Managed care in the doctor's office: has the revolution stalled?

OBJECTIVE: To assess trends in the involvement of US physicians with managed care. STUDY DESIGN: Comparison of data from 2 consecutive rounds of a national survey. METHODS: Longitudinal data were obtained from the 1996/1997 (n = 12,528) and the 1998/1999 (n = 12,304) rounds of the Community Tracking Study (CTS) Physician Survey, a large, ongoing nationally representative survey of US physicians involved in patient care. Indicators used to assess involvement with managed care included global measures of managed care participation, risk contracting, exposure to financial incentives, and impact of care management tools. Changes in these measures over the 2 study periods are reported. Analyses were conducted for all physicians, as well as for primary care physicians (PCPs) and specialists separately. RESULTS: The percentage of practice revenue derived from managed care increased only modestly over the study period (from 42% to 45%). Mean numbers of managed care contracts per physician increased minimally (from 12 to 13). Trends in acceptance of capitation and exposure to financial incentives remained stable over the study period. Among PCPs, employment in staff/group health maintenance organizations declined slightly, whereas gatekeeping function increased modestly. Among care management tools, only treatment guidelines had a significantly increased impact on medical practice, primarily among PCPs (from 46% to 52%; P < .001). CONCLUSIONS: Many aspects of managed care leveled off between 1996 and 1999 in ways not accurately reflected by plan enrollment patterns. This "flattening of the curve" trend appears to hold generally across multiple measures. A stalling of the managed care "revolution," if it is sustained, may portend future escalation in healthcare costs.

Managed care, professional autonomy, and income: effects on physician career satisfaction.

CONTEXT: Career satisfaction among physicians is a topic of importance to physicians in practice, physicians in training, health system administrators, physician organization executives, and consumers. The level of career satisfaction derived by physicians from their work is a basic yet essential element in the functioning of the health care system. OBJECTIVE: To examine the degree to which professional autonomy, compensation, and managed care are determinants of career satisfaction among physicians. DESIGN: Cross-sectional analysis using data from 1996-97 Community Tracking Study physician telephone survey. SETTING AND PARTICIPANTS: A nationally representative sample of 12,385 direct patient care physicians. The survey response rate was 65%. MAIN OUTCOME MEASURE: Overall career satisfaction among U.S. physicians. RESULTS: Bivariate results show that physicians with low managed care revenues are significantly more likely to be "very satisfied" than are physicians with high managed care revenue (P < .05), and that physicians with low managed care revenues are significantly more likely to report higher levels of clinical freedom than are physicians with high managed care revenue (P < .05). Multivariate analyses demonstrate that, among our measures, traditional core professional values and autonomy are the most important determinants of career satisfaction after controlling for all other factors. Relative income is also an important independent predictor. Multiple dimensions of professional autonomy hold up as strong, independent predictors of career satisfaction, while the effect of managed care does not. Managed care appears to exert its effect on satisfaction through its impact on professional autonomy, not through income reduction. CONCLUSIONS: Our results suggest that when managed care (or other influences) erode professional autonomy, the result is a highly negative impact on physician career satisfaction.

Physicians pulling back from charity care.

Physicians have long provided care to the medically indigent for free or at reduced rates. However, recent findings from the Center for Studying Health System Change (HSC) indicate that the proportion of physicians providing charity care dropped from 76 percent to 72 percent between 1997 and 1999. In the short term, most medically indigent people are still getting care. But policy makers should take note that reduced physician participation in charity care will hurt the poor if-as projected-growth in physician supply slows and the number of uninsured rises along with escalating health care costs. This Issue Brief discusses the extent of the decline in physician provision of charity care, the reasons for the decline and implications for the future of the safety net.

Minority physicians' experiences obtaining referrals to specialists and hospital admissions.

