What's the score? States vary widely in health care for children
What's the score? States vary widely in health care for children
There are great differences among states in the quality of health care children receive along with their access to care, family insurance premiums, equity, and the potential to lead long, healthy, and productive lives. That's the conclusion drawn from a state-by-state scorecard developed by the Commonwealth Fund. The scorecard is the first report to assess how the nation's health system performs for children on those five dimensions on a state-by-state basis.
Report authors Edward Schor, Katherine Shea, and Karen Davis say the differences among states have real consequences for children and their families. If all states performed as well as the top states, they say, these would be the results:
- 4.6 million more children nationwide would have health insurance;
- 11.8 million more children would receive recommended yearly medical and dental checkups;
- 1.6 million fewer children would be at risk for developmental delays;
- 10.9 million more children would have a medical home; and
- nearly 800,000 more children would be up to date on their vaccines.
The report ranked states on 13 indicators for children grouped in categories including access, quality, costs, equity, and healthy outcomes. While no state performed at the top across all categories, some states far surpassed others, the researchers say. States in the Northeast and Upper Midwest often rank high in multiple areas, while states with the lowest rankings tended to be concentrated in the South and Southwest. But there was room for improvement in all states, including the highest-ranked states, which still fell short of established standards on some indicators.
Mr. Schor, one of the report's co-authors, tells State Health Watch the issue of children's health care is important because so many children receive publicly funded health care services, particularly in the first year of life. But despite very large Medicaid budgets, he says, a disproportionately small amount is spent on children, with most Medicaid money going for long-term care and the disabled.
He says the Commonwealth Fund researchers used the same basic framework and methodology used in an earlier state scorecard on overall health care to focus attention specifically on children. "The health domains we evaluated are pretty much the same," he says. "We found, however, there is very little data available on children's health status by state. And there is virtually none below the state level other than vital statistics information. So most of the items we looked at were taken from existing national surveys."
The study was limited by the lack of data, Mr. Schor says, and the researchers tried to find indicators that would fit the elements in the earlier scorecard.
The question of why there is such variability among states requires a look at each individual indicator, Mr. Schor tells SHW. But a driving factor for many areas of concern is access. With the uninsurance rate varying considerably, access varies as well. The researchers found a fourfold difference in state rates of uninsured children and a fivefold difference in insurance rates among low-income children. "It's basically a matter of what policies have been enacted and what priorities are given to coverage," he says. "Some states are very restrictive on Medicaid and SCHIP, while others are working hard to achieve universal coverage. If children's health care is important, states have to make sure that children have access and that the care they are buying meets the needs of children."
The report compares each state to benchmarks that have already been achieved in one or more states, rather than to a theoretical goal. "In looking at the country as a whole we found that, while there are pockets of excellence, there is no one state or region that is doing as well as it could be," says Mr. Schor, a Commonwealth Fund vice president. "This scorecard points to the need to make more information available about children's health care and to improve the health care system for children. The good news is that we know improvements can be made because we didn't judge these states based on a pie-in-the-sky standard; we judged them against one another."
No quality without access
Access to care seems to be a key factor in quality and equity. While the rate of uninsured children varies widely across states, from 5% in Michigan to 20% in Texas, the scorecard found that states with the highest access to care rankings, meaning that nearly all of their children are insured, were almost uniformly among the best scorers on quality of care and equity measures.
States that were at the bottom of the overall ranking lagged well behind other states on access to care and struggled with other measures. Thus, Arizona, Florida, Louisiana, Mississippi, New Jersey, Nevada, and Texas scored in the bottom 10 states overall and also were at the bottom on the access measure. And five of the lowest ranked states for access to care (Arizona, Louisiana, Mississippi, New Mexico, Nevada, and Texas) all ranked at the bottom on quality measures.
The scorecard researchers say generally children who are in the bottom-ranked states are less likely to get the recommended health care, including vaccines, dental care, and regular checkups. And children in those states are at greater risk for developmental delays and infant mortality.
While quality of care varied widely across states, even in the highest-ranked states quality falls short of set standards. Thus, 75% of children in Massachusetts had at least one medical and one dental visit in the past year, compared to 46% of Idaho children. Even though Massachusetts ranked first in that measure, fully 25% of its children still didn't receive annual preventive medical and dental care.
