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INTRODUCTION

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In order to provide high-quality care to children in an evolving healthcare landscape, it is becoming increasingly imperative that pediatricians become familiar with the fundamental components of the US healthcare system. Over the past decade, healthcare providers have experienced reforms across a diverse set of areas—frameworks of health and health care, reimbursement, performance measurement and performance-based incentives, healthcare coverage, quality improvement, and information technology. All of these reforms critically impact the environment in which pediatricians practice, the types of functions to which they are accountable, and how they can best advocate for the needs of children. As pediatricians attempt to adapt and thrive in the new environment of health care, they do so with the understanding that many reforms are based on adult models of care that do not reflect the unique characteristics and experiences of children within the healthcare system. According to a model first conceptualized by Forrest et al in 1997, and later modified by Stille et al in 2010, children differ from adults in the 5 Ds:

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  • Demographics

  • Differential epidemiology

  • Development over time

  • Dependency on adults

  • Dollars

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Understanding the changing demographics of US children is critical to informing both health and healthcare policy. The number of children and how they use health care influence the demands for access to care, insurance provision, and models of care. Children currently make up approximately 23% of the US population with increasing racial/ethnic diversity. Racial/ethnic minority children account for over half of US children. The population of the US is projected to grow even more diverse in the coming decade. In terms of epidemiology, an increasing percentage of children experience chronic conditions or medical complexity. This may impact the composition of practices and how pediatricians allocate resources and time. The prevalence of chronic conditions among the pediatric population is estimated to be 15% to 20%. Also important to the health care of children is that their needs and engagement in health care evolve over time as they progress through the stages of infancy, early childhood, school age, adolescence, and adulthood. Therefore, children’s engagement in their health care will change over time. Children rely heavily on adults for their health care. Consequently, the health of the entire family is an important consideration in care. Lastly, children have greater reliance on public insurance relative to adults. Roughly 40% of US children are publicly insured through Medicaid or the Children’s Health Insurance Program (CHIP). Despite the importance of the unique attributes of children, these factors are not routinely incorporated into current reforms. Therefore, knowledge of the US healthcare system is paramount for both aspiring pediatricians and those well established in their practices as a first step in understanding their practice environment and ensuring that children receive the best health care possible according to their unique needs.

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INSURANCE COVERAGE FOR CHILDREN

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While many children receive health insurance coverage through private insurance, a significant proportion ...

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