CONTEXT: Over the past 15 years, policy makers, healthcare providers, and researchers have focused their attention on understanding and reducing ethnic disparities in access to healthcare. Efforts to understand and reduce these disparities in access are driven by the wealth of studies that document significant differences in the health of ethnic minority groups in the United States. OBJECTIVE: To assess differences in access to medical care from African American, Hispanic, and white physicians' perspectives. DESIGN: Using the Community Tracking Study Physician Survey, a nationally representative survey of US physicians, this study assesses physicians' abilities to obtain medically necessary services for their patients. Physicians were asked how often they could arrange referrals to specialists and inpatient admissions for their patients. RESULTS: Controlling for physician characteristics (eg, providing charity care, participation in managed care, Medicaid, and Medicare) and community characteristics (eg, average managed care participation, supply of hospital beds and specialists per capita) reduces the magnitude of differences between white and ethnic minority physicians. Nevertheless, after controlling for a wide range of practice and environmental characteristics, African American physicians were more likely to report problems obtaining hospital admissions, and Hispanic physicians were more likely to report problems obtaining referrals to specialists, compared with white physicians. CONCLUSIONS: Disparities in ethnic minority physicians' abilities to get medical services for their patients exist. This study corroborates that ethnic disparities are not limited to gaining access to primary health services (eg, having a doctor visit or a usual source of medical care) but extend into the healthcare delivery system itself (eg, getting a referral or hospital admission).

The impact of managed care on children's access, satisfaction, use, and quality of care.

OBJECTIVE: To examine the impact of managed care on children's access, satisfaction, use, and quality of care using nationally representative household survey data. DATA SOURCE: The 1996 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: Bivariate and multivariate analyses are used to detect independent effects of managed care on access, satisfaction, utilization, and quality of pediatric health services. DATA COLLECTION/EXTRACTION METHODS: Data were obtained from rounds 1, 2, and 3 of the 1996 MEPS. MEPS collects data on health care use, insurance, access, and satisfaction, along with basic demographic and health status information for a representative sample of the U. S. civilian, noninstitutionalized population. Our sample consists of 5,995 children between the ages of 0 and 17. FINDINGS: Among the 18 outcome indicators examined, the bivariate analysis revealed only three statistically significant differences between children enrolled in managed care and children in traditional health plans: children enrolled in managed care were more likely to receive physician services, more likely to have access to office-based care during evening or weekend hours, and less likely to report being very satisfied with overall quality of care. However, after controlling for confounding factors, none of these differences remained statistically significant. CONCLUSIONS: Our findings suggest that there are no statistically significant differences in self-reported outcomes for children enrolled in managed care and traditional health plans. This conclusion is provisional, however, because of limitations in the data set.

Minority and nonminority pediatricians' care of minority and poor children.

BACKGROUND: Although it has been established that minority physicians tend to see more minority and more poor or uninsured patients, pediatrics as a specialty has not been studied in this regard. OBJECTIVE: To determine if minority pediatricians disproportionately provide care to minority children and to poor and uninsured children, relative to nonminority pediatricians, while controlling for possible confounding variables (socioeconomic background, sex, use of non-English languages in practice, and subspecialty training). METHODS: In 1996, a stratified random sample of 1044 pediatricians, half of whom were underrepresented minorities (URMs) (African, Native, and Mexican Americans, mainland Puerto Ricans, and other Hispanics) and half of whom were Asian or Pacific Islanders, commonwealth Puerto Ricans, and whites (non-URMs), were surveyed about personal, practice, and patient characteristics. RESULTS: Multivariate analyses reveal that, independent of other variables, being a URM pediatrician is significantly (P = .001) and positively associated with caring for a greater proportion of minority and Medicaid-insured or uninsured patients. Underrepresented minority pediatricians saw 24 percentage points more minority patients and 13 percentage points more Medicaid-insured or uninsured patients than did non-URM pediatricians. CONCLUSIONS: Compared with what non-URM pediatricians report, URM pediatricians report caring for significantly (P =.001) more minority and poor and uninsured patients. Given the few pediatricians who are URM, non-URM pediatricians should be adequately prepared to provide care for minority patients, as the proportion of minority children is high and will be increasing significantly in the next several years. Most important, efforts to ensure a racially and ethnically diverse health care workforce should be greatly enhanced, as its diversity, and hence representativeness, will improve the health care system for all Americans.

