Conclusions and Future Directions for Periodic Reporting on the Use of Selected Clinical Preventive Services to Improve the Health of Infants, Children, and Adolescents — United States

Lorraine F. Yeung, MD1

Ralph J. Coates, PhD2

Laura Seeff, MD3

Judith A. Monroe, MD4

Michael C. Lu, MD5

Coleen A. Boyle, PhD6

1Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, CDC

2Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology, and Laboratory Services, CDC

3Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, CDC

4Office of the Director, Office for State, Tribal, Local, and Territorial Support, CDC

5Maternal and Child Health Bureau, Health Resources and Services Administration

6Office of the Director, National Center on Birth Defects and Developmental Disabilities, CDC

Corresponding author: Lorraine F. Yeung, Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, CDC. Telephone: 404-498-3824; E-mail: lyeung@cdc.gov.

The findings described in this supplement can help improve collaboration among public health and other stakeholders who influence infant, child, and adolescent health (e.g., parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) to increase the use of selected clinical preventive services among U.S. infants, children, and adolescents. Increased use can substantially reduce illness and long-term disability and improve health and quality of life (1–21). This supplement underscores that the use of the clinical preventive services among U.S. infants, children, and adolescents is not optimal and is variable, ranging from <10% to approximately 85%, depending on the particular service (Table). Use was particularly low for developmental screening and receipt of dental preventive services in young children, and for human papillomavirus (HPV) vaccination and tobacco cessation assistance, including counseling, in adolescents; however, opportunities exist to improve use of all of these services (2–12). Children and adolescents with no insurance and those with no usual source of health care (if available for analysis) were the groups least likely to have used the services (2–12). Use among the uninsured ranged from 1–39 percentage points below the general population averages, suggesting that improvements in insurance coverage that will result from the implementation of health-care reform are likely to increase use of these clinical preventive services. In 2012, a total of 4.9 million children (6.6% of children) were uninsured at the time of interview (22), and approximately 15% of eligible children in the United States are not enrolled in Medicaid and Children's Health Insurance Program (CHIP) programs (23). In addition, although opportunities exist for greater insurance coverage and for use of recommended clinical preventive services under the Patient Protection and Affordable Care Act of 2010 (P.L. 111–148), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111–152, together referred to as the Affordable Care Act [ACA]) (13), a survey among the uninsured found a low level of awareness of the Health Insurance Marketplace (or Health Insurance Exchange) that can be used by families to acquire insurance or Medicaid coverage (24). The survey highlights the importance of focused efforts by governmental health agencies and other stakeholders to enroll uninsured children and adolescents in health plans. Also, although use of clinical preventive services in insured populations was greater than among the uninsured, use among the insured was generally <85%, and often much less (2–12). Therefore, having health insurance coverage alone might not be sufficient to optimize use of clinical preventive services, and additional measures to improve use probably will be necessary.

Key Findings and Opportunities

The findings in this supplement document suboptimal rates of use for many of the recommended clinical preventive services for infants, children, and adolescents which, if used at optimal rates, could make important and measureable contributions to reducing illness, long-term disability, and improvements in health and quality of life (1–21). In general, use of clinical preventive services was lower in infants, children, and adolescents without insurance coverage, with low family income, with low education level by head of household, without a usual source of medical care/medical home, or from minority racial/ethnic groups as compared to children with insurance, with higher income, with higher education level by head of household, with a medical home, or from majority racial/ethnic groups. Each of the 11 reports in this supplement identifies opportunities to leverage available public health and clinical strategies at the local and community, state, and/or federal levels to improve use of clinical preventive services for infants, children, and adolescents.

Despite the fact that 83% of women had received breastfeeding counseling during prenatal care visits in 2010, only approximately 50% of women breastfed their infant to any extent 6 months after birth. Expanding access to comprehensive support and counseling from trained providers during prenatal and postpartum period and infancy and breastfeeding supplies is vital to improve breastfeeding practice.

