation to transform child and adolescent health care, making the United States a place for children to grow and thrive, and building a lasting, effective, diverse, and creative workforce.

OVERARCHING CONCLUSIONS

Based on the background and findings presented in the chapters of this report and in the extensive literature on the state of children’s health and health care delivery in the United States, the committee makes these overarching conclusions:

1. The United States faces a major crisis with the poor and worsening health and wellbeing of children and youth and the impact on the workforce of the future. Despite many advances, the United States currently ranks at the bottom among wealthy nations on the mental wellbeing, physical health, and academic and social skills of children. Children living in poverty, from historically marginalized groups, in foster care, or involved with the juvenile justice system all face poorer health and higher rates of mental health conditions. The incidence of several chronic diseases among children has increased over the past half century, along with growing concerns with children’s mental, emotional, and behavioral health. Many of these conditions are preventable or can be well managed with little disability. Further, working-age adults in the United States have experienced substantial increases in mortality and morbidity, with high rates of mental health conditions, obesity and associated cardiovascular and pulmonary disease, and substance use. These increases make the U.S. workforce less prepared for the needs of business and industry and diminish military preparedness. At a time when the U.S. birth rate has also decreased, increasing numbers of older people have rising support needs but fewer workers to assist.

2. The committee examined the evidence of what works to improve child health and health care and to advance health equity. Social and relational experiences and environments shape the health and wellbeing and development of children and youth in positive and negative ways. Major advances in early childhood science show that health early in the life course sets the foundation for health throughout childhood, adolescence, young adulthood, and beyond. Many adult chronic illnesses have early antecedents that are discernable in childhood. Scientific and technological advances in epigenetics, advanced treatments, and new prediction by artificial intelligence help identify conditions earlier and provide strategies for prevention and early treatment. Health care has seen growth in innovations applying this knowledge to clinical care, with positive outcomes in both primary and subspecialty care.
3. Previous efforts have led to real progress in some communities, but the lack of an ongoing focus on children, youth, and families has hampered continuing progress. Broader health care discussions and policy, program, and funding in the United States have paid limited attention to the health care delivery needs of children and youth. Most health care investment and reform have been directed toward the adult care delivery systems.
4. Families and communities are experts in their own health needs and have expressed desires to be informed and part of the process of improving health care. Their engagement in broad aspects of health care decisions has led to real changes in some communities and improvements in the organization and delivery of services and their impact on the populations engaged.
5. The current child health care system has made major gains in broadening primary care content and building teams in primary and subspecialty care, with many strong programs presenting clear evidence for their impact. Multidisciplinary teams often involve nurses, mental/behavioral health providers, community health workers, and others. Recent innovations include providing family supports and building capacity to address mental and behavioral health and school issues, as well as linking the health care team to other sectors and community services that support child and family wellbeing and development. Nonetheless, current health care financing arrangements have made it difficult to bring innovations to scale.
6. Community health centers have had leading roles in providing high-quality and comprehensive services to many low-income children. Hospital and subspecialty care have changed in recent years,

6. with fewer hospitalizations; more concentration in urban centers; and greater capacity in subspecialty care, coordinated with the primary care community. However, access to quality health care continues to be problematic for many individuals and communities, including those with certain health conditions (e.g., mental health conditions, where health care delivery and financing are often siloed), children with special health care needs, low-income and historically marginalized populations, and those in certain geographic areas.
7. Schools have been a central partner in child health through health education, socioemotional learning, nursing services, counseling, and the provision of nutritious meals and other wellbeing supports. They provide important services, and their growth offers opportunities to strengthen the health of young people. In many communities, school-based health clinics have increased access to clinical care and improved outcomes for children.
8. Children benefit from many public health activities, including those to improve the health of communities as well as many programs directed to maternal and child health, including vaccine programs, various preventive efforts (e.g., car seats, toxin exposures, climate preparedness), and efforts to support families during early childhood (e.g., Head Start, several nutrition programs), among many others. Key federal agencies engaged in public health efforts include the Health Resources and Services Administration (and its bureaus of Primary Care and Maternal and Child Health), Centers for Disease Control and Prevention, Indian Health Services, and U.S. Department of Agriculture.
9. The current health care financing for children and youth has major strengths but also numerous weaknesses that need correction. Current health insurance coverage for children is high—around 95% have some insurance. About half of U.S. children and youth depend on public health insurance through Medicaid and the Children’s Health Insurance Program (CHIP), two critical programs that provide a major safety net for large numbers of children who would otherwise lack any health insurance. However, major fluctuations in Medicaid and CHIP administration can change coverage levels significantly and contribute to racial and geographic inequities. Current payment mechanisms, funding, and financial incentives within both public and commercial insurance programs tend to emphasize diagnosis and treatments rather than prevention and health promotion—and limit opportunities to implement health care innovations widely.