The unmet health needs of America's children.

OBJECTIVE: Unmet need for health care is a critical indicator of access problems. Among children, unmet need for care has special significance inasmuch as the failure to obtain treatment can affect health status and functioning in the near- and long-term. The purpose of this study was to present current prevalence estimates and descriptive characteristics of children with unmet health needs using nationally representative household survey data. METHODS: We analyzed 4 years of National Health Interview Survey data spanning 1993 through 1996. Our analysis included 97 206 children <18 years old. Measures of unmet need for medical care, dental care, prescription medications, and vision care were obtained from an adult household member (usually the mother) responding for the child. Bivariate and multivariate analyses were used to assess the degree to which unmet need was related to the demographic and socioeconomic characteristics of the child and family. RESULTS: Overall, 7.3% (4.7 million) of US children experienced at least 1 unmet health care need. Dental care was the most prevalent unmet need. After adjustment for confounding factors, near-poor and poor children were both about 3 times more likely to have an unmet need as nonpoor children (adjusted odds ratio [95% confidence interval] = 2.89 [2.52, 3.32], 3.0 [2.53, 3.56], respectively). Uninsured children were also about 3 times more likely to have an unmet need as privately insured children (adjusted odds ratio [95% confidence interval] = 2. 92 [2.58, 3.32]). CONCLUSIONS: Despite the nation's great wealth, unmet health needs remain prevalent among US children. A combined public policy that addresses financial and nonfinancial barriers to care is required to reduce the prevalence of unmet need for health care.

The respective racial and ethnic diversity of US pediatricians and American children.

BACKGROUND: Much effort has been directed toward increasing the training of physicians from underrepresented minority groups, yet few direct comparisons have examined the diversity of the racial/ethnic backgrounds of the physicians relative to the patient populations they serve, either currently or into the future. This has been particularly true in the case of pediatrics, in which little information has emerged regarding the racial/ethnic backgrounds of pediatricians, yet evidence points to ever-growing diversity in the US child population. OBJECTIVE: We embarked on a comparative analysis to examine trends in the racial and ethnic composition of pediatricians vis-a-vis the patient population they serve, America's infants, children, adolescents, and young adults. METHODS: Data on US pediatricians sorted by racial/ethnic group came from Association of American Medical Colleges distribution data and is based on the cohort of pediatricians graduating from US medical schools between 1983 and 1989 extrapolated to the total number of pediatricians actively practicing in 1996. Data on the demographic diversity of the US child population came from the US Census Bureau. We derived pediatrician-to-child population ratios (PCPRs) specific to racial/ethnic groups to measure comparative diversity between and among groups. RESULTS: Our results show that the black PCPR, currently less than one third of the white PCPR, will fall from 14.3 pediatricians per 100 000 children in 1996 to 12 by 2025. The Hispanic PCPR will fall from 16.9 in 1996 to 9.2 in 2025. The American Indian/Alaska Native PCPR will drop from 7.8 in 1996 to 6.5 by the year 2025. The PCPR specific to the Asian/Pacific Islander group will decline from 52.9 in 1996 to 26.1 in 2025. For whites, the PCPR will increase from 47.8 to 54.2 during this period. For 1996, each of the 5 PCPRs is significantly different from the comparison ratio. The same is true for 2025. For the time trend comparison (between 1996 and 2025), there is a significant difference for each ratio except for American Indian/Alaska Native. CONCLUSION: The racial and ethnic makeup of the US child population is currently far more diverse than that of the pediatricians who provide their health care services. If child population demographic projections hold true, and no substantial shifts transpire in the composition of the pediatric workforce, the disparities will increase substantially by the year 2025.

Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce.

