SECURING A HEALTHY FUTURE The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Sabrina K. H. How, Ashley-Kay Fryer, Douglas McCarthy, Cathy Schoen, and Edward L. Schor February 2011 Photo Credits Front cover top: Fotosearch. Front cover middle and bottom, pages 2 and 4: Dwight Cendrowski. Page 8: Bill Gallery. SECURING A HEALTHY FUTURE The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Sabrina K. H. How, Ashley-Kay Fryer, Douglas McCarthy, Cathy Schoen, and Edward L. Schor February 2011 ABSTRACT The State Scorecard on Child Health System Performance, 2011, examines states’ performance on 20 key indicators of children’s health care access, affordability of care, prevention and treatment, the potential to lead healthy lives, and health system equity. The analysis finds wide variation in performance across states. If all states achieved benchmark performance levels, 5 million more children would be insured, 10 million more would receive at least one medical and dental preventive care visit annually, and nearly 9 million more would have a medical home. The findings demonstrate that federal and state policy actions maintained and, in some cases, expanded children’s insurance coverage during the recent recession, even as many parents lost coverage. The report also highlights the need for initiatives specifically focused on improving health system performance for children. The report includes state-by-state insurance coverage projections for children once relevant provisions of the Affordable Health Act are implemented. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. This and other Fund publications are available online at www.commonwealthfund.org. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1468. CONTENTS 5 List of Exhibits 6 About the Authors 7 Acknowledgments 9 Executive Summary 14 Highlight: Iowa 20 Introduction 21 What the Scorecard Measures 22 Access and Affordability 25 Highlight: Alabama 31 Prevention and Treatment 34 Highlight: Colorado 36 Highlight: North Carolina 38 Highlight: Massachusetts 40 Highlight: Cincinnati, Ohio 4 1 Children’s Potential to Lead Healthy Lives 44 Highlight: Minnesota 47 Equity 5 4 Impact of Improved Performance 5 5 Policy Implications: Moving Forward to Improve Children’s Health, Access, and Care Experiences and Address Costs Concerns 58 Highlight: Oregon 60 Conclusion 62 Notes 67 Appendices 88 Further Reading LIST OF EXHIBITS EXHIBIT 1 Indicators of State Child Health System Performance EXHIBIT 2 State Scorecard Summary of Child Health SystemPerformance Across Dimensions EXHIBIT 3 State Ranking on Child Health System Performance Access and Affordability EXHIBIT 4 State Ranking on Access and Affordability Dimension EXHIBIT 5 Percent of Children Ages 0–18 Uninsured by State EXHIBIT 6 Percent of Parents Ages 19–64 Uninsured by State EXHIBIT 7 Uninsured Rates and Medicaid/CHIP Income Eligibility Standards by State EXHIBIT 8 Affordability of Health Insurance: Premiums for Employer-Based Family Coverage Relative to Median Incomes for Family Households Under Age 65 EXHIBIT 9 State Ranking on Access and Affordability Dimension vs. Prevention and Treatment Dimension Prevention and Treatment EXHIBIT 10 State Ranking on Prevention and Treatment Dimension EXHIBIT 11 State Variation: Medical Home and Preventive Care EXHIBIT 12 State Initiatives to Advance Medical Homes in Medicaid/CHIP EXHIBIT 13 State Rates of Hospital Admissions for Asthma Among Children, 2006 Healthy Lives EXHIBIT 14 State Ranking on Potential to Lead Healthy Lives Dimension EXHIBIT 15 Infant Mortality by State Deaths per 1,000 Live Births, 2006 EXHIBIT 16 State Rates on Infant Mortality and Low-Birthweight Babies EXHIBIT 17 State Variation: Healthy Lives Equity EXHIBIT 18 Equity Dimension and Equity Type Ranking EXHIBIT 19 Children Without a Medical Home by Income and Insurance EXHIBIT 20 Children Without Both Preventive Medical and Dental Care Visits by Income and Insurance EXHIBIT 21 Children with Oral Health Problems by Income and Insurance Impact of Improved Performance EXHIBIT 22 National Cumulative Impact if All States Achieved Top State Rate Policy Implications EXHIBIT 23 Post-Reform: Percent of Children Ages 0–18 Uninsured by State EXHIBIT 24 Post-Reform: Percent of Parents Ages 19–64 Uninsured by State www.commonwealthfund.org5 About the Authors to the Fund’s bimonthly newsletter, Quality Matters. He has more than 20 years of experience working and Sabrina K. H. How, M.P.A., is senior research consulting for government, corporate, academic, and associate for the Commonwealth Fund’s Health philanthropic organizations in research, policy, and System Scorecard and Research Project, a three- operational roles, and has au­hored or coauthored t person research team based in Boston at the Institute reports and peer-reviewed articles on a range of for Healthcare Improvement with responsibilities health care–related topics. Mr. McCarthy received for developing and producing national, state, and his bachelor’s degree with honors from Yale College substate regional analyses on health care system and a master’s degree in health care management performance. She also served in this capacity from from the University of Connecticut. During 1996– 2006 until July 2010, when the project team was 1997, he was a public policy fellow at the Hubert H. created. Previously, Ms. How was a program associate Humphrey Institute of Public Affairs at the University for the Fund’s former Health Care in New York City of Minnesota. and Medicare’s Future programs. Prior to joining the Fund in 2002, she was a research associate for a Cathy Schoen, M.S., is senior vice president for Policy, management consulting firm focused on the health Research, and Evaluation at The Commonwealth care industry. Ms. How holds a B.S. in biology from Fund. Ms. Schoen is a member of the Fund’s Cornell University and an M.P.A. in health policy and executive management team and research director management from New York University. of the Fund’s Commission on a High Performance Health System. Her work includes strategic oversight Ashley-Kay Fryer is research associate for the and management of surveys, research, and policy Commonwealth Fund’s Health System Scorecard and initiatives to track health system performance. From Research Project, a three-person research team based 1998 through 2005, she directed the Fund’s Task in Boston at the Institute for Healthcare Improvement Force on the Future of Health Insurance. Prior to with responsibilities for developing and producing joining the Fund in 1995, Ms. Schoen taught health national, state, and substate regional analyses economics at the University of Massachusetts School on health care system performance. She provides of Public Health and directed special projects at the research and writing support for the ongoing series of UMASS Labor Relations and Research Center. During national and state scorecard reports and new health the 1980s, she directed the Service Employees care market analyses and supports the work of the International Union’s research and policy department. team. Ms. Fryer joined the Fund in June 2009 as In the late 1970s, she was on the staff of President the program assistant for Health System Quality and Carter’s national health insurance task force, where Efficiency. Upon graduation from Harvard College she oversaw analysis and policy development. Prior in 2008, she worked at J.P. Morgan Chase as an to federal service, she was a research fellow at the investment banking equity sales analyst. Ms. Fryer Brookings Institution in Washington, D.C. She has graduated cum laude from Harvard College with a authored numerous publications on health policy B.A. in a self-designed major, “The Determinants of issues, insurance, and national/international health Population Health,” and a minor in health policy. system performance and coauthored the book, Health and the War on Poverty. She holds an undergraduate Douglas McCarthy, M.B.A., president of Issues degree in economics from Smith College and a Research, Inc., in Durango, Colorado, is senior research graduate degree in economics from Boston College. adviser to The Commonwealth Fund. He supports the Commonwealth Fund Commission on a High Edward L. Schor, M.D., is vice president of The Performance Health System Scorecard and Research Commonwealth Fund, where he directs the State Project, conducts case studies on high-performing Health Policy and Practices program. The goal of that health care organizations, and is a contributing editor program is to help state leaders create the policies 6 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 and programs that will lead to higher health system Acknowledgments performance, especially for low-income populations, The authors owe sincere appreciation to Christina emphasizing the integration of services to achieve Bethell, Ph.D., M.P.H., M.B.A., and her team at better coordination of care and efficiency. He the Child and Adolescent Health Measurement previously directed the Fund’s Child Development and Initiative for their thoughtful review and assistance Preventive Care program. He is a pediatrician and in interpreting data from the National Survey of has held a number of positions in pediatric practice, Children’s Health and National Survey of Children with academic pediatrics, health services research, and Special Health Care Needs. We thank Paul Fronstin, public health. Prior to joining The Commonwealth Ph.D., at the Employee Benefit Research Institute, for Fund he was medical director for Family and providing uninsured rates derived from the Current Community Health in the Iowa Department of Public Population Survey; Jonathan Gruber, Ph.D., and Ian Health. Perry at the Massachusetts Institute of Technology for providing projected uninsured rates using the Gruber Microsimulation Model; and Nicholas Tilipman, Columbia University Mailman School of Public Health, for programming support. We are especially grateful to the Fund’s communications team, including Barry Scholl, Chris Hollander, Martha Hostetter, Mary Mahon, Christine Haran, Suzanne Barker Augustyn, and Paul Frame, for their guidance, editorial and production support, and public dissemination efforts. The authors also wish to acknowledge the Institute for Healthcare Improvement for its support of the research unit, which enabled the analysis and development of the report. www.commonwealthfund.org7 8 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 EXECUTIVE SUMMARY health care for more than one-third of all children A child’s health, ability to participate fully nationally. Children’s coverage has expanded in 35 in school, and capacity to lead a productive, states since the start of the last decade and held healthy life depend on access to preventive and steady even in the middle of a severe recession. effective health care—starting well before birth At the same time, coverage for parents—lacking and continuing throughout early childhood and similar protection—deteriorated in 41 states. adolescence. Since healthy children are key to the With the goal of identifying opportunities well-being and economic prosperity of families to improve, this Scorecard examines state and society, investing in child health has long been performance on 20 key health system indicators a high priority for federal and state policy. This for children clustered into three dimensions: access State Scorecard on Child Health System Performance, and affordability, prevention and treatment, and 2011, finds that federal action to extend insurance potential to lead healthy lives. It also examines to children has made a critical difference in state performance by family income, insurance reducing the number of uninsured children across status, and race/ethnicity to assess the equity of the states and maintaining children’s coverage during child health care system—the fourth dimension the recent recession. However, the report also finds of performance. The analysis ranks states and the that where children live and their parent’s incomes District of Columbia on each indicator and the significantly affect their access to affordable four dimensions. The analysis finds wide variation care, receipt of preventive care and treatment, in system performance, with often a two- to and opportunities to survive past infancy and threefold difference across states, as illustrated in thrive. Better and more equitable results will Exhibit 1. require improving the quality of children’s health Benchmark levels set by leading states show care across the continuum of their needs as well there are abundant opportunities to improve as holding health care systems accountable for health system performance to benefit children. If preventing health problems and promoting health, all states achieved top levels on each dimension not just caring for children when they are sick or of performance, 5 million more children would injured. be insured and 10 million more children would The Scorecard’s findings on children’s health receive at least one medical and dental preventive insurance attest to the pivotal role of federal and care visit per year. About six hundred thousand state partnerships. Until the start of this decade, more children ages 19 to 35 months would be the number of uninsured children had been rising up to date on all recommended doses of six key rapidly as the levels of employer-sponsored family vaccines, and 370,000 fewer children with special coverage eroded for low- and middle-income health care needs