For an effective overhaul of US health, prioritize the youngest and most vulnerable

The Biden administration has vowed to “Build Back Better” from COVID-19, particularly in producing more robust health systems that rectify health inequities.

If health systems are to be part of the solution to ensuring health equity, one thing is clear: Child health must be at the forefront. 

This is not only because half of all U.S. children today are people of color, which are disproportionately impacted by health disparities, while less than one in four seniors are. This is not only because the human and economic benefits of improving health at the beginning of life are much greater than trying to repair health later. These alone would be sufficient to focus our attention on children. But there is more.

Childhood is the time when actions to promote health have the most pronounced impact upon lifelong health. Childhood is the time when society has a particular responsibility to ensure equitable access to critical supports, buffers and equal opportunities for success — and the time when the nation is most at risk if that responsibility is not met.

We depend upon a healthy and well-educated next generation to be prosperous. We cannot achieve this without dramatically reducing health disparities by race and socioeconomic status as the next generation grows into adulthood. Reducing health disparities is not merely treating disease but, more importantly, is about ensuring access to health and behavioral care for children to ensure optimal development. Providing equal opportunity for success for all children is a core American value across the political spectrum.

The Affordable Care Act concentrated its attention on expanding health care coverage, while also seeking to contain health care expenditures through payment reforms. Focused on seeking alternatives to high-cost management and treatment of illnesses and morbidities, the ACA’s efforts to improve health while containing costs overwhelmingly focused on older adults. The act was important in extending broader coverage to all Americans. Yet the ACA and its emphasis upon cost containment must not become the model for advancing child health or health equity. A model for child health equity must invest in prevention and healthy development with a long-term and multi-sector view of its value and benefits.

Now is the time to focus upon investing in primary, preventive and developmental child health care. This requires starting early, including ensuring the well-being of pregnant mothers and focusing on supportive communities.

The health care field has recognized the need to move from “sick care” to a “health and well-being care” system, one that responds to social determinants of health as well as biomedical ones. This movement has its greatest potential through investing in child and family health.  

Recognized, research-based programs and practices in child health care need to be scaled. The challenge is adequately financing those programs, particularly through Medicaid and CHIP, which covers four out of every 10 of the nation’s children and more than half of Black, Hispanic and Indigenous children. This is part of the health care infrastructure that we must “Build Back Better” — it deserves primary focus and investment by Congress and the president.

Now also is the time to rebuild a public and community health system that improves health environments and the ability to respond to future pandemics at the community level, specifically in medically underserved and low-income communities. This, too, requires a prioritized focus upon children and the families and communities that support them.

The Centers for Disease Control and Prevention constructed a Social Vulnerability Index (SVI) to identify by census tract the neighborhoods and communities most vulnerable to health crises and compromised health. The index shows the most socially vulnerable neighborhoods have high concentrations of Black, Indigenous and other people of color (BIPOC) and a very high proportion of children (and a very low proportion of seniors) compared with the nation as a whole.

While the highest SVI neighborhoods include 10 percent of the nation’s overall population, they are home to nearly 40 percent of all BIPOC children. A major focus of improving public and community-based health workforces must be in these neighborhoods and with these children and families in mind.

If we are to truly address health inequities, we simply cannot look for the solutions under the adult health care lamppost, with its high costs and intensive medical interventions. We must go into areas now in the policy shadows, where we find the children’s health system and the community-based public and preventive health system. 

To do otherwise would squander the opportunity to truly “Build Back Better” a health system that improves overall health and ensures health equity.

Charles Bruner, Ph.D., is director, The Integrated Care for Kids (InCK Marks) Initiative, a child care advocacy nonprofit funded by the Robert Wood Johnson Foundation. Twitter: @CharlesHBruner

Maxine Hayes, M.D., is chair of InCK Marks’ national advisory team and a former state health officer in Washington state.