OBJECTIVE: To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market. BACKGROUND: Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies. METHODS: Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed. RESULTS: For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%). CONCLUSION: This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.

General pediatricians, pediatric subspecialists, and pediatric primary care.

OBJECTIVE: To assess the respective roles of general pediatricians and pediatric subspecialists in the provision of primary pediatric care. DESIGN AND METHODS: A practice characteristics questionnaire that included questions about primary care was sent to a random sample of 1616 board-certified and board-eligible active Fellows of the American Academy of Pediatrics; 1145 (70.9%) responded. Analyses pertain to those pediatricians who provided ambulatory patient care and were not in graduate medical education training at the time of the survey. Respondents were divided into 2 groups for purposes of analysis: the 527 pediatricians whose practice was primarily in general pediatrics (defined as 80% of time spent in general pediatrics or any time spent in adolescent medicine) and the 213 pediatricians whose practice was subspecialty focused (all others). These groups were then further stratified according to whether they provided primary care. The resultant subgroups contained 518 general pediatricians and 98 subspecialists who provided primary care. RESULTS: Among the entire sample, general pediatricians indicated that general pediatricians provide 93% of the primary care delivered by their practice and that pediatric subspecialists provide 2% of the primary care. In contrast, pediatric subspecialists reported that general pediatricians provide 53% of the primary care delivered by their practice and that subspecialists provide 32% of such care (P<.001). Among the subsample of pediatricians who provide primary care, general pediatricians reported delivering 88% of the primary care received by their patients and subspecialists reported delivering 74% of the primary care received by their patients (P<.001). CONCLUSION: Perspectives on the degree to which pediatric subspecialists provide primary pediatric care vary depending on generalist vs subspecialist self-identification.

Health insurance and access to primary care for children.

BACKGROUND: Numerous studies have demonstrated that insurance status influences the amount of ambulatory care received by children, but few have assessed the role of insurance as a determinant of children's access to primary care. We studied the effect of health insurance on children's access to primary care. METHODS: We analyzed a sample of 49,367 children under 18 years of age from the 1993-1994 National Health Interview Survey, a nationwide household survey. The overall rate of response was 86.5 percent. The survey included questions on insurance coverage and access to primary care. RESULTS: An estimated 13 percent of U.S. children did not have health insurance in 1993-1994. Uninsured children were less likely than insured children to have a usual source of care (75.9 percent vs. 96.2 percent, P<0.001). Among those with a usual source of care, uninsured children were more likely than insured children to have no regular physician (24.3 percent vs. 13.8 percent, P<0.001), to be without access to medical care after normal business hours (11.8 percent vs. 7.1 percent, P<0.001), and to have families that were dissatisfied with at least one aspect of their care (19.6 percent vs. 14.0 percent, P=0.01). Uninsured children were more likely than insured children to have gone without needed medical, dental, or other health care (22.2 percent vs. 6.1 percent, P<0.001). Uninsured children were also less likely than insured children to have had contact with a physician during the previous year (67.4 percent vs. 83.8 percent, P<0.001). All differences remained significant after we controlled for potential confounders using linear and logistic regression. CONCLUSIONS: Among children, having health insurance is strongly associated with access to primary care. The new children's health insurance program enacted as part of the Balanced Budget Act of 1997 may substantially improve access to and use of primary care by children.

Patient-physician pairing: does racial and ethnic congruity influence selection of a regular physician?

Many public and private sector efforts are devoted toward increasing the training of physicians from under-represented minority groups, yet little has been documented regarding the association between physicians' racial backgrounds and the patient populations they serve. To address this question, we use 1987 National Medical Expenditure Survey to examine the impact of race/ethnicity on the matching between physician and patients. Our results show that minority patients are significantly more likely to report having a minority physician as their regular doctor. We estimate that minority patients are five times as likely as non-minorities to report that their regular physician is a member of a racial/ethnic minority. This effect is especially pronounced among Hispanics who identify a Hispanic physician as their regular provider 19 times more often than non-minorities. After controlling for other socioeconomic factors, both these figures remain significant, but drop by approximately one-half. These results support the notion that minority patients tend to see minority physicians at a disproportional rate independent of other socio-economic factors.