would have problems getting families. This trend was reversed across the nation referrals to specialty care services. Likewise, nearly as a result of state-initiated Medicaid expansions 9 million additional children would have a medical and enactment and renewal of the Children’s home to help coordinate their care. Health Insurance Program (CHIP). Currently, The 14 states in the top quartile of the overall per- Medicaid, CHIP, and other public programs fund formance ranking—Iowa, Massachusetts, Vermont, www.commonwealthfund.org9 EXECUTIVE SUMMARY Exhibit 1 Indicators of State Child Health System Performance Range of performance All (Bottom state states rate—Top Dimension and indicator Year median state rate) Best state Access & Affordability 1 Children ages 0–18 insured 2008–09 91.4 82.0–96.7 MA 2 Parents ages 19–64 insured 2008–09 83.7 65.5–95.6 MA 3 Currently insured children whose health insurance 2007 77.0 68.7–83.8 HI coverage is adequate to meet needs 4 Average total premium for employer-based family coverage as percent of median income for family 2009 18.6 24.9–13.9 CT household (all members under age 65) Prevention & Treatment 5 Children with a medical home 2007 60.7 45.4–69.3 NH 6 Young children (ages 19–35 months) received all 2009 74.4 64.6–84.1 IA recommended doses of six key vaccines 7 Children with a preventive medical care visit in the 2007 87.8 76.7–97.7 RI past year 8 Children ages 1–17 with a preventive dental care visit 2007 79.1 68.5–86.9 HI in the past year 9 Children ages 2–17 needing mental health treatment/ counseling who received mental health care in the 2007 63.0 41.7–81.5 PA past year 10 Young children (ages 10 months–5 years) received 2007 18.8 10.7–47.0 NC standardized developmental screening during visit 11 Hospital admissions for pediatric asthma per 100,000 2006 128.7 251.0–44.1 OR children ages 2–17 12 Children with special health care needs who had no 2005–06 80.3 70.3–89.8 RI problems receiving referrals when needed 13 Children with special health care needs whose families 2005–06 72.8 56.7–83.0 IN received all needed family support services Potential to Lead Healthy Lives 14 Infant mortality, deaths per 1,000 live births 2006 6.8 11.9–4.7 WA 15 Child mortality, deaths per 100,000 children ages 1–14 2007 20.0 34.0–9.0 RI 16 Young children (ages 4 months–5 years) at moderate/ 2007 25.8 35.2–18.6 ME & MN high risk for developmental or behavioral delays 17 Children ages 10–17 who are overweight or obese 2007 30.6 44.4–23.1 MN & UT 18 Children ages 1–17 with oral health problems 2007 25.8 31.6–20.0 MN 19 High school students who currently smoked cigarettes 2009 18.3 26.1–8.5 UT 20 High school students not meeting recommended physical activity level 2009 56.0 66.7–46.4 ID Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 10 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Maine, New Hampshire, Rhode Island, Hawaii, policies are needed to improve child health system Minnesota, Connecticut, North Dakota, Penn- performance for all families. States that invest sylvania, Wisconsin, Kansas, and Washington— in children’s health reap the benefits of having often perform well on multiple indicators and children who are able to learn in school and across dimensions (Exhibit 2). At the same time, become healthy, productive adults. Other states the Scorecard finds that even the leading states have can learn from models of high performance to opportunities to improve: no state ranks in the top shape policies that ensure all children are given the half of the performance distribution on all indica- opportunity to lead long, healthy lives and realize tors. At the other end of the spectrum, states in their potential. the bottom quartile generally lag in multiple areas, Greater investment in measurement and with worse access to care, lower rates of recom- data collection at the state level could enrich mended prevention and treatment, poorer health understanding of variations in child health system outcomes, and wide disparities related to income, performance. For many dimensions, only a limited race/ethnicity, and insurance status. set of indicators is available. Moreover, there is Throughout, the findings underscore the often a time lag in the availability of data. National importance of policy action to sustain children’s surveys of children’s health care are conducted at access to care in the midst of rising health care four-year intervals, for example. Hence, a large costs and financial stress on families. Access to care number of indicators discussed in this Scorecard must be coupled with statewide initiatives and date from 2007. The indicators of child health community efforts to improve health care system care quality presented here are also largely parent- performance for children. reported. The collection of more robust clinical The State Scorecard on Child Health System data on children’s health care quality is integral to Performance, 2011, finds that some states do future state and federal child health policy reform markedly better than others in promoting and could modify the state rankings provided in the health and development of their youngest this report. The CHIP program reauthorization residents, and in ensuring that all children are has begun to lead the way by creating a set of on course to lead healthy and productive lives. standardized quality measures for use by CHIP, As states, clinicians, and hospitals prepare to Medicaid, and health plans. The availability of core implement health reforms, the Scorecard provides a measures and information on community-level framework to take stock of where they stand today variation will enable states to learn from innovative and what they could gain by reaching and raising models. Work under way in many states as well benchmark performance levels. as efforts supported by CHIP and the Affordable The findings reveal crucial areas in which Care Act should lay a foundation for public and comprehensive federal, state, and community private action. www.commonwealthfund.org11 EXECUTIVE SUMMARY Exhibit 2 State Scorecard Summary of Child Health System Performance Across Dimensions es State Rank L iv hy Top Quartile t a lt en y Second Quartile ilit He tm ab rea Third Quartile ad rd Le &T Bottom Quartile f fo l to ion &A tia nt ss y ten ve uit ce Pre Po Ac RANK S TAT E Eq 1 Iowa 6 1 2 7 1 Massachusetts 1 4 7 4 3 Vermont 9 8 3 2 4 Maine 7 5 10 1 5 New Hampshire 2 2 13 11 6 Rhode Island 9 2 14 14 7 Hawaii 3 12 23 3 8 Minnesota 18 11 1 12 9 Connecticut 8 26 6 6 10 North Dakota 16 23 11 17 10 Pennsylvania 11 17 24 15 12 Wisconsin 21 14 8 25 13 Kansas 19 6 20 26 13 Washington 12 26 12 21 15 Michigan 14 29 21 9 16 Nebraska 22 16 14 23 17 West Virginia 24 10 39 5 18 Maryland 4 18 26 34 19 Ohio 14 8 36 27 20 Colorado 28 28 4 27 21 Missouri 26 19 30 13 21 New York 27 34 17 10 23 Utah 17 25 5 42 24 Virginia 4 34 25 27 25 Indiana 31 15 33 22 26 Tennessee 32 7 44 19 27 South Dakota 25 13 33 35 28 Illinois 33 22 31 32 29 New Jersey 23 41 16 39 30 Alaska 34 38 40 8 31 Delaware 13 33 32 45 32 North Carolina 35 20 28 43 33 South Carolina 44 23 45 15 34 Montana 42 49 17 20 35 Wyoming 36 31 22 41 36 Kentucky 40 30 46 17 37 Alabama 29 32 48 27 38 Oregon 39 46 9 47 39 District of Columbia 20 39 51 33 40 Louisiana 43 21 47 37 41 Idaho 38 50 17 44 42 Arkansas 41 37 49 23 43 Georgia 29 34 42 46 44 California 44 42 27 39 45 Oklahoma 36 47 41 31 46 New Mexico 46 40 37 35 47 Florida 49 44 35 38 48 Texas 50 48 29 50 49 Arizona 47 45 38 49 50 Mississippi 51 43 50 48 51 Nevada 48 51 43 51 Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 12 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Highlights Across states, the extent to which children have access to care is closely related to their Children’s health insurance coverage has receipt of preventive care and treatment. Yet expanded in many states, while parents’ cov- insurance does not guarantee receipt of rec- erage has eroded. Yet the number of unin- ommended care or positive health outcomes. sured children continues to vary widely Seven of the 13 leading states in the access and across states. affordability dimension also rank among the Currently 10 percent of children are uninsured top quartile of states in terms of prevention and nationally, and the uninsured rate for children treatment. Children in states with the lowest exceeds 16 percent in three states. In contrast, 19 uninsured rates are more likely to have a medical percent of parents are uninsured nationally, and home and receive preventive care or referrals to there are nine states in which 23 percent or more needed care than children in states with the highest of parents are uninsured. The difference between uninsured rates. While insurance matters, good children’s and parents’ coverage rates reflects federal care and outcomes are also a function of a well- action taken early in the last decade to insure functioning health care delivery system. Securing children, as well as continued federal support for coverage and access to affordable care for families children’s coverage. There is no national standard is only a first step to ensure that children obtain for coverage of parents, however poor. Still, the essential care that is well coordinated and patient- percent of uninsured children continues to vary centered. widely across states, ranging from a low of 3 percent in Massachusetts to a high of 17 percent Children’s access to care, health care qual- to 18 percent in Nevada, Florida, and Texas. The ity, and health outcomes vary widely across states. range underscores the importance of state as well The Scorecard findings show that where a child as federal action to ensure access and continuity of lives has an impact on his or her potential to lead care. a healthy life into adulthood. States vary widely The passage of the Affordable Care Act will— in their provision of children’s health care that is for the first time—provide health insurance to effective, coordinated, and equitable. This variability all low- and middle-income families. To achieve extends to states’ ability to ensure opportunities for this, the law will expand Medicaid to low-income children to achieve optimal health. parents as well as childless adults with incomes There is a twofold or greater spread between the up to 133 percent of the federal poverty level, best and worst states across important indicators of beginning in 2014. This represents a substantial access and affordability, prevention and treatment, change in Medicaid’s coverage of adults. The law and potential to lead healthy lives (Exhibit 1). will also assist families with low and moderate The performance gaps are particularly wide on incomes to purchase coverage through insurance indicators assessing developmental screening rates, exchanges and tax credits. These policies will provision of mental health care, hospitalizations directly benefit children as families gain financial because of asthma, prevalence of teen smoking, security, and parents’ health improves. and mortality rates among infants and children. Lagging states would need to improve their www.commonwealthfund.org13 performance by 60 percent on average to achieve children would receive recommended vaccines by benchmarks set by leading states. the age of 3 years. If all states were to improve their performance Leading states—those in the top quartile— to levels achieved by the best states, the cumulative often do well on multiple indicators across effect would translate to thousands of children’s dimensions of performance; public policies lives saved because of more accessible and and state/local health systems make a improved delivery of high-quality care. In fact, difference. improving performance to benchmark levels across The 14 states at the top quartile of the overall the nation would mean: 5 million more children performance rankings generally ranked high on would have health insurance coverage, nearly 9 multiple indicators and dimensions (Exhibit 2). million children would have a medical home to In fact, the five top-ranked states—Iowa, Massa- help coordinate care, and some 600,000 more chusetts, Vermont, Maine, and New Hampshire— IOWA’S COMPREHENSIVE PUBLIC POLICIES MAKE A DIFFERENCE FOR CHILDREN’S HEALTH Iowa, tied in first place with Massachusetts in terms notifies the 1st Five Child Health Center. The center’s of overall children’s health system performance, has care coordinator then contacts the family to link them had a long-standing commitment to children. In the to appropriate services in the community or help coor- past decade, the state paid particular attention to the dinate referrals. needs of its youngest residents, from birth to age 5. Iowa also has expansive policies in place to ensure chil- After piloting a variety of programs in the early 1990s dren have health care coverage. The State Children’s to identify and serve at-risk children and families, the Health Insurance Program covers all children under Iowa legislature established a statewide initiative to age 19 in families with income levels up to 133 per- fund “local empowerment areas” across the state. cent of the federal poverty level (FPL). Children ages The partnerships among clinicians, parents, child care 6–18 whose family income is between 100 percent and representatives, and educators seek to ensure children 133 percent of FPL and infants whose family income is receive needed preventive care. between 185 percent and 300 percent of FPL are cov- State leaders have focused on child health outcomes