During infancy, early detection of conditions through hearing screening and continuous developmental screening mitigates long-term disability and helps ensure overall health and quality of life.

• During 2009–2010, approximately 50% of infants who failed their hearing screening were not documented to have received testing needed to diagnose hearing loss. Opportunities that will help improve follow-up services include:
  • Standardizing and adopting health information technologies to improve the exchange of clinical data between health-care providers and public health programs so providers can better coordinate and document the receipt of follow-up services.
  • Improving health insurance coverage for hearing diagnostic and follow-up services.
• During 2007, parents of approximately 80% of children aged 10–47 months were not asked by health-care providers to complete a formal screen for developmental delays during the preceding 12 months. Opportunities to improve developmental screening include:
  • Expanding health insurance coverage and the professional workforce for developmental assessment and behavioral services.
  • Broadening support for programs to increase use of developmental monitoring, screening, referral, follow-up, and support within early childhood service systems.
  • Integrating developmental monitoring, screening, referral, and follow-up as components in electronic health records.

During early and middle childhood, when major chronic disease/lifestyle risk factors begin to emerge, provision of lead screening, vision screening, blood pressure screening, and oral health services can prevent illness, long-term disability, and improve health and quality of life.

• During 2010, two thirds (67%) of children aged 1–2 years were not screened and reported to CDC for lead poisoning. Opportunities to increase lead screening include:
  • Developing state-specific screening plans targeting high-risk children.
  • Improving communication between state and local health departments and primary care providers on high-risk populations using geographic information system mapping.
• During 2009–2010, according to their parents, approximately one in five (22%) children aged 5 years never had their vision checked by a doctor or other health-care provider. Opportunities to increase vision screening include:
  • Establishing evidence based guidelines for vision screening and follow-up.
  • Improving delivery of vision screening within primary care settings.
  • Developing state-based data systems for monitoring and reporting vision screening, follow-up eye care, and vision outcomes.
• During 2009–2010, approximately one in four (24%) clinic visits for preventive care made by children and adolescents aged 3–17 years to office-based physicians and hospital outpatient departments had no documentation of blood pressure measurement. Opportunities to increase blood pressure screening include:
  • Encouraging health-care providers to perform blood pressure checks during well-child visits and physical examinations for sports participation.
  • Providing financial incentives to providers through Stages 1 and 2 of Meaningful Use* to record blood pressure in the electronic medical record in patients aged ≥3 years.
• During 2009, more than half (56%) of U.S. children and adolescents did not visit the dentist during the preceding year, and 86% of children and adolescents did not receive a dental sealant or a topical fluoride application during the preceding year. During 2005–2010, more than two thirds (69%) of persons aged 5–19 years did not have a dental sealant. Opportunities to increase use of dental care and dental preventive services include:
  • Increasing dental insurance coverage.
  • Increasing the supply of dental providers through incentives such as establishing a loan repayment program for dental faculty in institutions.
  • Increasing the number of school-based sealant programs serving high-risk schools.

During adolescence, vaccination against HPV infections, screening for risky behaviors (e.g., tobacco use) and potential untoward consequences of these behaviors (e.g., sexually transmitted infections, unintended pregnancy), provision of interventions to help mitigate consequences, and provision of clinical reproductive health services are essential.

