Although Bradford Gray became editor of the Milbank Quarterly on July 1 of this year, all the articles in both this issue and the next were accepted before he assumed that title. It seems appropriate, therefore, that I, as the editor who accepted the papers, describe and comment on them. Comments by Brad about future directions of the Quarterly follow “In This Issue.”

Any assessment of the performance of our health care system must take into account the care received by the most vulnerable members of our society, and older persons and children constitute two such groups. This issue contains two articles on long-term care and two on care for children. Readers are also encouraged to view an electronic publication by Robyn Stone, “Long-Term Care for the Disabled Elderly: Current Policy, Emerging Trends and Implications for the 21st Century,” on the Milbank Web site (

Informal family caregiving has been a critical part of the care provided to older persons in the United States. In the lead article, “Potential and Active Family Caregivers: Changing Networks and the “Sandwich Generation,” Brenda C. Spillman and Liliana E. Pezzin use data from the National Long Term Care surveys to examine changes in the population of older persons with chronic disabilities, sources of care, and the role of family caregivers over the course of the past decade. They found both a decrease in the number of active family caregivers and higher disability levels, a combination of factors that has resulted in greater reliance on formal care.

I have regularly published analyses from other countries in order to gain new perspectives on health care issues that we face in the United States and possibly to derive from them some solutions. Max Geraedts, Geoffrey V. Heller, and Charlene A. Harrington analyze the long-term-care insurance program that Germany implemented in 1995. In their article, “Germany’s Long-Term-Care Insurance: Putting a Social Insurance Model into Practice,” they describe the model’s organizational principles, eligibility criteria, and benefits and discuss as well how that country tries to promote cost containment and quality care.

The State Child Health Insurance Program (SCHIP), a provision of the Balanced Budget Act (BBA) of 1997, represents the largest, most significant expansion of health insurance for children since the introduction of Medicaid more than three decades ago. In a previous issue (MQ 77:2), I noted that the way we care for children often offers important insights into the workings of our health care system. Many consider the health care of children to be a mirror of the system’s successes and failures. In that same issue, Neal Halfon and his colleagues described a framework for evaluating SCHIP programs that covers not only eligibility thresholds and enrollment volume but also program retention, transitions in coverage, and access to medical care. In this issue, Leiyu Shi, Thomas Oliver, and Virginia Huang, authors of “The Children’s Health Insurance Program: Expanding the Framework to Evaluate State Goals and Performance,” also present a framework for evaluating SCHIP programs, and they work within this framework to review the program information in state SCHIP applications. Their focus on proposed program objectives measures reveals considerable variation among the states, which tend to stress enrollment and access while overlooking aspects of the services children receive once they are enrolled. One of several conclusions they reach is that evaluators should emphasize the quality of primary care because this will have the greatest impact on children’s health.

In the final article in this issue, “The Health Development Organization: An Organizational Approach to Achieving Child Health Development,” Neal Halfon, Moira Inkelas, and Miles Hochstein describe a new approach to the organization and delivery of children’s health and social services: the child development organization. This new approach was conceived in order to incorporate the advantages of vertically integrated HMOs into programs that combine pediatric social services and health promotion.

Paul D. Cleary

Author(s): Paul D. Cleary

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Volume 78, Issue 3 (pages 343–344)
DOI: 10.1111/1468-0017.00190
Published in 2000