ered through an expansion of Medicaid. Meanwhile, by promoting the federal Early and Periodic Screening, children in families with income from 133 percent to Diagnosis, and Treatment (EPSDT) program. In 1993, 300 percent of FPL are covered through private insur- an EPSDT Interagency Collaborative was formed with ance, in a program known as Healthy and Well Kids a fourfold purpose: to increase the number of Iowa in Iowa (hawk-i). Iowa contracts with private health children enrolled in EPSDT; to increase the percent- plans to provide covered services to children enrolled age of children who receive well-child screenings; to in the hawk-i program, with little or no cost-sharing ensure effective linkages to diagnostic and treatment for families. Recently, in the spring of 2010, hawk-i services; and to promote the overall quality of services implemented a dental-only plan. delivered through EPSDT. As a result of these efforts, Iowa’s innovative policies and public–private partner- the statewide rate of well-child screenings rose from 9 ships to improve children’s health care serve as ev- percent to 95 percent in just over five years. idence-based models that other states can follow to Iowa has also been making strides in providing high- move toward a higher-performing child health system. quality mental health care for children. Its 1st Five Healthy Mental Development Initiative focuses on a child’s first five years. The state-led initiative helps pri- For more information see N. Kaye, J. May, and M. K. Abrams, vate providers to develop a sound structure for assess- State Policy Options to Improve Delivery of Child Development Services: Strategies from the Eight ABCD States (Portland, ing young children’s social and developmental skills. Maine, and New York: National Academy for State Health Under the 1st Five system, a primary care provider Policy and The Commonwealth Fund, Dec. 2006); and S. Silow- screens children and their caregivers when they come Carroll, Iowa’s 1st Five Initiative: Improving Early Childhood in for a visit; if a concern is identified, the provider Developmental Services Through Public–Private Partnerships, (New York: The Commonwealth Fund, Sept. 2008). 14 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 performed in the top quartile on each of the four Virginia and Tennessee face high rates of poverty, dimensions of performance. Many have been lead- unemployment, and disease yet rank in the top half ers in improving their health systems by taking of performance on indicators of children’s health. steps to cover children or families, promote public West Virginia does exceptionally well in ensuring health, and improve care delivery systems (See box access and high-quality care for its most vulnerable on Iowa). children, ranking fifth in terms of equity. Alabama In contrast, states at the bottom quartile of is in the top quartile for children’s insurance, with overall child health system performance lagged nearly 94 percent insured. And North Carolina well behind the leaders on multiple indicators of leads in providing developmental screening for performance. These states had rates of uninsured young children. children and parents that were, on average, more Leading states as well as those that outperform than double those in the top quartile of states. Re- neighboring states within a region have often made flecting the strong association between access to concerted efforts to improve through coverage and care and the quality and continuity of care, chil- quality improvement initiatives. Learning about dren in the lowest-quartile states were among the these initiatives can offer insights for other states, least likely to receive routine preventive care vis- particularly those starting with similar health its or mental health services when needed, or to systems or resource constraints. report having a primary care practice that serves as There is room to improve in all states. Even in a medical home to provide care and care coordi- the best states, performance falls short on at nation. Notably, rates of developmental delays and least some indicators and state averages are infant mortality are more than 20 percent to 30 below what should be achievable. percent higher, respectively, in the lowest-quartile All states have room to improve. None ranked in states compared with top-quartile states. the top half of the performance distribution across These patterns indicate that public policies, all indicators. For some indicators, performance as well as state and local health systems, can was not outstanding even in the high-ranked make a difference to children’s health and health states. For example, North Carolina ranked first care. But socioeconomic factors also play a role— in terms of screening children for developmental underscoring the importance of federal and state or behavioral delays, yet more than half of policies in areas with high rates of poverty. children in the state were not screened, based on parents’ reports. Nearly a third of children did Regional performance patterns provide valuable insight. not have access to care meeting the definitions of The Scorecard revealed regional patterns in a medical home, even in the top-ranked state in child health system performance (Exhibit 3). this indicator. Conversely, states that performed Across dimensions, states in New England and poorly overall outperformed higher-ranking states the Upper Midwest often rank in the highest on some indicators. There is value in learning from quartile of performance, whereas states with best practices around the nation. the lowest rankings tend to be concentrated Rising rates of childhood overweight or in the South and Southwest. Yet within any obesity plague all states. Moreover, many children region, there are exceptions. For example, West live with oral health problems that could be www.commonwealthfund.org15 EXECUTIVE SUMMARY Exhibit 3 State Ranking on Child Health System Performance NH WA VT ME MT ND MN OR NY MA WI ID SD MI RI WY PA CT NJ IA NE OH NV IN DE IL WV MD UT CO VA DC CA KS MO KY NC TN OK AR SC AZ NM MS AL GA TX LA FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. addressed with timely, affordable access to effective POLICY IMPLICATIONS preventive dental care and treatment. Even in the Overall, the Scorecard indicates that multiple top-ranked state on this indicator, Minnesota, one dimensions of health system performance of five children has oral health problems such as for children are related. Reducing high rates tooth decay, pain, or bleeding gums. of admission to the hospital or emergency Inequitable care and outcomes by insurance department for children’s asthma requires primary status, income, and race/ethnicity remain a large care resources and, potentially, public health concern. Uninsured, low-income, and minority interventions to reduce the triggers of asthma children have less than equal opportunity to thrive attacks. Poor access undermines the quality of care in nearly all states. Yet in some higher-performing and drives up costs for complications that could states, these vulnerable children do nearly as well have been prevented. High rates of infant mortality as the national average and rival performance levels are related to high rates of low-birthweight babies, achieved for children in higher-income families, which in turn are related to the mother’s health indicating that gains in statewide performance and care during pregnancy. Promoting healthy are achievable by focusing on the most vulnerable family behaviors in medical and community children. settings is a key component to preventing 16 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 unnecessary deaths, chronic conditions, and Provisions for support of pediatric accountable care complications among both children and adults. organizations through state Medicaid programs will Ensuring well-coordinated, high-quality care, promote innovative, integrated care systems that including preventive care, will require physicians emphasize the “triple aim” of better health, better and hospitals to work together with families and care experiences, and slower cost growth.3 share accountability for children’s health. Clinical Overall, the State Scorecard on Child Health care systems also need to work hand in hand with System Performance, 2011, reveals that—in the public health professionals and community-based period leading up to the enactment of federal health groups to implement programs and evaluate care reforms—there were wide geographic variations progress toward achieving population health in health care system performance for children and goals.1 ample opportunities to improve. The gaps between The report indicates that federal action is benchmarks set by top-performing states and essential to support state and community efforts average performance, as well as the wide range of for children. This year will mark the second performance across the nation, indicate that the anniversary of the Children’s Health Insurance United States is failing to ensure that all children Program Reauthorization Act (CHIPRA), an receive the timely, effective, and well-coordinated event that affirmed the national commitment care they need for their health and development. to expanding coverage of children in low- and This Scorecard documents geographic variations in modest-income families. The federal stimulus bill risk factors such as developmental delay and obesity, strengthened this support by increasing federal pointing out the need for comprehensive medical matching rates for Medicaid to enable states to and public health interventions to support children maintain these programs in the midst of a severe and their families in obtaining needed services and recession. adopting healthy lifestyles. By expanding coverage to adults, as well as While top-performing states provide examples to children, the Affordable Care Act will for the for other states, the fact remains that none of the first time ensure that coverage will be accessible states performed well on all indicators and many and affordable for families in all states. Insurance performed at levels that are far from optimal— expansion to parents will enhance children’s highlighting the need for systemic change. Compared health and financial security, based on studies with other states, poorly performing states often that find that children are more likely to be have fewer resources, larger uninsured populations, enrolled in coverage and receive care when their and greater socioeconomic challenges that may parents are also insured and have the ability to limit their capacity for improvement.4 The formula pay for care. for determining federal funding of state Medicaid Health system provisions of the Affordable programs recognizes this inequality among states. Care Act will improve primary care in all states Likewise, the recent economic recession illustrates by enhancing Medicaid as well as Medicare how federal funding plays a countercyclical role to payments for primary care and encouraging help all states maintain coverage during times of physician practices to serve as medical homes.2 fiscal duress. The Affordable Care Act will continue www.commonwealthfund.org17 this precedent with a flow of resources into states 4. Promote accountable, accessible, patient- with the highest rates of poverty. centered, and coordinated care for children Hence, a coherent set of national and state by participating in various Medicaid policies is essential to sustain improvements in pilots and demonstrations as well as grant children’s health care across the nation. Federal opportunities to create integrated care health reform provides the common foundation delivery models to improve care in local on which states can build to help eliminate the communities. variations, gaps, and disparities in children’s 5. Support information systems to inform coverage and care documented in this Scorecard. and guide efforts to improve quality, health Notably for children, the Affordable Care Act outcomes, and efficiency. This includes: strengthens and depends on successful federal– adoption of pediatric quality measures to state partnership—not only to expand coverage report on CHIP performance; expanded use but also to improve the quality of care for children. of children’s outcome measures, including State action and leadership will be essential tracking potentially preventable rates of to implement reforms effectively and to support hospital and emergency department use; and initiatives tailored to specific state circumstances. promoting effective use of health information Actions states can take include: technology with exchange across sites of care to enhance coordination and safety and to 1. Ensure continuous insurance coverage for all support clinicians caring for children and children by making it easy to sign up for and their families. keep insurance for children and families. This 6. Participate in statewide initiatives, including includes: removing administrative barriers, support for shared resources such as after- streamlining applications, and coordinating hours care and community health teams, public and private coverage for lower-income to provide the accountable leadership and families through health insurance exchanges. collaboration essential to set and achieve 2. Strengthen Medicaid and CHIP provider goals for children’s health. networks with support of care systems that provide high-quality care and superior With costs