• During 2011, nearly half (47%) of females aged 13–17 years had not received their recommended first HPV vaccine dose, and almost two-thirds (65%) had not received ≥3 doses required for series completion. Among males, approximately 90% had not yet received ≥1 dose of HPV vaccine. However, because most 2011 NIS–Teen data were collected before the Advisory Committee on Immunization Practices recommended routine male HPV4 vaccination in October 2011, these findings represent baseline data for monitoring implementation of the recommendations. Opportunities to improve HPV vaccination rates include:
  • Decreasing client out-of-pocket costs by providing insurance coverage, or by vaccination providers participating in the Vaccine for Children program.
  • Expanding access to primary care and vaccination services by providing increased funding to community health centers.
  • Establishing additional school-based health centers.
  • Implementing reminder/recall systems at health-care providers' offices and school-based health centers.
• During 2004–2010, approximately one in three (31%) outpatient visits made by persons aged 11–21 years to office-based physicians had no documentation of tobacco use status, and 80% of those who screened positive for tobacco use did not receive any cessation assistance including tobacco counseling and/or provision of cessation medication. Opportunities to increase tobacco use screening and brief cessation interventions include:
  • Expanding insurance coverage for screening of adolescents and ensuring comprehensive coverage of cessation treatments.
  • Implementing provider reminder systems in health-care settings.
  • Providing training to health-care providers of adolescents that includes effective intervention strategies and information on how to access referral and treatment resources.
• During 2006–2010, 60% of sexually active females aged 15–21 years did not receive chlamydia screening during the preceding 12 months. Opportunities to increase chlamydia screening include:
  • Expanding access to health care through improved health insurance coverage.
  • Using electronic health record prompts.
  • Ensuring that providers are aware that the chlamydia screening test can easily be performed without a pelvic exam.
  • Supporting social marketing campaigns for young females.
• During 2006–2010, approximately one fourth (24%) of sexually experienced females aged 15–19 years and more than one third (37.5%) of sexually experienced males aged 15–19 years did not receive a reproductive health service from a health-care provider during the preceding 12 months. Opportunities to improve use of reproductive health services include:
  • Increasing health-care access through expanded health insurance.
  • Establishing linkages between community-based organizations and health-care providers.
  • Adopting recommendations from the Community Guide for Preventive Services for adolescents.

Public health surveillance reports, such as this supplement, can play a key role in promoting commitment and accountability among stakeholders by reporting on successful implementation of strategies designed to improve use of clinical preventive services and monitoring improvements in service use.

Health System Reforms at Federal, State, and Local Levels

All 11 reports in this supplement identified aspects of recent health-care reform initiatives that should facilitate increased use of the clinical preventive services (2–12). ACA expands insurance coverage, consumer protections, and access to care and places a greater emphasis on prevention (13). Children with insurance are more likely to receive preventive services and to have access to health-care services and consistent medical care (25). ACA contains provisions that will likely increase health insurance coverage for most legal residents of the United States, including children (13). By 2019, ACA is projected to extend health insurance coverage to 89% of the nonelderly U.S. population (26). Implementation of the law is primarily the responsibility of states and communities, health insurers, and health-care providers. For example, one provision allows children aged 19–25 years to remain on their parent's health insurance plan. According to government estimates, an additional 3.1 million young adults had health insurance coverage in 2011 as a result of the law (27). Up to 24% of children have a pre-existing condition that has placed them at risk for being denied coverage in the past. Under ACA, insurers cannot deny coverage to children or adults because of a pre-existing condition (28). This provision of the law is particularly relevant to many children with chronic conditions identified through newborn and continuous developmental screening.

As of September 23, 2010, Section 1001 of ACA requires nongrandfathered private health plans to cover, with no cost-sharing, a collection of four types of clinical preventive services. Among them were 1) recommended services of the U.S. Preventive Services Task Force graded A (strongly recommended) or B (recommended) (29); 2) vaccinations recommended by the Advisory Committee on Immunization Practices (30); 3) services adopted for infants, children, and adolescents under the Bright Futures guidelines supported by the Health Resources and Services Administration (HRSA) and the American Academy of Pediatrics (31) and those developed by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (32); and 4) women's preventive services as provided in comprehensive guidelines supported by HRSA (33).

ACA provides strong incentives for all states to expand Medicaid eligibility to cover persons with incomes ≤138% of the federal poverty level starting in 2014. However, a Supreme Court ruling in June 2012 held that a state will not lose federal funding for its existing Medicaid program if it chooses not to participate in the Medicaid expansion (34). As of June 2014, a total of 27 states plus the District of Columbia had indicated that they would expand Medicaid (35). Starting in 2014, although many children are already covered for these services through traditional Medicaid's Early Periodic Screening, Diagnostic, and Treatment benefit and CHIP, under regulations adopted by the U.S. Department of Health and Human Services (HHS), coverage for the same set of preventive services as required by nongrandfathered private health plans must be covered with no cost-sharing by state alternative benefit plans for newly eligible beneficiaries of the Medicaid expansion.