10. Medicaid and CHIP have characteristics that make them strong supports for children, including the requirement that states enroll all eligible children who apply and the major Early and Periodic Screening, Diagnosis, and Treatment statute that requires states to provide a wide range of health care services to younger populations. Major state variations, while allowing states to experiment with services and payment strategies focused on their own population needs, have also meant that children have access to very different services and providers in different states, even to the degree that a child would be eligible for Medicaid in one state but not in a neighboring one. Opportunities exist to standardize key characteristics of public insurance across states, including eligibility, enrollment, scope of services, payment, and quality, and to make payment levels high enough to assure equal access to needed services.
11. Most efforts at payment reform have focused on older populations. Although many of these advances could have value for child health as well, payment reform for children must recognize the limited short-term financial return on investment and the need to value longer-term outcomes, often in sectors other than health care. Managed care organizations currently cover the large majority of children in Medicaid and CHIP, and most still pay providers using some form of fee for service. Experimentation and improvement in payment through managed care could enhance progress in health care transformation.
12. The committee found good evidence that transformation of health care for children can take place. The growth in innovations, new science, evidence from family engagement, recognition of how to center health, and opportunities for reformed financing provide the basis for transformation.

THE VISION FOR IMPROVED HEALTH CARE

Prevention has been a cornerstone of child and adolescent health care, and the current state of child health calls for even greater investment in prevention, given the strong evidence of major poor health outcomes downstream. Critically, preventive gains cannot be achieved without greater equity in access and receipt of quality care. Sustained progress in transforming child and adolescent health care requires a coordinated and ongoing focus from federal, state, and local governments on children, youth, and families in all relevant programs and policies, and it requires strong and predictable financing. Moving toward health equity requires an intentional focus on communities that have long endured underinvestment and structural

disadvantage. With these aims, the committee identified five implementation goals:

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 following sections articulate the importance of each goal and how it relates to the issues in the committee’s charge, along with key recommendations. Further details on the implementation goals and recommendations can be found in Chapter 10.

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

Without dedicated and sustained policy and funding prioritization of children at federal, state, and local levels, the nation will continue to lag behind other industrialized countries in most indicators of child, adolescent, and adult health and wellbeing. Limited and late concern for children during the COVID-19 pandemic and other social crises exemplifies the major lapses that occur without sustained federal leadership around the central needs of children. Coordination and communication among agencies serving children and a child-health-in-all-policies lens will be important and will necessitate aligning strategies and funding plans and maintaining a robust process for collecting and disseminating actionable data on the health and wellbeing of all children across federal agencies. The locus of leadership and coordination will need to be at the highest levels of the federal government, but clear participation and shared accountability across key government agencies, states, and the private sector will also be needed. Additionally, similar structures will be needed at the state level.

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.

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.

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.

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 Prevention and Health Promotion

The committee was tasked with considering the gaps and barriers in current payment models for both public and commercial insurance, and with suggesting potential solutions for addressing them. Goal 2 and its recommendations focus on reform of Medicaid and the CHIP and on changing payment incentives to transform the pediatric health care system so that it provides more prevention and health promotion services. Although the current child health care system promotes wellbeing and prevention, it is hampered by being modeled after an adult system focused on disease identification and treatment and reinforced by fee-for-service payment models. These models do not allow clinicians the flexibility to work with families and communities to address health and developmental goals for children. Instead, payment models are needed that can support team and cross-sector care, including mental and behavioral health integration and other innovations that support the development of safe, stable, and nurturing relationships between caregivers and children; improve health equity; and build community health.

Medicaid and CHIP, the payers for health care for about half of children and youth, ensure a major safety net for large numbers of American children who would otherwise have no insurance. Yet, state variation in implementation of federal Medicaid law creates barriers to enrollment and differences in program eligibility and accessibility that have widened gaps between groups in insurance coverage and access to care. On the other hand, state variation can have positive impacts, especially in allowing innovations and rewarding improvements in accessibility, quality, and costs. Barriers to care affect historically marginalized populations disproportionately, contributing to place-based racial and ethnic health inequities.