The researchers say the quality scores show that children across the country aren't receiving the vaccines they need, don't have access to mental health care for emotional problems and are at high risk for developmental delays, aren't getting their regular medical and dental checkups, don't have a medical home, and are more likely to end up in the hospital if they have asthma.
The report finds that investing in child health is a high priority for state officials, with more than one-third of children nationally receiving health care funded by the federal government and the 50 states plus the District of Columbia. Some 28 million children are covered by Medicaid and 6 million are covered by SCHIP.
The scorecard authors say their analysis produced six important findings:
1. High performance is possible. Iowa and Vermont have created children's health care systems that are seen as accessible, equitable, and deliver high-quality care, all while controlling spending levels and family health insurance premiums. In the last 10 years, those two states each adopted policies to expand children's access to care and improve the quality of their care. They expanded SCHIP and mandated that all child health plans and local and regional children's health systems publicly report data on care quality.
2. Leading states consistently outperform lagging states on multiple child health indicators and dimensions. Thirteen states, including Iowa, Vermont, Maine, Massachusetts, New Hampshire, Ohio, Hawaii, Rhode Island, Kentucky, Kansas, Wisconsin, Michigan, and Nebraska, were the top quartile of the overall performance rankings. The report shows those states generally rank high on multiple indicators along each of the five dimensions assessed. And many have the nation's lowest uninsured rates for children.
In the bottom quartile were Illinois, New Mexico, Alaska, New Jersey, Oregon, Arkansas, Nevada, Texas, Arizona, Louisiana, Mississippi, Florida, and Oklahoma. They scored well behind other states on multiple indicators across dimensions and their uninsured rates for children are well above national averages and more than double those in the quartile of states with the lowest rates. Rates for receiving preventive care generally are low in the bottom states, while rates of infant mortality and risk of developmental delay often are high.
3. There is wide variation in children's access to care and health care quality across the United States. As examples, the researchers state that the proportion of children who are uninsured ranges from 5% in Michigan to 20% in Texas. The proportion of children who have regular medical and dental preventive care ranges from 75% in Massachusetts to 46% in Idaho. And the proportion of children hospitalized for asthma ranges from 55 per 100,000 children in Vermont to 314 per 100,000 in South Carolina.
4. Children's access to medical homes varies widely across states. Some 61% of children in New Hampshire and more than half of all children in the New England states have a medical home, defined as a primary care provider who delivers health care services that are easily accessible, family-centered, continuous, comprehensive, coordinated, and culturally competent. That compares with only 33% in Mississippi.
5. Across states, better access to care is closely associated with better quality of care. Seven statesRhode Island, Wisconsin, Iowa, Michigan, Connecticut, Vermont, and New Hampshireare national leaders in giving children access to care and ensuring high-quality care.
6. There are strong regional patterns in child health system performance. Although there are strong regional patterns, there are exceptions within each region and learning more about such exceptions to regional patterns may provide insights into effective policies to support children's health.
The report says that benchmarks set by leading states show there are opportunities to improve health system performance to benefit children. It also reveals critical areas in which state and federal policies are needed to improve child health system performance for all U.S. families.
"Further investment in children's health care measurement and data collection at the state level could enrich understanding of variations in child health system performance," the report says. "For many dimensions, only a limited set of indicators is available."
SCHIP must be expanded
Mr. Schor says it is clear that the problems with children's health will not be adequately addressed unless the SCHIP program expands. That becomes a political question because congressional efforts to expand the program this year were rebuffed by the administration. He says SCHIP reauthorization and expansion seems to be the logical place to start to address the concerns, followed by consideration of the value being received in terms of children's health for the money being spent.
"Where there are variations in quality and access, some are getting it right and some are not," he asserts. "Because the indicators are benchmarked against what has been attained by some states, our advice to states is that unless there's something very strange about your state, you should be able to do this as well as the high-ranking states. Getting this right, particularly for young children, is truly an investment. It's the right thing to do but it also makes economic sense."
An interactive map of the scorecard is available at: www.commonwealthfund.org/usr_doc/site_docs/slideshows/ChildScorecard/ChildScorecard.html.
Download the report at http://www.commonwealthfund.org/newsroom/newsroom_show.htm?doc_ id=686461. Contact Mr. Schor at (212) 606-3866.
There are great differences among states in the quality of health care children receive along with their access to care, family insurance premiums, equity, and the potential to lead long, healthy, and productive lives.Subscribe Now for Access
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