rising faster than incomes and outcomes for children and their families. pressuring families and businesses, effective public 3. Align provider incentives to promote access policies as well as improvement efforts within care and high-value care. This includes participat- systems are needed. Realizing the potential of recent ing in multipayer initiatives that support care federal reforms that focus on children will require coordination in primary care medical homes, a team effort, calling upon both community-level which can help reduce hospitalizations and interventions and effective state policies. One of emergency department use. 18 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 the strengths of the U.S. health care system is its long-term payoffs: healthy children are better able examples of excellence and innovation. Ensuring to learn in school and are more likely to become that all children have the opportunity to thrive healthy, productive adults. Individuals, families, through a health care system that responds to their and society as a whole benefit from reduced needs will depend on learning from these diverse dependency and disability, a healthier future experiences and spreading successful improvement workforce, and a stronger economy. strategies. Investing in children’s health yields www.commonwealthfund.org19 INTRODUCTION performers on child health system measures is one The early years of a child’s life are pivotal to their such way; it provides achievable benchmarks and future health and development. Disparities in focuses attention on opportunities to improve. health and development emerge during children’s The State Scorecard on Child Health System first few years and worsen with age.5 The nation’s Performance, 2011, builds on The Commonwealth health care system plays a vital role in helping Fund’s series of scorecards assessing national and children get a healthy start so they can lead state health care systems across core dimensions long, healthy, and productive lives, laying the of performance. Prepared for state policymakers, groundwork for a strong workforce and economy. national leaders, and other health care A high-performing health care system would stakeholders, this Scorecard offers information on ensure that all children have equal access to high- states’ performance with respect to children’s access quality and efficiently delivered care and would to care, health care quality, population health, and partner with schools and community organizations equity. It also provides a means to gauge the impact to support families in effectively meeting children’s of reform efforts as states, communities, providers, health and developmental needs. and other constituencies work to organize more Despite the best efforts of health care effective local delivery systems that, collectively, professionals, our current health system determine statewide performance. underperforms in accomplishing these goals in This report follows and expands on a report comparison with other industrialized countries.6 published in 2008 on state variations in child Recent reports, for example, find the United States health system performance.9 It expands the set falling further behind other wealthy countries on of indicators and omits others that could not be one key indicator: survival of children past age 5.7 updated. Changes in the definitions of several Within the United States, children’s health and the indicators subsequent to the 2008 report made it care they receive, to a certain extent, depends on impossible to compare trends for those indicators. where they live. National and state-level analyses As a result, this 2011 report provides a new state repeatedly find that the performance of the health baseline rather than trends, and is not directly care system varies widely across states in terms of access comparable to the 2008 report. to care as well as the quality, cost, and equity of This report follows the methodology used in care that children receive.8 The Children’s Health the earlier report and The Commonwealth Fund’s Insurance Program Reauthorization Act of 2009 general state health system scorecards. The analysis (CHIPRA) and enactment of federal health reform ranks states relative to the performance of other provide a strong foundation on which the nation states based on the most recent data available— and states can build more effective systems of care typically from 2007 to 2009—and clusters for children, who are the future of our nation. indicators into four dimensions of performance. As states implement reforms to achieve higher- Specifically, the report includes 20 key indicators of value, affordable health care systems for children health system performance for children along the and their families, they need a way to take stock dimensions of access and affordability, prevention of their performance and identify areas for and treatment, the potential to lead healthy lives, improvement. Canvassing states to identify top and equity. The methods box below explains the 20 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Scorecard methodology and limitations on data each state had in each performance quartile. The currently available at the state level. The Appendix Appendix also includes demographic tables that to this report provides data for all indicators profile states by incidence of poverty, health risks, organized by dimension and shows the states’ and race/ethnicity. rates and rankings on each indicator. The first two The State Scorecard Data Tables, which are appendix tables display summary information: available online at http://www.commonwealthfund. Appendix A1 shows overall state rankings and org/~/media/Files/Publications/Fund%20 where each state ranks on the four dimensions, Report/2011/Feb/Child%20Health%20Scorecard/ and Appendix A2 shows how many indicators state_data_tables.pdf, show differences by family WHAT THE SCORECARD MEASURES Dimensions and Indicators As child-specific indicators evolve, future child health The State Scorecard on Child Health System system scorecards will add new measures to enrich the Performance, 2011, measures health system perfor- cross-state comparisons. mance for all 50 states and the District of Columbia us- Appendix B describes the 20 indicators, years, and ing 20 key indicators (Exhibit 1). It organizes indicators data sources for the State Scorecard on Child Health by four broad dimensions that capture critical aspects System Performance, 2011. of health system performance: • Access and Affordability—includes rates of in- Scorecard Ranking Methodology surance coverage for children and parents as The State Scorecard on Child Health System well as indicators of coverage adequacy and the Performance, 2011, first ranks states from best to worst affordability of care. on each of the 20 performance indicators. We aver- aged rankings for those indicators within each of the • Prevention and Treatment—includes indicators four dimensions to determine a state’s dimension rank that measure three related quality-of-care com- and then averaged the dimension rankings to arrive ponents: effective primary and preventive care, at an overall ranking on health system performance. provision of mental health services, and care This approach gives each dimension equal weight and, coordination, including supportive services for within dimensions, weights indicators equally. We use children with special health care needs. average state rankings for the Scorecard because we • Potential to Lead Healthy Lives—includes in- believe that this approach is easily understandable. dicators that measure the degree to which a This ranking method follows that used by Stephen state’s children enjoy long and healthy lives. Jencks and colleagues when assessing the quality of care for Medicare beneficiaries at the state level across • Equity—includes differences in performance multiple indicators.* on selected indicators from the other three dimensions associated with children and par- For the equity dimension, we ranked states based on ent’s income level, type of insurance, or race or the difference between the most vulnerable subgroup ethnicity. (i.e., low-income, uninsured, or racial/ethnic minority) and the national average on selected indicators. The Where possible, indicators for this report were se- gap indicates how the vulnerable subgroup fares com- lected to be equivalent to those used in the National pared with the U.S. average—an absolute standard. Scorecard on U.S. Health System Performance. However, for some areas, there are no child measures available across states that are comparable to indica- *S. F. Jencks, T. Cuerdon, D. R. Burwen et al., “Quality of tors that are available in the National Scorecard. For Medical Care Delivered to Medicare Beneficiaries: A Profile at instance, databases do not currently track effective State and National Levels,” Journal of the American Medical Association, Oct. 4, 2000 284(13):1670–76; and S. F. Jencks, management of chronic conditions, adverse medical E. D. Huff, and T. Cuerdon, “Change in the Quality of Care or medication events, utilization of the emergency Delivered to Medicare Beneficiaries, 1998–1999 to 2000– department, or potential overuse or duplication of 2001,” Journal of the American Medical Association, Jan. 15, health services across all states for adults or children. 2003 289(3):305–12. www.commonwealthfund.org21 income as well as insurance status and race/ coverage. Massachusetts achieved top ranking on ethnicity for the subset of indicators used in the this dimension because it has the lowest rates of equity dimension. State profiles, available online uninsured children and parents in the country. at http://www.commonwealthfund.org/Charts- and-Maps/State-Data-Center/Child-Health.aspx, Health Insurance Coverage provide estimates for each state of the potential Over the last decade there has been considerable gain it could achieve if it met the benchmark expansion of health coverage for children (Exhibit performance level set by the leading state for each 5). From 1999–2000 to 2008–09, the number of indicator. states with high rates of uninsured children (16% or more) has declined from 11 to three states. The remaining three states—Florida, Nevada, ACCESS AND AFFORDABILITY and Texas—fall within the bottom five states on Access to health care is the foundation and this Scorecard’s access dimension. West Virginia hallmark of a high performance health system. is particularly notable for having reduced their The foremost factor in determining whether children’s uninsured rate by half in the last 10 years, people have access to care when needed is having as is Alabama for having one of the lowest rates insurance that covers essential care. Consequently, of uninsured children among Southern states and the extent to which families are able to obtain ranking high among all states—with 94 percent coverage that is both comprehensive and affordable of children insured as of 2008–09. The high rates plays a critical role. The access and affordability of children insured in Alabama compared with dimension of this Scorecard looks at the percent other states in the region reflect that state’s targeted of children and parents with health insurance effort to expand insurance to children. (See box on coverage, the percent of currently insured children Alabama.) whose health coverage is adequate based on reports Much of the success in expanding the number by their parents, and the average total premium of insured children can be attributed to federal and for employer-based family coverage as a percent of state action to cover low- and moderate-income median income for family households. families. Medicaid expanded coverage to young This analysis finds that significant gaps and children living in poverty by providing states with variability in access to care persist across the nation. federal matching funds for this purpose. In 1997, Children in the Northeast and Midwest as well as the State Children’s Health Insurance Program in the Pacific states of Hawaii and Washington (CHIP) was enacted to provide a capped amount generally were more likely to be insured and have of federal matching funds to states for coverage better access to care than their peers in the West of children and some parents with incomes and South (Exhibit 4). The three top-ranked too high to qualify for Medicaid, but for whom states in this dimension—Massachusetts, New private health insurance was either unavailable or Hampshire, and Hawaii—performed well on all unaffordable. Covering nearly 8 million children four access indicators. These states are among those in 2009, CHIP has played an important role in with the most expansive policies supporting public reducing the number of uninsured children.10 health insurance for low- and moderate-income In particular, investments in CHIP and families and insurance market reforms to expand Medicaid support to states have largely offset the 22 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 impact of the economic downturn and resulting made it possible for more than half of states to loss of employer-based coverage. Unlike adult increase eligibility levels or streamline enrollment coverage rates, which declined during the recent and retention procedures since the passage of recession, coverage of children held and improved CHIPRA, despite coping with excruciating budget slightly, with one of 10 children uninsured, on pressures.11 average, in 2008–09. The coverage landscape Still, children’s risk of being uninsured remains for children would have looked far worse had uneven across states (Appendix A3). In 2008–09, states not had federal financial support to expand the percentage of children age 18 and under who eligibility for children and increase outreach and were uninsured ranged from a low of 3 percent in enrollment efforts, as well as the enhanced federal Massachusetts to a high of 18 percent in Texas. support of Medicaid with the stimulus funds. This gap in part reflects the differences in current With the congressional reauthorization of CHIP eligibility standards in addition to enrollment in 2009, as well as additional Medicaid funds made and retention barriers for public health insurance available to states under the American Recovery programs across states. Varying Medicaid/CHIP and Reinvestment Act (ARRA) of 2009, states have policies across states are illuminated by the even managed to preserve and in some cases broaden wider variation in insurance coverage among health coverage for children. Such federal action children living in low-income families. (The Equity ACCESS AND AFFORDABILITY Exhibit 4 State Ranking on Access and Affordability Dimension NH WA VT ME MT ND MN OR MA WI NY ID SD MI RI WY PA CT IA NJ NE OH DE NV IL IN WV MD UT VA CO DC CA KS MO KY NC TN OK SC AZ AR NM MS AL GA TX LA FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org23 ACCESS AND AFFORDABILITY Exhibit 5 Percent of Children Ages 0–18 Uninsured by State 1999–2000 2008–2009 NH ME NH ME WA VT WA VT MT ND MT ND MN MN OR NY MA OR NY MA WI WI ID SD RI ID SD RI MI MI WY CT WY CT PA NJ PA NJ IA IA NE OH NE OH IN DE IN DE NV NV IL WV VA MD IL MD UT UT WV VA CO DC CO DC CA KS MO KY CA KS MO KY NC NC TN TN OK AR SC OK SC AZ NM AZ NM AR MS AL GA MS AL GA TX LA TX LA FL FL AK AK HI HI 16% or more 10%–15.9% 7%–9.9% Less than 7% Data: U.S. Census Bureau, 2000–01 and 2009–10 Current Population Survey ASEC Supplement. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. ACCESS AND AFFORDABILITY Exhibit 6 Percent of Parents Ages 19–64 Uninsured by State 1999–2000 2008–2009 NH ME NH ME WA VT WA VT MT ND MT ND MN MN OR NY MA OR NY MA WI WI ID SD RI ID SD RI MI MI WY CT WY CT PA NJ PA NJ IA IA NE OH NE OH IN DE IN DE NV NV IL WV VA MD IL WV VA MD UT UT CO DC CO DC CA KS MO KY CA KS MO KY NC NC TN TN OK AR SC OK AR SC AZ NM AZ NM MS AL GA MS AL GA TX TX LA LA FL FL AK AK HI HI 23% or more 19%–22.9% 14%–18.9% Less than 14% Data: U.S. Census Bureau, 2000–01 and 2009–10 Current Population Survey ASEC Supplement. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 24 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 section of this report examines coverage variations increased from just three to nine (Exhibit 6). At by income in more detail.) the same time, the number of states with low The contrast between children’s coverage trends rates of uninsured parents (under 14%) declined and those for parents highlights the importance of from 29 states to 17 (including the District of federal as well as state action. While states have Columbia). Across states, the share of parents made great strides in covering children following who were uninsured ranged from 4 percent in federal Medicaid and CHIP expansions, the Massachusetts to nearly 35 percent in Texas. number of parents under age 65 without health In all, 41 states experienced some decline in the insurance has remained high and risen rapidly as percentage of parents with insurance from 1999– lower-income parents have been unable to afford 2000 to 2008–09 (Appendix A4). coverage on their own and secure jobs with health The failure of states to insure parents—and benefits. In the past decade, the number of states entire families—hinders their ability to sustain and with 23 percent or more of parents uninsured advance access for children. Studies show that if A COLLABORATIVE RELATIONSHIP IN ALABAMA THAT MAXIMIZES ENROLLMENT FOR CHILDREN Alabama has made great strides in expanding chil- the application and renewal process for insurance. dren’s access to health care. With 94 percent of chil- An initiative to create a common client index across dren insured as of 2008–09, the state has one of the Alabama’s social service agencies further simplifies data- highest children’s insurance rates among Southern sharing and may also make Express Lane Eligibility states. Much of Alabama’s success can be attributed for children in other public programs easier to imple- to high enrollment rates in the state’s children’s in- ment. Alabama also has raised Medicaid reimburse- surance programs. Alabama’s State Children’s Health ment rates for physicians and dentists in an effort to Insurance Program (SCHIP), the first such program to increase provider participation and improve access for be approved nationally, began in February 1998 as an enrollees. effort to expand Medicaid eligibility to children up to States can learn from Alabama’s success in fielding age 19 in families with incomes up to 100 percent of effective outreach efforts, establishing community- the federal poverty level (FPL). In late 1998, Alabama based partnerships, building trust among both families rolled out a separate program through the Blue Cross/ and providers, and fostering relationships at the local Blue Shield network. Called All Kids, it covers children level; all have yielded statewide support for children’s under age 19 in families with incomes up to 200 per- coverage. States can also look to the Children’s Health cent FPL. One year ago the Alabama legislature voted Insurance Program Reauthorization Act (CHIPRA), to expand All Kids eligibility to children in families which provides states with new tools and incentives with incomes up to 300 percent FPL. The Alabama to address shortfalls in participation in Medicaid Department of Public Health estimates an additional and CHIP. The tools include outreach and enrollment 10,000 children will be eligible for coverage under this grants and bonus payments to states that adopt five expansion. of eight enrollment and retention strategies, as well The Alabama Department of Public Health, which ad- as to states that experience Medicaid enrollment in- ministers All Kids, and the Alabama Medicaid Agency creases that exceed target growth rates. have created a successful collaborative relationship that benefits enrollees of both programs and encour- ages administrative efficiencies. By sharing marketing For more information see R. Kellenberg, L. Duchon, and and outreach efforts, aligning eligibility rules, and im- E. Ellis, Maximizing Enrollment in Alabama: Results from a Diagnostic Assessment of the State’s Enrollment and proving system interfaces, the two agencies have over- Retention Systems for Kids, Maximizing Enrollment for Kids come many common barriers to enrolling children in Program (Portland, Maine, and Princeton, N.J.: National health insurance. Technology-driven solutions such as Academy for State Health Policy and Robert Wood Johnson an online joint application are being used to simplify Foundation, Feb. 2010), available at http://www.rwjf.org/ files/research/56388alabama.pdf. www.commonwealthfund.org25 parents are insured, the likelihood is greater that not provide adequate benefits, provider choices, or their children will be insured and receive necessary coverage of costs. Parents’ rating of their children’s care.12 Still, Medicaid eligibility levels for parents coverage as adequate ranged from a high of 84 remain incredibly low: in 33 states, a working percent of all insured children in Hawaii to a parent would have to earn less than 100 percent low of 69 percent in Minnesota. Interestingly, of the federal poverty level to qualify.13 In contrast, children residing in the Midwest—a region with nearly all states extend CHIP coverage to children higher-than-average rates of coverage—were in families with incomes up to 200 percent of the less likely to be adequately covered, based on federal poverty level or higher. In some states, their parent’s assessment. A separate study of eligibility extends to as much as 300 percent and inadequate coverage among children found that 400 percent of poverty (Exhibit 7). those classified as underinsured have many of the Past studies find that states that implemented same negative experiences affecting children who broad coverage expansions to low-income parents were uninsured, including delayed or forgone care, had higher child participation rates, compared lack of a medical home, and difficulty obtaining with states that had not done so.14 Not surprisingly, referrals and specialty care.16 there is a strong positive relationship between Parents’ views of the adequacy of their coverage among parents and children across children’s coverage varied by insurance type. On states.15 Massachusetts, Hawaii, Maine, Wisconsin, average, according to parents’ reports, a larger and Vermont—the five states with the lowest rates portion of children with private insurance than of uninsured parents—also have among the lowest with public insurance had coverage that did not rates of uninsured children in the nation (with an meet their needs (26% vs. 19%). In the majority average of 8% of parents who are uninsured and of states, rates of inadequate insurance among 5% of children who are uninsured). Meanwhile, privately insured children exceeded rates for Texas, New Mexico, Florida, Arizona, and Nevada children covered by public programs by more than stand out for having high uninsured rates for both 50 percent; in eight states, ratings of the adequacy parents and children (averaging 27% and 17%, of private compared with public insurance respectively). A few states with relatively high rates differed more than 200 percent (Appendix A5). of uninsured parents have achieved especially low The stronger performance of public insurance in rates of uninsured children, such as Alabama and terms of meeting children’s needs underscores the West Virginia. protection both Medicaid and CHIP provide low- It is also critical to understand that health income families against high out-of-pocket costs. insurance coverage does not guarantee receipt Private coverage, on the other hand, may contain of appropriate care. Insurance is not enough if fairly substantial cost-sharing requirements, a it does not adequately cover needed services and narrower scope of benefits, and coverage limits or offer financial protection in the event of illness. exclusions. As an exception, there was no difference In 2007, a quarter of parents (24%) across the between parents’ perceptions of private and public country reported that their children’s current plans’ adequacy for their children in Hawaii, the health insurance coverage was insufficient for state with the best ratings of coverage adequacy their child’s needs. These parents said that it did overall. 26 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 ACCESS AND AFFORDABILITY Exhibit 7 Uninsured Rates and Medicaid/CHIP Income Eligibility Standards by State Income Eligibility for Medicaid/CHIP Percent Uninsured, 2008–09 (as percent of federal poverty levels), 2009 State Children Ages 0–18 Parents Ages 19–64 Children Working Parents Alabama 6.5 20.0 300 24 Alaska 12.4 20.0 175 81 Arizona 15.0 23.2 200^ 106 Arkansas 11.0 24.3 200 17/2001 California 11.1 23.5 250 106/2001 Colorado 11.4 17.2 250 106 Connecticut 6.8 11.2 300 191/3061 Delaware 9.5 13.4 200 121 District of Columbia 7.5 10.5 300 207 Florida 17.8 26.4 200 59 Georgia 11.5 22.6 235 50 Hawaii 4.6 7.4 300 100/2001 Idaho 9.7 18.7 185 39/1851 Illinois 8.1 16.4 200/3002 191/2001 Indiana 7.7 15.5 250 25/2001 Iowa 5.8 11.9 300 83/2501 Kansas 10.0 15.7 241 32 Kentucky 9.6 20.3 200 62 Louisiana 10.3 23.0 250 25 Maine 5.3 8.5 200 200/3001 Maryland 6.8 15.4 300 116 Massachusetts1 3.3 4.4 300 133/3001 Michigan 5.6 13.4 200 64 Minnesota 6.1 10.1 275 215/2751 Mississippi 12.3 23.4 200 44 Missouri 8.5 16.3 300 25 Montana 11.1 20.9 250 56 Nebraska 8.4 13.6 200 58 Nevada 16.6 23.3 200 88/2001 New Hampshire 3.9 11.7 300 49 New Jersey 10.4 16.1 350 133/2001 New Mexico 15.6 28.8 235 85/4081^ New York 7.6 15.9 400 75/1501 North Carolina 11.0 18.7 200 49 North Dakota 7.3 10.1 160 59 Ohio 7.5 12.0 200 90 Oklahoma 10.4 22.1 185 53/2001 Oregon 11.9 19.2 300 40/2011 Pennsylvania 7.3 12.0 300 46/2081^ Rhode Island 7.4 12.6 250 116/1811 South Carolina 12.9 18.1 200 93 South Dakota 9.9 15.6 200 52 Tennessee 8.6 16.7 250 127 Texas 18.0 34.5 200 26 Utah 11.0 14.4 200 44/1501^ Vermont 4.9 8.6 300 83/3001 Virginia 7.5 15.0 200 31 Washington 6.1 16.3 300 74/2001^ West Virginia 6.2 19.0 250 33 Wisconsin1 5.5 8.5 300 200 Wyoming 9.3 16.9 200 52 1 Denotes income eligibility for a more limited waiver/state-funded coverage or premium assistance with work-related eligibility requirement. 2 Denotes income eligibility for state-funded coverage to insure children in families with incomes above CHIP levels. ^ Denotes enrollment is closed to new applicants. Note: Income eligibility listed for children is the highest level reported among regular Medicaid, CHIP-funded Medicaid expansions, or separate state programs. Data: Uninsured—2009–2010 CPS ASEC Supplement; Income eligibility for children and parents—M. Heberlein, T. Brooks, J. Guyer et al., Holding Steady, Looking Ahead: Annual Findings of a 50-State Survey of Eligibility Rules, Enrollment and Renewal Procedures, and Cost Sharing Practices in Mediciad and CHIP, 2010–2011 (Menlo Park, Calif.: Kaiser Family Foundation, Jan. 2011), available at http://www.kff.org/medicaid/upload/8130.pdf. Data based on a national survey conducted by the Center on Budget and Policy Priorities for the Kaiser Commission on Medicaid and the Uninsured, January 2011. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org27 The full effects of the recession that officially Connecticut to a high of 25 percent in Mississippi. ended in 200917—in terms of access to care— The financial burden of insurance was highest in remain to be seen. When parents lose jobs, Southern and lower-income states. In particular, privately insured children lose their coverage, and families in Louisiana and Texas face private health these losses are greatest among children in middle- insurance costs that are above the national average and low-income families.18 Helping to provide while having among the lowest median incomes in coverage for these vulnerable families amidst the country. continued job losses and rising poverty is essential The increasing cost of health insurance, to maintaining the gains in insurance rates for combined with the severe downturn in the children. CHIPRA extended federal commitment economy, have forced difficult choices at to funding for CHIP through September 30, 2013, workplaces and among families. Slower growth in and is projected to cover 4.1 million children wages as employers absorb increasing insurance who would otherwise be uninsured by 2013.19 costs, as well as reduced savings for retirement, The Affordable Care Act further extended CHIP have been part of the trade-offs to preserve health funding through 2015. Yet unprecedented budget benefits.21 Provisions in the Patient Protection and shortfalls, combined with accelerated demand for Affordable Care Act of 2010, if successfully tested public programs, will still make it difficult for and adopted by private and public payers, could states to maintain coverage. provide substantial relief to families by slowing the growth in health insurance premiums.22 Yet, before Affordability of Health Insurance reforms are fully phased in, families will remain at The rapid rise in health insurance premiums and risk. deductibles has severely strained the finances of Given states’ current fiscal duress and their U.S. families and employers. From 2003 to 2009, failure to enact comprehensive reforms in the employer-based premiums for family coverage years before the recession, it is unlikely that increased an average of 41 percent across states— many will succeed in getting close to universal more than three times faster than increases in coverage on their own. The Affordable Care Act median family incomes. If recent state cost trends provides a common insurance coverage framework continue, the average annual family premium is and financing to support state efforts, which projected to reach $23,342 by 2020.20 As a result, is especially important for states that face large acquiring health insurance has become out of coverage gaps and socioeconomic challenges. reach for many low- and middle-income working The Affordable Care Act aims to provide families who are buying coverage on their own. access to affordable, comprehensive coverage to In 2009, the average annual premium for many families, particularly for those with low and family coverage—including employee and moderate incomes. The provisions are expected to employer shares—equaled or exceeded 20 percent greatly benefit the lives of low- and middle-income of the median family household income for the children by securing coverage for entire families. working-age population in 14 states and the In particular, many low-income parents will gain District of Columbia (Exhibit 8). The variability coverage with the expansion of Medicaid to 133 of premiums relative to incomes for families is percent of the federal poverty level in 2014. At notable, ranging from a low of 14 percent in 28 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 ACCESS AND AFFORDABILITY Exhibit 8 Affordability of Health Insurance: Premiums for Employer-Based Family Coverage Relative to Median Incomes for Family Households Under Age 65 Average Total Premium for Employer-Based Median Income for Average Total Premium Family Coverage as Percent of Median Family Household for Employer-Based Income for Family Household (All Under Age 65) Family Coverage State 2009 Rank 2008–09 2009 United States 19.0 $68,683 $13,027 Alabama 20.9 41 $57,189 $11,978 Alaska 17.0 14 $83,548 $14,182 Arizona 21.4 44 $59,787 $12,813 Arkansas 20.9 41 $52,500 $10,969 California 19.2 31 $65,788 $12,631 Colorado 16.4 10 $81,700 $13,360 Connecticut 13.9 1 $101,103 $14,064 Delaware 17.4 19 $72,965 $12,682 District of Columbia 21.5 46 $66,000 $14,222 Florida 19.9 35 $65,000 $12,912 Georgia 19.0 28 $67,500 $12,792 Hawaii 17.4 19 $68,000 $11,826 Idaho 18.2 24 $65,460 $11,887 Illinois 19.3 32 $71,002 $13,708 Indiana 19.9 35 $64,749 $12,872 Iowa 16.6 11 $72,306 $12,036 Kansas 16.9 13 $70,200 $11,829 Kentucky 21.4 44 $58,010 $12,407 Louisiana 22.2 48 $62,500 $13,846 Maine 18.9 27 $71,720 $13,522 Maryland 14.8 4 $93,221 $13,833 Massachusetts 15.2 6 $96,800 $14,723 Michigan 18.6 26 $70,670 $13,160 Minnesota 16.7 12 $79,016 $13,202 Mississippi 24.9 51 $50,630 $12,590 Missouri 17.9 22 $69,000 $12,353 Montana 17.1 16 $66,514 $11,365 Nebraska 17.2 18 $71,050 $12,227 Nevada 20.1 37 $63,301 $12,700 New Hampshire 14.5 3 $95,000 $13,822 New Jersey 14.0 2 $98,000 $13,750 New Mexico 22.3 49 $57,490 $12,848 New York 20.4 40 $67,546 $13,757 North Carolina 21.5 46 $61,000 $13,087 North Dakota 16.1 9 $71,841 $11,590 Ohio 17.4 19 $68,064 $11,870 Oklahoma 18.2 24 $62,605 $11,417 Oregon 19.0 28 $67,400 $12,783 Pennsylvania 17.9 22 $74,000 $13,229 Rhode Island 17.0 14 $80,065 $13,608 South Carolina 20.1 37 $61,373 $12,343 South Dakota 17.1 16 $68,000 $11,596 Tennessee 20.2 39 $60,000 $12,134 Texas 23.0 50 $57,500 $13,221 Utah 15.5 7 $76,675 $11,869 Vermont 19.4 33 $74,908 $14,558 Virginia 14.8 4 $85,000 $12,622 Washington 15.9 8 $80,400 $12,758 West Virginia 20.9 41 $60,100 $12,554 Wisconsin 19.7 34 $74,500 $14,656 Wyoming 19.1 30 $75,000 $14,319 Data: Median income for family household—2009–10 CPS ASEC Supplement; Average total premium for employer-based family coverage—2009 MEPS-IC. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org29 the same time, uninsured children and families and treatment services and continuity of care that are not eligible for Medicaid or CHIP will (Exhibit 9). In states with higher insurance rates gain premium assistance up to 400 percent of the among children, children are more likely to have federal poverty level ($88,000 for a family of four) a primary source of care that serves as a “medical to purchase coverage through newly established home,” to receive recommended preventive care, state health insurance exchanges. States will have and to receive more specialized care when needed. the critical task of implementing reform; how At the same time, although insurance is essential, they go about this will determine the success of it is not sufficient to ensure high-quality care for the federal law and its potential to improve overall children. The wide variations across states and health system performance. often low rates achieved by even top-performing Across states, higher insurance rates and more states highlight gaps in health care delivery system affordable access are closely associated with better performance. quality of care in terms of receipt of preventive ACCESS AND AFFORDABILITY Exhibit 9 State Ranking on Access and Affordability Dimension vs. Prevention and Treatment Dimension Top 1 RI IA NH Rank ME MA KS 6 TN OH VT State Ranking on Prevention and Treatment WV MN 11 HI SD WI IN 16 NE PA MD NC MO LA 21 IL ND SC UT WA CT 26 CO KY MI WY 31 AL DE VA GA NY 36 AR AK NM DC CA NJ 41MS FL AZ R2 = 0.48 OR 46 TX OK MT ID NV 51 51 46 41 36 31 26 21 16 11 6 1 Bottom Top Rank State Ranking on Access and Affordability Rank Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 30 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 PREVENTION AND TREATMENT quality and better care coordination across a The receipt of high-quality treatment and continuum of care, with the capacity to identify preventive primary care throughout a child’s gaps within as well as across states. development is instrumental in promoting and Effective Primary Care: The Medical Home establishing good health and growth. Timely Primary care is the foundation for an effective receipt of recommended preventive care, screening and efficient health care system.23 Children and for potential developmental delays in early their families benefit from having an ongoing childhood, and referral to more specialized care relationship with a primary care provider, especially when needed are all indicators of how well care one who takes a holistic approach to child health systems meet children’s health care needs. Further, and assumes responsibility for coordinating all families expect and rely on clinicians working health services for his or her patients.24 A model of together to ensure that care is well coordinated and enhanced primary care, called the patient-centered timely, and that those delivering services will be medical home, seeks to address these needs by responsive to their child’s needs and focus on the emphasizing access and establishing stronger whole child. This report examines nine indicators partnerships between primary care providers, of health care prevention and treatment, including: children, and their families. five that assess the extent to which children receive Providers with practices aiming to serve as effective primary and preventive care; one that medical homes work cooperatively with families assesses the provision of mental health services; to manage children’s health, share information and three that assess care coordination, including and resources, coordinate care across disciplines supportive services for children with special health and service settings, and ensure smooth care needs. transitions of care throughout all stages of a child’s The Scorecard revealed wide variations among development.25 Studies find that children who states in terms of the preventive and treatment have a medical home, especially those with special services that children receive. There are also distinct needs and chronic conditions, are more likely to geographic patterns in states’ overall rankings on receive the preventive care they need and adhere to this dimension (Exhibit 10). With some notable prescribed medications, and are less likely to visit exceptions, states in the South, Southwest, and the emergency department or be hospitalized.26 West rank lowest on this dimension, while states As of 2007, a majority of children and in New England and pockets of the Midwest adolescents did not receive care that meets all of rank highest. However, even the top-ranked the elements of a medical home, based on parents’ states on this dimension (Iowa, New Hampshire, reports (Exhibit 11 and Appendix A6). The Rhode Island, Massachusetts, and Maine) did not elements of this indicator include: parents’ reports perform well across each of the nine indicators. that their child had a personal doctor or nurse, This underscores the extensive variability in quality had a usual source for sick care, received family- across care settings and types of services, as well centered care, received effective care coordination as among geographic regions. The variability when needed, and had no problems getting highlights the need for state and federal action to referrals when needed. expand child-health metrics to promote higher www.commonwealthfund.org31 The likelihood of a child having a medical adequate reimbursement for primary care and care home varies widely across states, from a high of coordination, lack of available community services 69 percent in New Hampshire to less than half and support of teams, and poor collaboration in the lowest-rate states (Nevada, New Mexico, among different state programs, private health California) and the District of Columbia. plans, and providers serving children.28 Confirming findings in other studies, the As illustrated in the equity section of this Scorecard also found persistent disparities by report, the lack of medical homes is most prevalent income, insurance status, and race/ethnicity.27 The among uninsured and low-income children.29 To percentage of children with a medical home varies address this, many states are supporting initiatives regionally, ranging from nearly two-thirds in New that seek to improve access to care for low-income England and pockets of the Midwest to about children. This includes efforts in Colorado to half or less in the South and West. However, even improve the quality of care provided through among the highest-ranked states (New Hampshire, Medicaid and to stimulate multipayer initiatives. Nebraska, Vermont, Iowa, Massachusetts, and (See box on Colorado.) Ohio), one-third of children, on average, do not Nationally, the rate of children with a medical have a medical home. home is quite low (58% as of 2007). Still, the Studies indicate that barriers to providing medical home concept is gaining traction across medical homes for children include lack of states, with agreement on a common set of Exhibit 10 PREVENTION AND TREATMENT State Ranking on Prevention and Treatment Dimension NH WA VT ME ND MT MN OR WI NY MA ID SD MI RI WY PA IA NJ CT NE OH DE NV IN IL WV MD UT CO VA DC CA KS MO KY NC TN OK AR SC AZ NM AR MS MS AL GA TX LA FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 