Two years after the reauthorization and expansion of the Children's Health Insurance Program (CHIP), a new Commonwealth Fund state-by-state scorecard evaluating how the health care system is working for children finds that federal and state action on behalf of children has helped preserve, and even expand, health coverage for this group, despite the severe recession.
Yet wide differences persist among states when it comes to health insurance coverage, affordability of health care for families, children's receipt of preventive care and treatment, and the opportunity for children to lead healthy lives. Children living in the five top-ranked states -- Iowa, Massachusetts, Vermont, Maine, and New Hampshire -- are more likely to be insured and to receive recommended medical and dental check-ups than children living in poorer-performing states like Florida, Texas, Arizona, Mississippi, or Nevada.
The report finds strong evidence for the value of federal and state policies aimed at improving rates of health insurance coverage. Early expansions of Medicaid at the start of the decade, Medicaid stabilization funds from the American Recovery and Reinvestment Act (the stimulus bill), and the expansion and reauthorization of CHIP in February 2009 allowed states to continue to provide and, in some cases, expand health insurance for children during the economic downturn. While coverage rates for parents have declined in 41 states over the past decade, children have fared dramatically better, with rates increasing in 35 states over the same period.
The report, Securing a Healthy Future: The Commonwealth Fund State Scorecard of Child Health System Performance, 2011, analyzes 20 indicators of how the health system is performing for children in each state. Drawing on the most recently available data, the report compares each state to benchmarks that have already been achieved in one or more states. The researchers find that if all states could do as well as the best states:
"While children were able to gain and keep their health insurance thanks to Medicaid and CHIP, parents lost coverage as the job market deteriorated and cost of health insurance rose to unaffordable levels," said Cathy Schoen, Commonwealth Fund Senior Vice President and coauthor of the report. "The study demonstrates how policies designed to maintain children's health insurance and access to health care have helped children get the health care they need, especially in tough economic times. Yet, because so many parents are uninsured, children and their families will remain at high risk until 2014, when access to health insurance will be expanded to include nearly everyone in the U.S."
While states in New England and the Upper Midwest generally rank highest in the scorecard, and states across the South and Southwest rank lowest, there are exceptions. For example, 94 percent of children in Alabama are insured, making it a standout among Southern states. North Carolina, meanwhile, has the highest rate of developmental screening -- a direct result of an innovative statewide effort. The report notes that when state and local policies target specific issue areas, they are often effective in improving care and outcomes.
The states in the top-ranked quartile for overall performance -- Iowa, Massachusetts, Vermont, Maine, New Hampshire, Rhode Island, Hawaii, Minnesota, Connecticut, North Dakota, Pennsylvania, Wisconsin, Kansas, and Washington -- often perform well on multiple indicators and across dimensions. However, on many indicators there is room for improvement in all states. No state scores in the top 10 for all indicators. Further, the report finds that even leading states still have substantial shortfalls for children.
The report highlights the interrelationship between different components of states' health care systems. Seven of the 13 states that lead on access and affordability also rank among the top states in prevention and treatment. Children in states with the lowest uninsured rates are more likely to have a medical home, get preventive care, or receive referrals to needed care than children in states with the highest uninsured rates.
"A healthy start in life is essential for a child's success," said coauthor and Commonwealth Fund Vice President Edward Schor, M.D. "The wide differences in health care across the U.S. puts that healthy start in jeopardy for millions of children. We can do better. What is unique about this scorecard is that it looks at what has been achieved by the top states and holds that performance up as an example for other states -- because if it's possible to insure almost all of the kids in Alabama, it should be possible in Texas and Mississippi. State and health care system leaders just need to make it a priority."
Additional Report Findings:
Despite the broad gains in insuring children, there are still wide differences in insurance coverage rates among states. For example, only 3 percent of children in Massachusetts were uninsured in 2009, compared to 17 to 18 percent in Nevada, Florida, and Texas.
On children receiving all recommended doses of six key vaccines, there is a wide gap between the top-ranked state, Iowa, where 84 percent of children received all vaccines in 2009, and the bottom-ranked states, where only 65 percent of children were vaccinated. On hospital admissions for pediatric asthma, the best state, Oregon, had a rate of just 44 per 100,000 in 2006, compared to 251 per 100,000 in New York.
The report finds that where a child grows up matters for his or her ability to lead a healthy life into adulthood. Minnesota ranks first in the healthy lives category as a result of low rates of infant and child mortality, obesity, dental problems (toothache, decayed teeth or cavities, broken teeth, or bleeding gums), and children at risk for developmental delays, while Arkansas, Mississippi, and the District of Columbia rank last, with some of the worst rates on such indicators. The report also documents striking variations in childhood death rates, ranging from only nine child deaths for every 100,000 children ages 1 to 14 in Rhode Island, to 34 per 100,000 in Mississippi.
Uninsured, low-income, and minority children are at greater risk in nearly all states. Nationwide, more than one-third (35%) of low-income children have not received recommended medical and dental visits, while only one in five higher-income children have not gotten recommended check-ups. Disparities in oral health problems also stand out: in the five states with the largest gaps by income, 43 percent of children in low-income families had toothache, decayed teeth or cavities, broken teeth, or bleeding gums in the past six months, compared with 22 percent of children in higher-income families. The report also finds wide gaps by income, insurance, and minority status when it comes to children having a medical home. In addition, the report finds substantial racial/ethnic disparities in infant mortality rates.
The significant gap between what is being achieved in high- and low-performing states points to a health care system that is failing to ensure that all children receive the care they need to optimize their health and development. The report authors point to the potential of reforms in the Affordable Care Act to provide all states with new opportunities to improve children's health care, including a renewed focus on the health of families.
The authors note that previous research has shown that when parents have health insurance coverage, their children are more likely to also have coverage and get needed health care. When the Affordable Care Act is fully implemented, expanding access to insurance coverage to all low- and middle-income family members, children as well as parents will experience enhanced health and financial security. Assuming full implementation of the law, the report finds that rates of children with health insurance coverage will dramatically improve in every state, and parents will share in that progress. By 2019 insured rates are projected to be as high in every state as they are in the top-ranked stated today.
"We are entering a new era in American health care," said Commonwealth Fund President Karen Davis. "We made a commitment to insuring children a decade ago through Medicaid and CHIP. Now we have not only redoubled those efforts, but also expanded that same protection to their parents through the Affordable Care Act, finally giving the entire family the best chance to be healthy and productive without fear of ruinous medical bills."
The State Scorecard on Child Health System Performance, 2011, includes 20 key indicators grouped into four performance dimensions: access and affordability; prevention and treatment; potential to lead healthy lives; and equity. The analysis ranks all 50 states and the District of Columbia on each indicator and then averages the indicator ranks to determine the dimension rank. All four dimension scores are averaged to determine the overall rank. Equity measures the gaps in performance between vulnerable groups and the national average. This analysis uses the most recent data available at the time of publication -- typically from 2007 to 2009. Sabrina How, Ashley-Kay Fryer, Douglas McCarthy, Cathy Schoen, and Edward Schor authored the report.
The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system.
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