ACA authorizes states and the federal government to create the Health Insurance Marketplace, to make private health insurance easier to purchase at affordable rates by small employers and individuals.† The Health Insurance Marketplace opened for enrollment on October 1, 2013 for coverage beginning January 1, 2014. Seventeen states and the District of Columbia intended to establish state-based marketplaces; however, only 15 states were able to do so in time for open enrollment (36). Seven states have chosen to operate state-federal partnership marketplaces, and 27 states defaulted to federal marketplaces (36). Within broad parameters, ACA provides considerable discretion in how states structure features of the available plans, which can affect the delivery of clinical preventive services (37). Each of these decisions can directly or indirectly affect use of clinical preventive services and receipt of needed treatment. HHS estimated that 76 million persons in the United States, including 18.6 million persons aged <18 years, are newly eligible for expanded preventive services coverage without cost-sharing as a result of ACA (38).

Opportunities for states and communities to increase the use of clinical preventive services also are provided by national laws supporting increased use of health information technology (HIT) and electronic health records (EHR) in hospitals and clinics (13,39). State and local governments can play important roles in the implementation of such systems by providing leadership and governance, participating in the exchange of health information, and monitoring and reporting on adoption of health information systems to the public (39).

Public Health and Clinical Care

The clinical preventive services for infants, children, and adolescents discussed in this supplement can have greater uptake and impact if they are supported and reinforced by community-based prevention, policies, and programs (40). Recognizing the importance of broad collaboration for prevention, the National Prevention Strategy was created by ACA in 2011 (40). Integration of clinical and community preventive services is recognized as one of the four core strategies in the first National Prevention Strategy (40). The National Prevention Strategy encourages partnerships among federal, state, tribal, local, and territorial governments; business, industry, and other private sector partners; philanthropic organizations; community and faith-based organizations; and individuals to improve health through prevention (40). It is a cross-sector, integrated national strategy that identifies priorities for improving the health of the U.S. population and includes a variety of recommendations that are applicable to children's preventive services.

Use payment and reimbursement mechanisms to encourage delivery of clinical preventive services. ACA expands health insurance coverage and reduces barriers to obtaining preventive services. But as the National Prevention Strategy points out, "[m]aking preventive services free at the point of care is critical to increasing their use, but it is not sufficient" (40). Delivery of clinical preventive services increases when billing systems are in place to facilitate reimbursement and when payment systems are designed to incentivize quality and value of care. Access to preventive services can be enhanced by workforce development and payment systems that support team-based care and the use of nonphysician clinicians (e.g., nurse practitioners, physician assistants, pharmacists, and community health workers), especially in under-resourced communities. The expansion of the National Health Service Corps is intended to result in more primary care physicians in shortage areas. Medicaid payment rates to primary care physicians will be increased to 100% of the Medicare rate and fully funded by the federal government for 2 years (2013 and 2014). Expansion of community health centers under ACA is expected to increase the capacity to care for approximately seven million additional children (13,41,42). Accountable care organizations (ACO) can encourage delivery of clinical preventive services by holding provider groups accountable for improving care, reducing costs, and promoting population health (43). Accountable care communities take the ACO model one step further by holding provider groups, health systems, and public health accountable for the health of an entire community, which would require better integration of clinical and community preventive services (44).