32 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 principles and goals.30 As of January 2011, 40 well-child examinations, dental examinations, and states have initiated projects to advance medical developmental screening. homes (Exhibit 12). The National Academy for Vaccinating Children State Health Policy has partnered with the Patient- Vaccinations are a cost-effective disease prevention Centered Primary Care Collaborative to help strategy and central pillar in recommended advance medical homes in state Medicaid and preventive care for children.32 In the United CHIP programs. Reflecting this broad support, States, vaccination programs have made a major the Affordable Care Act includes several provisions contribution to the elimination of many deadly to promote the medical home concept, such as or debilitating infectious diseases and significantly enhanced Medicaid payment for primary care and reduced the incidence of others that result in an Innovation Center to enable payment pilots to absences from school and lost work days for support successful models of care.31 parents.33 Historically, rising rates of immunization Timely Preventive Care have been a direct result of partnerships between Childhood and adolescence are key times for local, state, and federal governments and the delivering preventive services to promote healthy private sector. The federal Vaccines for Children growth and development. Important preventive Program, for example, provides vaccinations at no services measured in this Scorecard are vaccinations, cost for eligible children and has been effective in PREVENTION AND TREATMENT Exhibit 11 State Variation: Medical Home and Preventive Care Percent Best state Top 5 states average All states median Bottom 5 states average Worst state 98 97 100 88 87 86 84 82 79 77 79 74 73 69 68 69 65 65 61 49 50 45 0 Children with a Young children (ages Children with Children with medical home 19–35 months) received preventive medical care preventive dental care Top 5 states six vaccines visits visits 1. New Hampshire 1. Iowa 1. Rhode Island 1. Hawaii 2. Nebraska 2. Tennessee 2. District of Columbia 2. Rhode Island 3. Vermont 3. Massachusetts 3. Massachusetts 3. Vermont 4. Iowa 4. Michigan 4. New York 4. Connecticut 5. Massachusetts 5. Louisiana 5. Connecticut 5. Iowa 5. Ohio Data: Medical home—2007 National Survey of Children’s Health; Vaccines—2009 National Immunization Survey; Medical and dental preventive care visits—2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org33 reducing gaps in immunization coverage resulting families to monitor children’s progress and from poverty.34 recommend services when needed. For this reason, Nevertheless, the timely and complete pediatric experts recommend that all children immunization of U.S. children ages 19 to 35 receive a series of well-child visits from birth to months has reached a plateau in recent years, age 21 years, during which clinicians conduct a leaving one of four young children exposed to physical examination, perform developmental vaccine-preventable diseases at some point in his screenings, and provide counsel for health-related or her early development. Moreover, substantial behaviors.35 The importance of preventive care has variation in vaccination rates persists among states, long been recognized in federal legislation, such as with a nearly 20 percentage point spread between Medicaid’s requirement that all states offer eligible the highest-ranked state, Iowa (84.1%), and the children access to Early and Periodic Screening, lowest-ranked states (64.6%), on rates of coverage Diagnosis, and Treatment services.36 Receiving the of all recommended doses of six key vaccines recommended number of preventive visits in early (Exhibit 11 and Appendix A6). Hence, intensified childhood may also reduce emergency department efforts are needed to reach the goal of universal visits and hospitalizations.37 vaccine coverage in all areas of the country. Disparities in receipt of preventive medical care persist across states (Exhibit 11 and Appendix Preventive Medical Visits A6). The percentage of children ages 0 to 17 who Pediatric primary care practitioners play a vital received a preventive medical care visit in the past role in promoting optimal child development year ranged from an average of 97 percent in the by regularly interacting with children and their top five states (Rhode Island, District of Columbia, COLORADO PROMOTES THE MEDICAL HOME MODEL AMONG PEDIATRIC PRACTICES: THE CHILDREN’S HEALTHCARE ACCESS PROGRAM A medical home is a place where children receive en- in medical homes can reduce the number of inpatient hanced access to comprehensive primary care that is stays. The organization also offers 14 support services well coordinated, efficient, and cost-effective. While to providers, including care coordination, a resource the medical home model has gained wide support, hotline, and Medicaid billing assistance. In addition, it many children without insurance or those with pub- links private practices with 30 community-based orga- lic insurance do not have access to medical homes nizations that provide families with services, including because many pediatricians do not participate in mental health counseling, social services, case man- Medicaid or the Children’s Health Insurance Program agement, and quality improvement coaching. (CHIP), and many are not equipped to provide the ar- The Children’s Healthcare Access Program has been ray of medical home services. replicated in Grand Rapids, Michigan. The success The Colorado Children’s Healthcare Access Program of these two organizations illustrates that the sup- is a nonprofit organization that addresses barriers port and spread of the medical home model can be that prevent private pediatric and family practices achieved through centralized support services. from participating in Medicaid and CHIP and seeks to ensure low-income children have access to medical homes. It helps participating practices negotiate with For more information visit http://www.cchap.org and Medicaid to receive enhanced payments for certain see S. Silow-Carroll and J. Bitterman, Colorado Children’s Healthcare Access Program: Helping Pediatric Practices preventive services. This can be economically feasible Become Medical Homes for Low-Income Children (New York: since improved preventive care and care coordination The Commonwealth Fund, June 2010). 34 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 PREVENTION AND TREATMENT Exhibit 12 State Efforts to Advance Medical Homes in Medicaid/CHIP NH WA VT ME ND MT MN OR MA WI NY ID SD MI RI WY PA IA NJ CT NE OH DE NV IN IL WV MD UT CO VA DC CA KS MO KY NC TN OK AR SC AZ NM AR MS MS AL GA TX LA FL AK HI Medical Home States Note: NASHP is monitoring state efforts to advance medical homes for Medicaid and CHIP participants and has identified 40 states that meet the following criteria: 1) program implementation (or major expansion or improvement) in 2006 or later; 2) Medicaid or CHIP agency participation (not necessarily leadership); 3) explicitly intended to advance medical homes for Medicaid or CHIP participants; and 4) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff. Source: National Academy for State Health Policy State Scan, Jan. 2011, http://www.nashp.org/med-home-map. Massachusetts, New York, and Connecticut) to 79 Preventive Dental Care Visits percent in the bottom five states (Idaho, North Preventive dental care is often overlooked but Dakota, Nevada, Oregon, and South Dakota). The equally important to children’s health and well- fact that some states are achieving very high rates being. It is estimated that children miss about 1.6 suggests that universal access to preventive care is million school days each year because of dental an achievable goal, especially as coverage expands disease.40 A lack of dental care can lead to tooth under federal reform in the coming years. decay, which can cause pain, infection, nutritional Attention also must be given to improving problems, and sleep deprivation and can affect the content of care provided during preventive children’s learning and growth.41 National health care visits. Research suggests that the quality of objectives, as set forth by the U.S. Department preventive medical care is inconsistent, with large of Health and Human Services in Healthy People variations among different populations.38 For 2010, include ensuring that children have a example, literature suggests that few adolescents minimum of one dental visit each year.42 Despite are screened or receive information during a this goal, performance remains uneven across physician visit about health risks such as unsafe states: almost one-third of children did not see a sexual practices or alcohol, tobacco, and drug use.39 dentist for a preventive visit in the bottom-ranked www.commonwealthfund.org35 state (Florida) and more than 10 percent did not care providers conduct developmental surveillance have a dental check-up in the top-ranked state at all well-child visits for children from birth to (Hawaii) (Exhibit 11 and Appendix A6). Better three years, and perform structured developmental access to oral health services can reduce tooth decay screening using a standardized instrument at and lead to a better quality of life for children, as nine, 18, and 30 months of age.44 The AAP also well as reduce financial and societal costs.43 As recommends that children judged to be at risk discussed in the Potential to Lead Healthy Lives for developmental delays are referred for detailed section below, the high rate of poor yet preventable developmental and medical evaluations and for dental health outcomes among children in many Early Intervention services. states attests to the need to improve preventive Literature suggests that few pediatricians dental health care. use effective means to screen their patients for developmental problems.45 This was evident in Developmental Screening the data available for this report. Only one of five The early identification of children at risk for young children (ages 10 months to five years) developmental delays or disorders can help families received a standardized developmental screening prepare for and seek intervention services to during their health care visit in 2007, according support children from a young age, when chances to their parents (Appendix A6). The variability are best to effect change. The American Academy among states on this indicator was wide, ranging of Pediatrics (AAP) recommends that primary NORTH CAROLINA’S USE OF COMMUNITY CARE NETWORKS TO IMPROVE THE DELIVERY OF CHILDHOOD DEVELOPMENTAL SCREENING AND REFERRAL TO EARLY INTERVENTION SERVICES Identifying and treating developmental problems dur- on how to implement them without disrupting their ing the early years of a child’s life is critical and requires workflow; building providers’ knowledge of refer- a well-coordinated system of care at the community ral agencies; helping practices develop processes for level. A 1999 survey revealed that only 2.6 percent tracking cases; and establishing relationships between of North Carolina children ages 0 to 3 were receiving practices and community agencies to enhance commu- essential Early Intervention services. To address this, nication and bridge gaps in understanding. North Carolina launched the Assuring Better Child To implement the ABCD program, North Carolina Health and Development (ABCD) program in 2000, with relied on 14 local community care networks—collec- support from The Commonwealth Fund. From 2004 tively known as Community Care of North Carolina— to 2008, North Carolina’s ABCD program quintupled that serve low-income children and adults enrolled in the number of screening tests administered during Medicaid or CHIP. The networks sought to forge part- Medicaid well-child visits. Screening tests are used to nerships between physicians and other local stake- identify young children at risk for developmental dis- holders, helped introduce easy-to-use screening tools, abilities and delays that can compromise their growth educated medical providers about community resourc- and readiness for school. Under the ABCD program, es, and enhanced communication between providers referrals to Early Intervention programs quadrupled. and referral organizations. As a result, fewer North Carolina children are entering school with unrecognized or untreated developmen- tal problems. North Carolina ranks first among states For more information see S. Klein and D. McCarthy, North on this Scorecard’s developmental screening measure. Carolina’s ABCD Program: Using Community Care Networks to Improve the Delivery of Childhood Developmental Key elements of the ABCD program include: identifying Screening and Referral to Early Intervention Services (New standardized screening tools and training physicians York: The Commonwealth Fund, Aug. 2009). 