Hospital readmission with feeding-related problems after early postpartum discharge of normal newborns.

CONTEXT: Increasingly short postpartum hospital stays in the United States precipitated a policy debate that culminated in passage of the Newborns' and Mothers' Health Protection Act of 1996. The debate occurred without population-based evidence for adverse health effects in newborns who are discharged early. OBJECTIVE: To determine whether early postpartum hospital discharge of normal newborns increases their risk for hospital readmission with feeding-related problems. DESIGN AND SETTING: Nested case-control analysis of 1991 to 1994 Wisconsin birth certificate and hospital discharge data. SUBJECTS: A total of 210 readmitted case patients and 630 control subjects selected from a cohort of 120 290 normal newborns who weighed at least 2500 g, were delivered vaginally of mothers with uncomplicated medical and obstetrical histories, and were discharged from the hospital either early (day of life 1 or 2) or conventionally (day 3). OUTCOME MEASURE: Readmission at age 4 to 28 days with discharge diagnoses indicating a primary feeding problem, secondary dehydration, or inadequate weight gain. RESULTS: Early discharges increased 3-fold (reaching 521/1000 discharges) during the study period, but feeding-related readmissions (1.7/1000) remained stable. Most readmitted newborns (53.8%) were 4 to 7 days old, many (34.3%) had concurrent dehydration and jaundice, and 29% were admitted through emergency departments. Readmitted newborns were significantly (P<.05) more likely to have been breast-fed, firstborn, or preterm or to have mothers who were poorly educated (<12th grade), unmarried, or receiving Medicaid. Readmission was not associated with early discharge (adjusted odds ratio, 1.05; 95% confidence interval, 0.71-1.53). CONCLUSION: Although several neonatal and maternal factors increase the risk that a normal newborn will be rehospitalized with a feeding-related problem, early discharge following an uncomplicated postpartum hospital stay appears to have little or no independent effect on this risk.

Tobacco and children. An economic evaluation of the medical effects of parental smoking.

OBJECTIVE: To determine the economic influence of pediatric disease attributable to parental smoking. DATA SOURCES: Computerized bibliographic databases were searched. Subject headings included asthma, burn, cost, low birth weight, otitis media, respiratory syncytial virus bronchiolitis, sudden infant death syndrome, and tobacco smoke pollution. The following constraints were applied to the published articles we studied: publication time, January 1980 through May 1996; age range of children studied, neonate to 18 years; and written in English. Articles used specifically as references for cost issues were limited to studies performed in the United States. DATA EXTRACTION: This study is a literature synthesis, which uses as its primary source the results of previously published best estimates. This is not a meta-analysis of studies analyzing the relationships between childhood disease and smoking. RESULTS: Using data for relative risk, prevalence, and cost of illness and death, we calculated the attributable risk fraction and corresponding direct medical expenditures and costs for loss of life. Costs are adjusted to 1993 dollars. Estimated annual excess cases of childhood illness and death attributable to parental smoking include low birth weight (46,000 cases, 2800 perinatal deaths), sudden infant death syndrome (2000 deaths), respiratory syncytial virus bronchiolitis (22,000 hospitalizations, 1100 deaths), acute otitis media (3.4 million outpatient visits), otitis media with effusion (110,000 tympanostomies), asthma (1.8 million outpatient visits, 14 deaths), and fire-related injuries (10,000 outpatient visits, 590 hospitalizations, and 250 deaths). CONCLUSIONS: Parental smoking is an important preventable cause of morbidity and mortality among American children; it results in annual direct medical expenditures of $4.6 billion and loss of life costs of $8.2 billion. Additional efforts to reduce children's exposure to tobacco smoke are warranted.

State-to-state variations in newborn screening policies.

