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Pediatricians have an important role to play in the advancement of child health research and should be encouraged and supported to pursue research activities. Education and training in child health research should be part of every level of pediatric training. Continuing education and access to research advisors should be available to practitioners and academic faculty. Recommendations to promote additional research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as suggestions for means to increase support and mentorship for research activities, are outlined in this statement.

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OBJECTIVE: To inform policymakers and child health advocates about children's health insurance coverage in each state as Congress debates proposals to restructure the Medicaid program amidst declining employer-based dependent health insurance coverage. METHODS: Multiple years of data from the March supplement of the Current Population Surveys were pooled to yield more reliable estimates of changes in children's health insurance coverage in each state from 1987 to 1993. RESULTS: Overall, the number of uninsured children grew by nearly 1 million between 1987 and 1993. The proportion of infants and children <7 years old without health insurance declined; the proportion of uninsured children between the ages of 7 and 22 increased. Between 1987-1990 and 1991-1993, six states experienced a significant increase in the number of uninsured children, only two states experienced a significant decrease in the number of uninsured children, although no progress was found in reducing the number of uninsured children in 43 states. Between 1987-1990 and 1991-1993, the proportion of children covered by employer-based private insurance decreased significantly in three-fourths of the states and the proportion of children with Medicaid coverage increased significantly in four-fifths of the states. CONCLUSIONS: In a period of fast-declining employer-based health insurance coverage for dependents, Medicaid expansions have worked to moderate the surge in the number of children without health insurance. Of the 30 million children without private health insurance in 1993, nearly 18 million were insured by Medicaid. As policymakers debate the future of the Medicaid program, they must consider seriously its role as the country's largest insurer of children's health and its efficacy as a vital safety net for the nation's children.

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About twelve million American children lack health insurance. Attempts to assess the effectiveness of Medicaid expansions and other reforms are hampered by the lack of reliable state-level data on this population. This DataWatch presents baseline statistics on the insurance status of children, based on the Current Population Surveys from 1988, 1989, and 1990. The study finds the sharpest increase in uninsured rates from 1987 to 1989 among middle-class children and among children ages seven to twenty-one, suggesting that expanding Medicaid will fail to reach a large portion of the population at greatest risk.

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This paper is a report of the results of a demonstration designed to provide empirical evidence regarding the effects of alternative approaches to paying physicians for serving children in the Medicaid program: (1) visit fees set at twice regular Medicaid fees in return for physician agreement to manage utilization and (2) capitation and financial risk-sharing along with the same physician agreement to manage utilization. Participating physicians were assigned randomly to either of the two payment groups. Comparisons of utilization and expenditures were made between these two plans and the regular Medicaid program (fee-for-service, low fees). Results showed no adverse effect of capitation payments on primary care visits to office-based physicians. Capitation physician referrals to specialists decreased relative to all other groups studied, consistent with the theory that the financial incentives in capitation will lead primary care physicians to reduce referrals to specialists.

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Anecdotal evidence suggests that children's access to pediatric subspecialty and inpatient care is hampered by referral barriers imposed by managed care systems. To identify such barriers and determine how they affect the referral process, a sample of American Academy of Pediatrics Fellows (n = 1598) was surveyed. The response rate was 79.1% (n = 1264). Of those pediatricians in direct patient care (n = 956), 71.4% participated in a managed care plan. Pediatricians referred patients in managed care systems somewhat less frequently than in traditional pay systems: 8.7% and 6.9% referred managed care patients to subspecialists and inpatient care, respectively, less often. More than 20% and 10% of pediatricians with patients in managed care systems had at least one referral to subspecialist care and inpatient care, respectively, denied in the previous year. Pediatricians experienced more barriers in preferred provider organizations than in health maintenance organizations. These data suggest that utilization management programs, such as those used in managed care systems, may limit necessary access to pediatric subspecialty and inpatient care.

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In this article, we measure the extent to which California Medicaid children in 1981 received preventive care services through either the regular or the Early and Periodic Screening, Diagnosis, and Treatment component of Medicaid. On average, 62 percent of children up to 15 years of age who were continuously enrolled for that year had no preventive care visits, with the percentage increasing with age. Forty-five percent of children under 5 had no preventive visits paid by Medicaid. Children outside of urban areas received fewer preventive care visits than did urban children.

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Optimal pediatrician participation in the Medicaid program is essential if the full benefits of recent eligibility expansions are to be realized. A 1989 national survey of the members of the American Academy of Pediatrics (n = 940), designed as a follow-up to similar studies conducted in 1978 and 1983, was an examination of the factors that influence pediatrician participation. Between 1978 and 1989: (1) basic participation (treating any Medicaid beneficiaries) declined to 77% from 85%; (2) limited participation (seeing only some Medicaid beneficiaries who request care) increased from 26% to 39.4%; and (3) extent of participation (the percentage of a pediatrician's patients who are Medicaid beneficiaries) increased from 15.7% to 19.4%. A dichotomous conceptualization of participation (restricted or unrestricted) was developed. By this definition, only 56% of pediatricians allowed comparable access to their practices for both Medicaid and private patients. Low reimbursement and slow payments discouraged participation. Medicaid reimbursement to pediatricians was approximately equal to their overhead costs. However, a high degree of willingness to care for Medicaid children remains if fees are increased to within 11% to 16% of the private market level. Policy options to enhance participation are discussed.

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This study reports the effects of a voluntary Medicaid case-management demonstration on the primary care provided to young children by office-based physicians. The MDs who participated were reimbursed at rates higher than the regular Medicaid fee schedule, either through augmented fees for specific services or through monthly capitation payments. Using the Medicaid Management Information System (MMIS) claims data, we compared the rates at which children in the experimental program and children in the regular Medicaid program were seen by a physician during a one-year period. The majority of experimental children received regular and frequent care from primary care physicians during the demonstration. After controlling for race and prior utilization differences, we found that augmented fee-for-service children received more primary care from office-based physicians than children in the regular Medicaid program. Capitation children received at least the same amount of primary care as children in the regular Medicaid program. We interpret our data to mean that capitation payment, untied to the delivery of services, does not necessarily reduce access to primary care and that higher fees for physicians who treat children may, in fact, increase access.

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