The most vital child health program is Medicaid.  The vast majority of at-risk children in America are eligible for Medicaid.  The federal government has decreed that these children shall receive comprehensive health services including the very impressive Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit package, but has given the responsibility for determining provider payment rates to the states, and further decreed that Medicaid payment rates shall never exceed those of Medicare.  The states, in their 40 years of Medicaid participation, have only rarely considered paying pediatricians on a par with the physicians who participate in Medicare. The national average for Medicaid fees is about 60% of the Medicare rate.  How will our at-risk children ever have access to comprehensive child health services in a medical home supervised by a qualified primary care physician if physicians cannot even recoup their overhead expenses when participating in Medicaid?  Pediatricians have resorted to bringing lawsuits against state governments for failing to meet the physician payment guidelines of the 1989 OBRA “equal access” clause of the federal Medicaid regulations.  This is a sad testimonial to a government program that was designed to be user friendly and economically feasible for children, families, and physicians.

The second most essential government-funded program for children is Vaccines for Children (VFC), established in 1994, to guarantee all indigent children access to protection from vaccine-preventable diseases according to the guidelines of the Centers for Disease Control (CDC).  The CDC has developed a habit of approving a new vaccine, recommending that all children receive that vaccine, while failing to assure that private industry is prepared to make enough of the vaccine for all eligible children, that state government administrators can afford to guarantee administration of the new vaccine to all VFC-eligible children, and that private insurers have agreed to reimburse pediatricians  fairly when pediatricians purchase the vaccine and give it to non-VFC-eligible children.  This really puts pediatricians in a bind, since they are liable for failing to provide vaccines to their patients that are recommended by national authorities; that is, if a child in a pediatrician’s practice dies from a vaccine-preventable disease, and that pediatrician failed to immunize that child, even though the pediatrician did not really have access to the vaccine, that pediatrician will probably be sued for failing to do all in his/her power to immunize that child.    Why does the CDC have to recommend a new vaccine for children if the CDC has not made sure that supplies of the vaccine are adequate, and that states and private insurers have developed the necessary infrastructure to make sure that all children have access to the vaccine?  

I have spent my life in pediatrics since 1974, and I really believe that child health outcomes are at the mercy of government officials who administrate and fund vital programs for at-risk children.  Pediatricians are willing and able to work closely with government leaders at all levels to implement programs that have the potential to improve the outcomes of this generation of children.  However, pediatricians cannot be subjected to dire economic and legal hardship by government leaders who could, and should, place a higher value on children.   We must help these leaders understand that if they really value children, they must create and fund children’s programs that are user-friendly and legally safe for pediatricians, and that allow pediatricians to make a reasonable living in this complex economy.

As we share our frustrations with government programs, we must do whatever we can to influence the evolution of the system.  By logging onto the Members Only Channel of the AAP’s website and going to Federal Affairs and joining the Federal Advocacy Action Network (FAAN), we can communicate regularly with our Senators and Representatives in Congress.  By becoming active players in the state government affairs programs of our Chapters, we can let our concerned voices be heard by state leaders.  I think we all went into medicine and pediatrics to serve at-risk indigent citizens, but we really cannot do that unless we have a government-administered/funded system of health care that allows us to offer our time and talents to the citizens who need us the most.   And only WE really understand that system and know how it should be organized.  Thanks for becoming involved in this extremely noble, but painfully incremental process.  I welcome your input as the AAP continues to move its child health agenda forward. 

July 23, 2005

home > PEDIATRICIAN newsletter