Women and Children First — Or Not

We are both pediatricians and parents. We have patients and children of our own, and we want them all to have the opportunity to embark on a lifelong trajectory of health and well-being. Unfortunately, neither of the presidential candidates has specified their healthcare proposals for the next generation, so the only option is to look back and review their previous records. Perhaps this offers some indication of their future plans.

We represent both the “patient in the doctor’s office” (Rosenbaum) and the more global public health (Meyer) perspectives relating to children’s health. We looked at “the big picture” regarding key issues where children are the most vulnerable by examining the social determinants of health (SDOH). This includes healthcare access, economic stability, educational opportunities, the neighborhood/built environment, and community support.

Let’s compare the records of each presidential candidate.

Maternal and Prenatal Care

The U.S. has the highest maternal mortality rate and one of the highest infant mortality rates among high income countries. Maternal and child well-being are intimately related over a lifetime via the health infrastructure laid down in utero. Maternal health, stress, substance abuse, and other factors affect the risk for neurodevelopmental delay and the chronic diseases of adulthood.

The rate of severe maternal morbidity has more than doubled during the past few decades in the U.S., leading to costs totaling more than $20 billion in 2019 alone from conception to the child’s first birthday. These costs increase to over $32 billion from conception to age 5. Approximately 58% of these are direct costs to the healthcare system, so investing in maternal-fetal care clearly pays off.

Both candidates have taken steps to support maternal-child healthcare, but in somewhat different directions.

Donald Trump is aware of the problem. As president, he expanded the Child Tax Credit providing up to $2,000/year in tax credits for families with children (however, critics argued it was skewed to favor the wealthy and ignored those who are too poor to pay the necessary amount of taxes to benefit). He also signed the Preventing Maternal Deaths Act in 2018 to establish a federal infrastructure to collect data on every maternal death and identify ways to improve maternal healthcare. While Trump has threatened to repeal Obamacare for years, he still has no alternative to replace it. Of note, more than 7 million women of reproductive age gained coverage between 2010 and 2019 under the Affordable Care Act.

Republican vice presidential nominee JD Vance has expressed concerns regarding the declining U.S. birth rate, yet he has also indicated support for healthcare plans that would allow companies to charge more for or deny coverage of expensive medical conditions, including pregnancy.

Now for Vice President Kamala Harris’ record on supporting prenatal care. As a senator, she proposed the Maternal CARE Act to support implicit bias training in ob/gyn care, as well as eight other bills (called “Momnibus Act”) specifically addressing black maternal healthcare disparities. None of these bills have been passed to date. The Biden-Harris administration proposed the Maternity Care Action Plan (pending), which improves care throughout pregnancy, places caps on co-payments, promotes rapid payments to child care providers, and gives parents better access to federal programs such as the Child Care and Development Fund, Healthy Start (funded), and the Enhancing Maternal Health Initiative. The administration also allocated $105 million to support community-based maternal and infant child health programs.

Democratic vice presidential nominee Tim Walz has also been a strong supporter of prenatal and early childhood care. As governor of Minnesota, he issued an executive order in 2019 to start the “Children’s Cabinet” childhood health initiative, and proposed budgets of tens of millions of dollars for pregnant women’s home visits and early child care.

Early Childhood

From birth to age 5 children’s brains develop rapidly as they form new neural connections and lay down a cognitive and behavioral framework for their futures. The major determinants of the quality of these experiences are the family/home environment and physical health. Diaper poverty — wherein families can’t afford to keep babies fed and diapered — affects millions of our children and can lead to consequences such as food insecurity, skin and urinary tract infections, poor sleep, and increased post-partum stress. It is just one example of problems that may cost more to treat than to prevent.

It’s essential to empower families to access financial and social support systems. Again, the candidates differ substantially in their approaches to this issue.

The Biden-Harris Blueprint for Addressing the Maternal Health Crisis empowered the Health Resources and Services Administration (HRSA) to spend more than $500 million (including the $470 million in the fiscal year 2023 budget) on maternal and infant care, including home visits to improve the SDOH environment. HRSA funds provide resources, support, and skills to help families keep children too young for kindergarten physically, socially, and emotionally healthy, and also help address healthcare disparities. Funding for these health resources was augmented by the order to Increase Access to High Quality-Care and Supporting Caregivers and non-regulatory guidance on Serving Preschool Children Through Title I, Part A, of the Elementary and Secondary Education Act.

The Biden-Harris administration has also supported universal pre-K, incentivized businesses to provide child care, and increased salaries for child care workers. Harris has proposed expanding the child tax credit from $2,000 to $3,000 — or $3,600 for preschoolers and $6,000 for babies. She and Walz support paid family and medical leave and increased support for child care workers.

The Trump-Pence administration’s 2017 Tax Cuts and Jobs Act doubled the child tax credit (as mentioned above), and the 2020 fiscal budget he signed into law increased funding via the Child Care and Development Block Grant supporting Head Start and Preschool Development. During his 2016 campaign, he supported emergency paid family leave, but during his administration he exempted companies with over 500 employees from this requirement, thereby excluding front-line workers at large chains such as Amazon. More recently, Trump said, “child care is child care,” and suggested that tariffs on foreign nations would cover child care costs, without discussing any specific legislation.

JD Vance’s health and school records relevant to children is mixed. He sponsored legislation to protect stay-at-home parents and to increase the child tax credit to $5,000. He previously opposed government spending on child care in favor of the benefits of having one parent or a grandparent at home as caretaker, but he seems to be more aligned with Governor Walz in supporting federally funded child care as of their recent debate.

Prenatal Health and Early Childhood Well-Being Should Be Priorities

To be sure, this is only a review of the candidates’ records on maternal and early childhood healthcare — and we may not have covered every policy from both candidates. We also reached out to both campaigns for more information regarding future plans, but did not receive a response. These considerations are most relevant to those of us who believe the well-being of children is a key election issue.

Based on the available information, it appears Trump was relatively inactive regarding child care as president, and Vance is encouraging Americans to have more children with few specific provisions for the pre- and post-natal care of the current pediatric population, much less a burgeoning one. Based on the same information, Harris and Walz have a history of prioritizing children, making or proposing detailed interventions to address specific concerns regarding maternal and early childhood care, and there is no evidence that she is “anti-child” as Vance has suggested.

We are currently First World leaders in maternal and infant death rates. We can do better. The phrase, “women and children first” needs to be revitalized and applied to the U.S. and to this election.

Michael Rosenbaum, MD, is a professor emeritus and special lecturer in pediatrics and medicine at Columbia University Irving Medical Center, a pediatrician in New York City, and graduate of the Columbia Narrative Medicine Journalism Workshop and Public Voices Op-Ed Program. Dodi Meyer, MD, is a professor of pediatrics and Vice Chair of Community Health at Columbia University and medical director of New York-Presbyterian Hospital’s Division of Community and Population Health.

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