Because of their prominence in the lives of most children and families, schools offer unique opportunities to advance child health. The number of school-based health centers that provide primary and preventive medical care to children is growing, serving more than 6 million children in

communities that face barriers to health care access. Expansion of school-based health centers is a promising strategy for improving equitable access to high-quality care for children; however, state variation on Medicaid payments currently makes broad expansion challenging.

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.

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 assure 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.

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

The committee was tasked with examining the interaction and integration of the child and adolescent health care system with key services that heavily influence the health and wellbeing of children and adolescents and with identifying ways to strengthen those connections. In the United States, far more of the investment in health flows through the health care system for medical care rather than to public health services for primary prevention. Given that a defining feature of public health is its focus on community-level actions to promote health and prevent disease, and given that children have the most to gain from a focus on primary prevention, the nation’s underinvestment in public health represents a missed opportunity to benefit child health and protect the nation from future high costs of health care and other services attributable to preventable poor health conditions. The committee views the 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. Child- and family-focused programs with proven benefits merit substantial new investments. Moreover, because public health spending is highly uneven across communities, the committee calls for assessing and strengthening local health departments to ensure that each has a minimum standard of core, foundational capabilities.

Schools provide a central focus and experience for children and youth—unlike any similar set of institutions for older populations. Schools already provide substantial amounts of preventive health and treatment services,

and their health care role should be continued and expanded to reach more children and families that need assistance, including early care and health education programs.

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.

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.

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.

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 committee was tasked with considering promising policies and practices that incorporate the lived experiences of underserved children, adolescents, parents, and caregivers and build needed trust, partnerships, and long-term relationships with health care systems. It was also tasked with looking at workforce development in regard to team-based care and more community-based, culturally and linguistically competent workers. The impact of family and community voices on system change has not yet been fully realized. Health disparities and structural racism remain and are prominent concerns, and for many families and communities in the United States, the health care system is still untrustworthy. Engaging youth, families, and community members in the design of health care systems provides an opportunity to improve trust and the delivery of care.

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

The committee was tasked with considering levers for establishing integration within health care and with other systems and with identifying promising mechanisms and policies for enhancing collaboration among and integration of data systems for health care, mental health, public health,

welfare, education, and other agencies. The committee concluded that a transformed health care system will emphasize accountability for equitable, whole child, family, and community population health outcomes among the health care system and public–private partners. Ongoing innovations in measurement, payment, and cross-sector service integration suggest that a child health care system that is accountable for improved child wellbeing outcomes is possible. These recommendations build on a renewed commitment to greater accountability for child and adolescent health and call on federal agencies to support expansion of evolved accountability systems to all communities and health care systems.

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.

CONCLUDING REMARKS

This report comes at a point of national crisis in the health and wellbeing of U.S. children and youth—and the graphic evidence of the effects of this crisis on the U.S. workforce, military preparedness, and burgeoning costs of adult ill health. Transforming child and adolescent health care requires an ambitious agenda. This report reviews the opportunities and challenges in several areas, including the science of early childhood, innovations in health care delivery, scientific advances and developing technology (e.g., epigenetics, predictive technologies, telehealth and other communication methods, new treatments), health care financing, advancement of health equity, public health, engagement of families and youth in their health care programs, and measurement of health outcomes. This work provides a guide and framework for needed transformation and seeks to establish the national imperative for change, to reverse troubling trends in the health of America’s children and in the current and future workforce and to promote wellbeing proactively.

Previous studies from the National Academies and elsewhere have highlighted many of the advances and opportunities documented in this report. Few have had broad impact, in part because of the lack of a coordinated, sustained focus on improving the health of all children, youth, families, and communities.

The report recommendations include strategies for strengthening the nation’s commitment and focus on children and youth and their health care, including better assessment of the child health and health equity impact of public policies, ways to reform health care financing for children, strategies for improving 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 for change and outcomes.

Such changes will require strong leadership and incentives at the federal and state levels. The need for sustained and focused attention on children, youth, and families is painfully clear, and lack of this effort will burden U.S. society with tremendous costs in the near future and for generations to come.