PERSPECTIVES Children and the Patient Protection and Affordable Care Act: Opportunities and Challenges in an Evolving System David Keller, MD; Lisa J. Chamberlain, MD, MPH From the Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo (Dr Keller); and Department of Pediatrics, Lucile Packard Children’s Hospital at Stanford, Stanford University School of Medicine, Palo Alto, Calif (Dr Chamberlain) The authors declare that they have no conflict of interest. Address correspondence to David Keller, MD, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 E 16th Ave, B065, Aurora, CO 80045 (e-mail: david.keller@childrenscolorado.org). Received for publication October 14, 2013; accepted February 14, 2014. ABSTRACT The Patient Protection and Affordable Care Act (ACA), passed in 2010, focused primarily on the problems of adults, but the changes in payment for and delivery of care it fosters will likely impact the health care of children. The evolving epidemiology of pediatric illness in the United States has resulted in a rela- tively small population of medically fragile children dispersed through the country and a large population of children with developmental and behavioral health issues who experience wide degrees of health disparities. Review of previous efforts to change the health care system reveals specific innovations in child health delivery that have been designed to address is- sues of child health. The ACA is complex and contains some language that improves access to care, quality of care, and the particular needs of the pediatric workforce. Most of the payment models and delivery systems proposed in the ACA, however, were not designed with the needs of children in mind and will need to be adapted to address their needs. To assure that the needs of children are met as systems evolve, child health profes- sionals within and outside academe will need to focus their ef- forts in clinical care, research, education, and advocacy to incorporate child health programs into changing systems and to prevent unintended harm to systems designed to care for children. KEYWORDS: child health; health reform; health care systems; pediatrics ACADEMIC PEDIATRICS 2014;14:225–233 WHAT’S NEW The Patient Protection and Affordable Care Act (ACA) is intended to expand insurance coverage, enhance the range of services covered, and change the payment and incentive structure of medical practice in the United States. The coming changes may have unintended con- sequences for children and for child health providers. Active engagement is required by the pediatric commu- nity to assure that children’s health is not adversely affected by implementation of the ACA. NO COUNTRY CAN be strong whose people are poor and sick. —President Theodore Roosevelt (1912) The explosion of knowledge in the life sciences over the last century has changed the morbidity, mortality, and life course of people in the developed world. As medicine improved the diagnosis and treatment of illness, health care delivery and payment systems evolved to support phy- sicians’ efforts. In 1929, as physicians and hospitals began incorporating science and technology into practice, the first Blue Cross health insurance plan began in Texas. 1 The concept quickly spread throughout the country, accelerated by tax incentives afforded companies that provided health insurance as an employee benefit during World War II. 2 Af- ter the war, the need for improved access to care for the newly insured led to passage of the Hill-Burton Act, fueling construction of thousands of hospitals across the country. 3 The new diagnostic and therapeutic modalities were expensive. To fill the gaps in care to the poor, disabled, and elderly, public insurance programs (Medi- care and Medicaid) were created in the 1960s, expanding insurance coverage to those outside the private health in- surance system. 4,5 In the 1970s, new delivery systems (community health centers and health maintenance organizations) were promoted, extending services to rural and urban underserved areas. 6,7 The United States has developed a wide variety of health care delivery systems that move medical science into med- ical practice. Each system is, in a sense, an answer to a larger societal question: “What level of access to care should we provide for patients, at what level of quality, and at what cost?” The multiplicity of responses to that question have re- sulted in a patchwork system, delivering excellent care locally to specific subpopulations within states or regions, ACADEMIC PEDIATRICS Volume 14, Number 3 Copyright ª 2014 by Academic Pediatric Association 225 May–June 2014