It is always difficult to anticipate the parameters of public debate. This is perhaps particularly true when it involves children, a group in society that enjoys both deep emotional sympathy and no power. However, what does seem certain is that major pressures are building on our current structure of child health policy and that change, perhaps dramatic change, will likely occur in the near future.

Perhaps the most fundamental pressure is coming from the success of pediatrics itself. The marked reduction of serious acute illness in childhood has profoundly shifted the burden of illness and death to chronic conditions.1,2 This, coupled with new insights into the childhood precursors of adult-onset disease, highlights the expanding gap between needed and extant pediatric services. The shift in the epidemiology of childhood illness alone will demand important changes in the structure of child health services in the years to come.

The epidemiologic imperative to constructively reconsider current child health policy could be functionally overwhelmed, however, by the mounting pressure to cut health care costs. The rising cost of Medicaid puts an enormous burden on state budgets.3 This burden has generated a growing activism among governors of both political parties to challenge long-standing Medicaid policies and protections. These efforts are being greatly enhanced by the general trend of "devolution," which provides the states with greater autonomy in shaping and implementing social policy. Because a significant portion of current state Medicaid expenditures on children are the product of optional state initiatives, significant service reductions could occur without major changes at the federal level.