BACKGROUND: Population-based newborn screening for genetic and metabolic disorders is standard practice in all states in the United States. Policies governing newborn screening are determined at the state level; however, and thus, a great degree of variability exists between states regarding many facets of such screening. OBJECTIVE: To gather information relating to the processes, content, and outcomes of policy making affecting newborn screening programs across the United States. METHODS: We surveyed the directors of newborn screening programs for each of the 50 states using a postal questionnaire. The questionnaire solicited information about the specific tests incorporated in each state's panel of screening tests and information pertaining to the policy-making processes by which decisions are reached regarding this testing. RESULTS: Substantial variation exists across states regarding both the processes of policy formulation and the outcomes of decisions made about newborn screening. All states currently screen for phenylketonuria and congenital hypothyroidism. Extensive variation exists across states in testing for other disorders. The processes by which state policy makers arrive at decisions in this area are extremely diverse. Almost three fourths of the states have standing expert advisory bodies who issue recommendations regarding screening program modifications, but the authority granted to these panels varies substantially. Some regional cooperation in this area exists. CONCLUSIONS: Further development of regional cooperation could offer some states greater efficiency in both laboratory testing and screening policy formulation. From the standpoint of an individual state. Wisconsin's approach to policy development in this area is described as a model worthy of consideration.

Maternal smoking and medical expenditures for childhood respiratory illness.

OBJECTIVES: This study sought to assess the association between environmental tobacco smoke exposure from maternal smoking and health care expenditures for respiratory conditions among US children. METHODS: Multivariate analysis of the 1987 National Medical Expenditure Survey was undertaken with a sample that included 2624 children 5 years of age and under. RESULTS: After analysis that controlled for various sociodemographic factors associated with health care usage, respiratory-related health care expenditures among children whose mothers smoke were found to be significantly higher than those expenditures for children of nonsmoking mothers. Truncated regression techniques were used to estimate that maternal smoking was associated with increased health care expenditures averaging (in 1995 dollars) $120 per year for children aged 5 years and under and $175 per year for children aged 2 years and under. Our analysis indicates that passive smoking was associated with $661 million in annual medical expenditures in 1987, representing 19% of all expenditures for childhood respiratory conditions. CONCLUSIONS: Maternal smoking is associated with significantly increased child health expenditures and contributes significantly to the overall cost of medical care.

Children's access to primary care: differences by race, income, and insurance status.

OBJECTIVE: Congressional initiatives to reduce spending under major public programs designed to improve access to health care have brought renewed attention to the health care needs of traditionally disadvantaged populations. The objective of this study was to assess access to and use of primary care services for poor, minority, and uninsured children in the United States. DESIGN AND SETTING: We analyzed data on 7578 1- to 17-year-old children of families responding to the 1987 National Medical Expenditure Survey, a nationally representative sample of families and children. OUTCOME MEASURES: Adult respondents were asked to report on several measures of access and use of care for children in the household. These included the presence of a usual source of care and its characteristics (type of site, travel time, waiting time, after-hours care, and availability of a regular physician). We also examined the volume of physician contacts relative to the sample child's health status, the receipt of measles vaccinations, and whether children received care in response to selected symptoms of ill health. Results are presented for children generally and for four subgroups: poor children; minority children; uninsured children; and white, non-poor, insured children (the reference group). RESULTS: Poor, minority, and uninsured children fared consistently worse than the children in the reference group on all indicators studied. For example, children in each of the three at-risk groups were twice as likely as the children in the reference group to lack usual sources of care, nearly twice as likely to wait 60 minutes or more at their sites of care, and used only about half as many physician services after adjusting for health status. Multivariate analyses revealed that poverty, minority status, and absence of insurance exert independent effects on access to and use of primary care. CONCLUSIONS: The existence of substantial barriers to the access to and use of primary care for low-income, minority, and uninsured children is cause for significant concern, especially in an era of program cutbacks. New initiatives are needed to address both financial and non-financial barriers to the receipt of primary care for disenfranchised children.