Expand use of interoperable health information technology. HIT can be used to improve the delivery of clinical and community preventive services for infants, children, and adolescents (45). Use of EHR systems in primary care is increasing (46). The capacity to capture and report quality-of-care measures, including use of preventive services, is being built into such systems in part because of incentives offered by Medicare (47–51). In addition to generating prompts and reminders to the providers and parents that the child is due for certain clinical preventive services (e.g., children who have not had vaccinations within the recommended interval), EHR also can provide decision support in the delivery of these services. If the child is receiving services in multiple settings, HIT can improve continuity of patient records, reduce errors, avoid omissions and duplications, and improve care coordination provided that data systems are interoperable and that safeguards are in place to protect patient confidentiality across multiple systems. At the community and public health levels, HIT can be used to increase consumer awareness (e.g., through the use of text messaging); to improve performance measurement (e.g., tracking the percentage of newborns who have been screened for hearing before hospital discharge); and to support collaborative quality improvement in the delivery of preventive services for infants, children, and adolescents. Increasing use of electronic health information systems and electronic data exchange systems offers the possibility of collecting and reporting on use of clinical preventive services at the national, state, and local levels (39,46–51).

Support implementation of community-based preventive services and enhance linkages with clinical care. Clinical and community preventive efforts should be mutually reinforcing (40). Persons should receive appropriate preventive care in clinical settings (e.g., a clinician providing breastfeeding counseling and support) and also be supported by community resources at home (e.g., lactation support by home visiting nurse or community health worker), in the workplace (e.g., availability of a lactation room), and in the community (e.g., lactation support group). For many school-aged children and adolescents, schools provide a convenient point-of-care for delivery of clinical preventive services.

Reduce barriers to accessing clinical and community preventive services, especially among populations at greatest risk. Many more infants, children, and adolescents will receive needed preventive services if logistical, financial, cultural, and health literacy barriers to care are removed (40). Community programs can play a role in addressing these barriers, including transportation, child care, and patient navigation issues.

Enhance coordination and integration of clinical, behavioral, and complementary health strategies. According to the National Prevention Strategy (40), integrated health care describes a coordinated system in which health-care professionals are educated about each other's work and collaborate with one another and with their patients to achieve optimal patient well-being. Integrated health care can be delivered through a variety of care coordination models, including medical homes, community health teams, and home visits. Authorized by ACA, the Maternal, Infant, and Early Childhood Home Visiting Program is designed to improve service coordination and outcomes for families residing in at-risk communities (52). Through the home visiting program, nurses, social workers, or other trained home visitors meet with at-risk families in their homes, evaluate their circumstances, and connect them to services such as health care, developmental services for children, early education, parenting skills, child abuse prevention, and nutrition education or assistance. The home visiting program offers another example of how community preventive services can reinforce clinical preventive services to improve outcomes for infants, children, and adolescents.

Improving Public Health Surveillance

Ideally, public health surveillance systems would have the capacity to track, in a timely, comprehensive, and accurate manner, the effects of numerous efforts that might influence use of clinical preventive services that can improve infant, child, and adolescent health. These efforts include implementation of ACA and electronic health information systems as well as actions by public health and other stakeholders. These systems would have the ability to characterize infants, children, and adolescents who are eligible for specific services and those who do or do not receive them, examine the effects of laws and other interventions, and assess resulting health outcomes at both the individual and population levels. The ability of current resources and public health surveillance systems to enable examination of such relationships is limited. However, surveillance reports such as those in this supplement can be helpful by highlighting underuse of the services in infants, children, and adolescents, identifying trends that might be due, in part, to various interventions currently underway, and illuminating disparities. The reports in this supplement also highlight several gaps in the types of health surveillance information needed to guide efforts to increase use of important clinical preventive services. For example, as noted in the Rationale for this supplement, several preventive services of interest in infants, children, and adolescents could not be addressed because of a lack of available information (1). Also, enhancement of survey tools (e.g., additional questions added to national and state-based surveys) as mentioned in several reports in this supplement would help determine the use of certain clinical preventive services (6,11). Although almost all of the reports in this supplement present national data, most of the surveys cannot provide data that are necessary to monitor progress at the state and local levels. State and local surveys, such as the Youth Risk Behavior Surveillance System, might be able to capture more of the kind of information included in this supplement. This supplement challenges health and public health professionals to identify resources that can be used to provide information at the state and local levels.

