Just when it looked as if the debate over the State Children’s Health Insurance Program (SCHIP) couldn’t get any more agonizing, some of the same folks who brought us the devastating RAND 55 percent study four years ago are back with the dismal news that children, on average, receive recommended treatment in only 46.5 percent of their ambulatory care encounters. Although the new study painstakingly examines a sample of 175 indicators, it is based on data that are 7-11 years old and is qualified by other significant limitations, including the murky question of how much the findings may be skewed by failures of documentation. But the study is sure to puncture forever the complacent assumption that quality concerns are less salient in children’s care than elsewhere. Providing coverage, it turns out, is barely half the battle.

In an astute editorial accompanying the study, which appeared in this week’s New England Journal of Medicine and is available at least temporarily online, James Perrin and Charles Homer say that public and private health plans for children have given less attention to quality than Medicare has, and that in fact states “have been highly reluctant to consider using common health care standards in the Medicaid and SCHIP programs.” So, two cheers for federalism. A recent Commonwealth Fund study argues that the current SCHIP reauthorization process offers the opportunity to make amends on this front. A perilous venture, but perhaps “The Quality of Ambulatory Care Delivered to Children in the United States” will help.

Indicators in the study span acute, chronic, and preventive care, but from an exhibit of sample measures, chronic care receives an appropriate emphasis. “How well chronic conditions are managed profoundly influences both short-term and long-term outcomes,” Perrin and Homer note, highlighting the particular significance of quality deficits in children’s care. Citing a recent Health Affairs paper by Neal Halfon et al., they conclude that the increasing prevalence of chronic conditions among children points ultimately to the need for innovation and transformation in children’s care to at least as great a degree as is needed in the health system generally. Halfon’s article appeared in a special issue on child health in this journal’s March/April 2007 issue.

Inside the Beltway, the argument is all about whether government or the private sector should take the lead in assuring adequate children’s health care. If it wasn’t clear before that this is a job that’s going to require everyone to get more involved, it ought to be now.