Initiatives are underway to improve the ability of health-care and public health agencies to share de-identified information from EHR systems to improve population health (39,47–50). Although challenges exist in the development of these electronic record and information sharing systems (47,51), these systems should contribute to monitoring and improving use of the preventive services noted in this report. De-identified information from Medicare and Medicaid databases also might provide new opportunities for this type of surveillance (53). Additional sources of information for surveillance and an increased ability to link information from various sources can help provide a more complete and integrated perspective on steps that stakeholders need to take to improve use of these services.

Future Reports on
Clinical Preventive Services

Reports updating the use of selected clinical preventive services to improve the health of U.S. infants, children, and adolescents might include additional indicators for clinical preventive services that are known to have important health benefits but were not included in this supplement for various reasons, primarily lack of adequate surveillance information (1). Such reports might include screening and counseling for obesity, alcohol consumption, and mental health, services that can benefit large segments of the child and adolescent population. As public health surveillance information becomes more available and as interventions to improve the use of clinical preventives services are implemented by public health and other stakeholders, future reports should be useful for monitoring and evaluating progress in achieving the goals of clinical preventive services.

References

1. Yeung LF, Shapira SK, Coates RJ, et al. Rationale for periodic reporting on the use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
2. Lind JN, Ahluwalia IB, Perrine CG, Li R, Harrison L, Grummer-Strawn LM. Prenatal breastfeeding counseling—Pregnancy Risk Assessment Monitoring System, United States, 2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
3. Gaffney M, Eichwald J, Gaffney C, Alam S. Early hearing detection and intervention among infants—Hearing Screening and Follow-up Survey, United States, 2005–2006 and 2009–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
4. Rice CE, Van Naarden Braun K, Kogan MD, et al. Screening for developmental delays among young children—National Survey of Children's Health, United States, 2007. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
5. Raymond J, Wheeler W, Brown MJ. Lead Screening and prevalence of blood lead levels in children aged 1–2 years— Child Blood Lead Surveillance System, United States, 2002–2010 and National Health and Nutrition Examination Survey, United States, 1999–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
6. Kemper AR, Crews JE, Strickland B, Saaddine JB. Vision screening among children aged <6 years —Medical Expenditure Panel Survey, United States, 2009–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
7. George MG, Tong X, Wigington C, Gillespie C, Hong Y. Hypertension screening in children and adolescents—National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and Medical Expenditure Panel Survey, United States, 2007–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
8. Griffin SO, Barker LK, Wei L, Li C, Albuquerque MS, Gooch BF. Use of dental care and effective preventive services in preventing tooth decay among U.S. children and adolescents—Medical Expenditure Panel Survey, United States, 2003–2009 and National Health and Nutrition Examination Survey, United States, 2005–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
9. Curtis CR, Dorell C, Yankey D, et al. National human papillomavirus vaccination coverage among adolescents aged 13–17 Years—National Immunization Survey – Teen, United States, 2011. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
10. Jamal A, Dube SR, Babb SD, Malarcher AM. Tobacco use screening and cessation assistance during physician office visits among persons aged 11–21 years—National Ambulatory Medical Care Survey, United States, 2004–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
11. Hoover KW, Leichliter JS, Torrone EA, Loosier PS, Gift TL, Tao G. Chlamydia screening among females aged 15–21 years—Multiple data sources, United States, 1999–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
12. Tyler CP, Warner L, Gavin L, Barfield W. Receipt of reproductive health services among sexually experienced persons aged 15–19 years—National Survey of Family Growth, United States, 2006–2010. In: Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999–2011. MMWR 2014;63(No. Suppl 2).
13. Patient Protection and Affordable Care Act of 2010. Pub. L. No. 114–148 (March 23, 2010), as amended through May 1, 2010. Available at http://www.healthcare.gov/law/full/index.html.
14. Institute of Medicine. The future of public health. Washington, DC: National Academies Press; 1988. Available at http://www.nap.edu/catalog.php?record_id=1091.
15. Institute of Medicine. The future of the public's health in the 21st century. Washington, DC: National Academies Press; 2003. Available at http://www.nap.edu/catalog.php?record_id=10548.
16. Institute of Medicine. Clinical practice guidelines we can trust. Washington, DC: National Academies Press; 2011. Available at http://www.nap.edu/catalog.php?record_id=13058.
17. Institute of Medicine. Finding what works in health care: standards for systematic reviews. Washington, DC: National Academies Press; 2011. Available at: http://www.nap.edu/catalog.php?record_id=13059.
18. Institute of Medicine. For the public's health: revitalizing law and policy to meet new challenges. Washington, DC: National Academies Press; 2011. Available at http://www.nap.edu/catalog.php?record_id=13093.
19. Institute of Medicine; Committee on Public Health Strategies to Improve Health. For the public's health: the role of measurement in action and accountability. Washington, DC: National Academies Press; 2011. Available at http://www.nap.edu/catalog.php?record_id=13005.
20. Fielding JE, Teutsch SM. Integrating clinical care and community health: delivering health. JAMA 2009;302:317–19.
21. CDC. The guide to community preventive services: what works to promote health? New York, NY: Oxford University Press; 2005. Available at http://www.thecommunityguide.org/index.html.
22. CDC. Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2012. Available at http://www.cdc.gov/nchs/data/nhis/earlyrelease/Insur201306.pdf.
23. Kenney GM, Lynch V, Huntress M, Haley J, Anderson N. Urban Institute. Medicaid/CHIP participation among children and parents. Timely analysis of immediate health policy issues. Available at http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf403218.
24. The Henry J. Kaiser Family Foundation. Kaiser health tracking poll— June 2013. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2013. Available at http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-june-2013.
25. Institute of Medicine. Health insurance is a family matter. Washington, DC: National Academies Press; 2002. Available at http://www.nap.edu/catalog.php?record_id=10503.
26. Congressional Budget Office. CBO's May 2013 Estimate of the effects of the Affordable Care Act on health insurance coverage. Available at http://www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2013-05-ACA.pdf.
27. US Department of Health and Human Services. State-level estimates of gains in insurance coverage among young adults. Available at http://www.hhs.gov/healthcare/facts/factsheets/2012/06/young-adults06192012a.html.
28. US Department of Health and Human Services. At risk: pre-existing conditions could affect 1 in 2 Americans: 129 million people could be denied affordable coverage without health reform. Washington, DC: US Department of Health and Human Services; 2011. Available at http://aspe.hhs.gov/health/reports/2012/pre-existing.
29. US Preventive Services Task Force. USPSTF A and B recommendations. Rockville, MD: Agency for Healthcare Research and Quality. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.
30. CDC. Advisory Committee on Immunization Practices Recommendations. Available at http://www.cdc.gov/vaccines/pubs/ACIP-list.htm.
31. Hagan JF, Shaw JS, Duncan PM, eds. Bright futures: guidelines for health supervision of infants, children, and adolescents. Third Edition. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
32. US Department of Health and Human Services. Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. About the Committee. Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration. Available at http://www.hrsa.gov/advisorycommittees/mchbadvisory/heritabledisorders/about/index.html.
33. Health Resources and Services Administration. Women's preventive services guidelines. Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration. Available at http://www.hrsa.gov/womensguidelines.
34. Supreme Court of the United States. National Federation of Independent Business et al. v. Sebelius, Secretary of Health and Human Services, et al. Available at http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf.
35. The Henry J. Kaiser Family Foundation. State health facts: status of state action on the Medicaid expansion decision, 2014. Menlo Park, CA: The Henry J. Kaiser Family Foundation. Available at http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-
    under-the-affordable-care-act.
36. The Henry J. Kaiser Family Foundation. State health facts. State decisions for creating health insurance marketplace, 2014. Available at http://kff.org/health-reform/state-indicator/health-insurance-exchanges.
37. Kingsdale J, Bertko J. Insurance exchanges under health reform: six design issues for the states. Health Aff 2010;29:1158–63.
38. US Department of Health and Human Services. ASPE issues brief. Increased coverage of preventive services with zero cost sharing under the Affordable Care Act. Washington, DC: Assistant Secretary for Planning and Evaluation; 2014. Available at http://aspe.hhs.gov/health/reports/2014/PreventiveServices/ib_PreventiveServices.pdf.
39. CDC. Electronic health records: what's in it for everyone? Atlanta, GA: CDC; 2011. Available at http://intranet.cdc.gov/connects/2011/07/19/
    16b-163a058c9b95/.
40. Office of the Surgeon General; National Prevention, Health Promotion, and Public Health Council. National prevention strategy: America's plan for better health and wellness. Rockville, MD: Office of the Surgeon General; 2011. Available at http://www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf.
41. US Department of Health and Human Services. Health care law increases payments to doctors for primary care, press release. Washington, DC: US Department of Health and Human Services. Available at http://www.hhs.gov/news/press/2012pres/05/20120509b.html.
42. Children's Health Fund. Children under siege: safeguarding provisions for children in the new health law, a children's health fund special report, March 2011. New York, New York: Children's Health Fund; 2011. Available at http://www.childrenshealthfund.org/sites/default/files/children-and-new-health-law-white-paper.pdf.
43. Berenson RA, Burton RA. Health Policy Brief: Next steps for ACOs. Princeton, NJ: Robert Wood Johnson Foundation; 2012. Available at http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=61.
44. Austen BioInnovation Institute. Healthier by design: creating accountable care communities. A framework for engagement and sustainability. Atkron, OH: Austen BioInnovation Institute. Available at http://www.faegrebdc.com/webfiles/accwhitepaper12012v5final.pdf.
45. Lu MC, Kotelchuck M, Hogan VK, Johnson K, Reyes C. Innovative strategies to reduce disparities in the quality of prenatal care in underresourced settings. Med Care Res Rev 2010;67:198S-230S.
46. Hsiao CJ, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2012. NCHS Data Brief, No. 11, CDC, Atlanta, GA, December, 2012.
47. Government Accountability Office. Electronic health records: number and characteristics of providers awarded Medicare incentive payments for 2011. GAO-12-778R. 2012. Washington, DC: Government Accountability Office. Available at http://www.gao.gov/products/GAO-13-146R.
48. CDC. Electronic health records meaningful use event, December 18, 2012. Atlanta, GA: CDC. Available at http://www.cdc.gov/ehrmeaningfuluse/virtual_event_2012-12-08.HTML/Docs/virtual_event_2012-12-08/Docs/virtual_event_2012-12-08/Docs/virtual_event_2012-12-08/Docs/virtual_event_2012-12-08/Session%202_Jeffrey%20Johnson_CDC_Virtual%20Event.pdf?
49. New York City Department of Health and Mental Hygiene. Primary care information project. New York, NY: New York City Department of Health and Mental Hygiene. Available at http://www.nyc.gov/html/doh/html/hcp/pcip.shtml.
50. Calman N, Hauser D, Lurio J, Wu WY, Pichardo M. Strengthening public health and primary care collaboration through electronic health records. Am J Pub Health 2012;102:e13-e18.
51. Parsons A, McCullough C, Wang J, Shih S. Validity of electronic health record-derived quality measurement for performance monitoring. J Am Med Inform Assoc 2012;19:604-9.
52. Health Resources and Services Administration, Maternal and Child Health Bureau. Maternal, infant and early childhood program. Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration. Available at http://mchb.hrsa.gov/programs/homevisiting.
53. Ogden LL, Richards CL, Shenson D. Clinical preventive services for older adults: the interface between personal health care and public health services. Am J Public Health 2012;102:419–25.