36 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 from a high of only 47 percent in North Carolina mental health providers, and inadequate insurance to a low of 11 percent in Pennsylvania. benefits contribute to underutilization of mental The leading performance of North Carolina health services among children.50 Moreover, up likely reflects extensive efforts across the state to half of families who begin therapy terminate it to emphasize early childhood, screen children, prematurely.51 While newly enacted federal mental and link children to care if identified as at risk health parity legislation may help to alleviate for developmental delays. (See box on North some financial barriers, other challenges remain.52 Carolina.) For example, many pediatricians report that they are ill-equipped to treat patients needing mental Mental Health Services health support, indicating the need for systemic More than one of five children and adolescents in changes such as collaborative care models in which the United States have mental and/or behavioral mental health specialists partner with primary care health problems.46 Mounting evidence suggests physicians to improve the detection and treatment that the early identification and treatment of of mental illness. behavioral health problems may decrease the risk For example, mental health specialists could of long-term disability for children and adolescents work in regional centers as consultants to primary and avert significant mental health problems care physicians. Massachusetts is supporting in adulthood.47 Left untreated among children, such a shared services approach for children with mental health disorders can lead to higher rates mental health needs, irrespective of their insurance of juvenile incarcerations, school dropout, family coverage; the approach has received high ratings dysfunction, drug abuse, and unemployment.48 from both families and providers. (See box on The lack of recognition and treatment of these Massachusetts.) disorders among children is of great concern.49 National survey data indicate that mental Coordinated Care health support for children in this country is Coordination of care is essential to a high- inadequate. On average, only 60 percent of performing and patient-centered health care children ages 2 to 17 needing mental health system and is a key component of the patient- treatment and/or counseling received such care centered medical home. Fragmentation of care in 2007, according to parents (Appendix A6). In can result in inefficiencies and lead to poor care the bottom five states (Texas, Mississippi, Oregon, experiences and poor health outcomes. Pediatric Georgia, and Florida), more than half who needed care coordination is intended to link children mental health care did not receive it. Even among and their families with appropriate services and the top five states (Pennsylvania, Connecticut, resources in an effort to achieve good health.53 Yet Delaware, Rhode Island, and Iowa), over 20 according to the professional literature, families percent on average did not receive needed mental and providers say that care coordination is often health care. lacking in primary care.54 The shortage of mental health providers for Care coordination is crucial to effectively children, stigma attached to receiving mental manage chronic conditions such as childhood health services, chronic underfunding of the public asthma, and may reduce hospital admissions mental health system, decreased reimbursement to through the prevention of acute flare-ups.55 www.commonwealthfund.org37 Asthma, one of the most prevalent chronic diseases hospital admissions (Vermont, Hawaii, New of childhood, affects 6.7 million children and is the Hampshire, and Iowa) are leaders in the overall most common cause of school absenteeism due to child health system performance ranking. These chronic conditions.56 Childhood asthma accounts states, along with Oregon, average 56 pediatric for almost 600,000 emergency department visits asthma hospital admissions per 100,000 children. and more than 150,000 hospitalizations annually.57 This contrasts with the average of the bottom There is great variability in rates of hospital five states (New York, Colorado, Oklahoma, admissions for pediatric asthma (Exhibit 13 and New Jersey, amd Kentucky), which is nearly 200 Appendix A6). Among the 39 states that collect admissions per 100,000 children. all-payer hospital data, rates of hospital admissions Data on the number of children’s asthma for childhood asthma range from a low of 44 per admissions are not available for 12 states because 100,000 children in Oregon to 251 per 100,000 in they do not collect and report all-payer hospital New York—nearly six times higher. Four of the top data to the Healthcare Cost and Utilization Project five states in terms of low rates of pediatric asthma (HCUP), from which this indicator was drawn. THE MASSACHUSETTS MENTAL HEALTH MODEL—SUPPORTING MENTAL HEALTH TREATMENT AND SCREENING SERVICES IN PRIMARY CARE Insufficient access to child and adolescent mental Massachusetts also has programs in place to help pri- health and screening services is a nationwide prob- mary care physicians identify children who may have lem and often leads to a failure to appropriately di- behavioral health problems. In 2006, the state formed agnose and treat children suffering from behavioral the Medicaid Children’s Behavioral Health Initiative to and developmental delays or emotional disturbances. serve low- to moderate-income residents. Under the Massachusetts has developed a variety of programs to initiative, pediatric primary care providers through- improve the early identification of children requiring out the state are offered training in behavioral health mental health services and provide primary care physi- screening and parents receive repeated notifications of cians with the tools needed to treat such patients. screenings and available services. By 2008, the percent of MassHealth (Medicaid) well-child behavioral health Because of a shortage in child psychiatrists nationwide, screenings for children under age 6 had nearly tripled primary care providers find themselves ill equipped compared with the previous year. Massachusetts is also to meet the burgeoning demand for children’s men- refining a comprehensive online information gateway tal health services. To support primary care providers, to support this initiative. Developmental screening Massachusetts developed the Massachusetts Child scores are entered into the system by clinicians and Psychiatry Access Project. Six regional teams, each con- can be accessed by other clinicians involved with the sisting of a child psychiatrist, licensed social worker, child’s care. The state also has procured a system of care coordinator, and administrative staff member, 32 community service agencies to provide wraparound serve pediatric and family practices in their communi- services and intensive care coordination for children ties. These teams provide primary care physicians with with serious emotional disturbances. timely access to child psychiatry consultation and, when indicated, help in arranging for families to re- ceive consultations or referrals for children, regardless For more information see B. Sarvet, J. Gold, J. Q. Bostic et of their insurance status. It is funded by the state and al., “Improving Access to Mental Healthcare for Children: The managed by a private organization, the Massachusetts Massachusetts Child Psychiatry Access Project,” Pediatrics, Behavioral Health Partnership. It has enrolled most Dec. 2010 126(6):1191–200; D. R. Lyman, W. Holt, and R. H. primary care practices, representing an estimated 95 Dougherty, State Case Studies of Infant and Early Childhood Mental Health Systems: Strategies for Change (New York: percent of all youth in the state, and has high rates of The Commonwealth Fund, July 2010); and W. Holt, The physician participation. Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment in Primary Care (New York: The Commonwealth Fund, March 2010). 38 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 PREVENTION AND TREATMENT Exhibit 13 State Rates of Hospital Admissions for Asthma Among Children, 2006 Admissions per 100,000 children ages 2–17 300 250 200 150 All states median = 128.7 100 50 0 Co ma Mi ut uri y Ok rsey Ne ado rk n tts s Vir d Ka a ect s Te land ee Ca da Ma ich a nn in na Ar ota as Ge na Ar ia io Vir is e I ia Da e ta shi da lifo n Ind ia Wi iana Ve on t i re a Ne tah ska Ha awai nsa xa on Ne tuck i in Iow uth ain ssa iga an to no gin gin org rn ns Oh Yo rth kans ko shi ic ess use uth Flori i izo Wa eva eg sso o rol Te rol bra es U ng rm lor We aryl Je Illi sco M lah s mp Or nn n w H ch Ca N w nn Ke M Ca M od Mi st Co Rh So w No So Ne Data: 2006 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (AHRQ, HCUP-SID 2006); not all states participate in HCUP. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. More generally, population data on the number of percent of U.S. children meet these criteria as children with asthma are not available across states. of 2005–2006, when the latest National Survey Still, there is ample evidence that effective of Children with Special Health Care Needs care for children with asthma can substantially occurred.59 These children, and their families, not lower the risk of complications leading to only have to manage a complex health condition, hospital or emergency department use or missed but also must learn to navigate an even more days of school. As illustrated by the Cincinnati complex and disorganized health care system. Children’s Hospital experience, and repeated by Families of children and adolescents with the Children’s Hospital initiative in Boston, a an array of medical and nonmedical issues, population approach with outreach to families and and families in which caregivers are stressed or children at risk makes a difference.58 (See box on depressed, often have difficulty navigating the Cincinnati.) health, mental health, education, social welfare, housing, and other support systems that might Children with Special Health Care Needs address their needs. Children with special health Children with special health care needs are care needs may require a variety of medical, social, identified by the Maternal and Child Health and educational services and frequently receive Bureau as those “who have or are at increased risk fragmented or duplicative services.60 According to for chronic physical, developmental, behavioral, or parents, the proportion of special needs children emotional conditions and who also require health who experienced problems getting referrals to see and related services of a type or amount beyond another doctor or receive services ranged from that required by children generally.” Fourteen a high of 30 percent in Arizona to a low of 10 www.commonwealthfund.org39 percent in Rhode Island. On average, one of five hospital stays, lower costs, greater satisfaction with special needs children had difficulty receiving services, and stronger relationships with primary referrals in 2005–2006 (Appendix A6). care providers.62 One reason for this is that making referrals Children with special health care needs can be time-consuming for pediatricians and also may require more specialized mental family practitioners, since they require in-depth health and other support services to cope with knowledge of the resources available in the stresses associated with their condition.63 Family community and state.61 Having better models members are put under a great deal of stress and of care coordination in pediatric practices would psychological burden in managing the complex facilitate the referral process. Care coordination care of children with special health needs and also has been shown to lead to shorter average may also require assistive services. Therapeutic HARNESSING THE POWER OF COLLABORATIVES—AN INNOVATIVE MODEL IN CINCINNATI LINKING POPULATION HEALTH IMPROVEMENT TO PAY-FOR-PERFORMANCE In Cincinnati, Ohio, 165 local physicians in 44 practices tool; all-payer asthma population identification; prac- have teamed up with Cincinnati Children’s Hospital tice workflow redesign; a patient self-management Medical Center to pool their expertise in helping chil- collaborative; a flu shot improvement collaborative; dren prevent asthma episodes before they become and multiple network meetings and conference calls life-threatening. In 2003, this group of physicians, to promote communication and collaboration among known as the Physician–Hospital Organization affili- practices. ated with Cincinnati Children’s Hospital, launched an From 2003 to 2006, the percentage of the asthma asthma improvement collaborative. Its aim is to ensure population in the network receiving “perfect care” children with asthma receive evidence-based care, increased from 4 percent to 88 percent, with 18 of thus reducing asthma-related emergency department/ 44 practices achieving a perfect care percentage of urgent care visits, office visits, missed school days, and 95 percent or greater. Compared with baseline per- missed parent workdays. The collaborative has served formance in 2004–05, the number of asthma-related more than 13,000 children with asthma in greater Cincinnati Children’s Hospital emergency department/ Cincinnati, representing approximately 35 percent of urgent care visits had decreased by 44.9 percent by the region’s pediatric asthma population. 2007–08. Similarly, the number of asthma-related hos- In early 2004, the Physician–Hospital Organization ap- pital admissions decreased by 47.1 percent over this proached Anthem Blue Cross and Blue Shield in Ohio, period. While the pay-for-performance program has which provides coverage to the highest percentage since concluded, the asthma improvement collabora- of the commercially insured population in greater tive continues. Recent recognition includes selection Cincinnati, to elicit its support for an asthma pay-for- by the American Academy of Pediatrics for a national performance program. The program sought to reward spread campaign, and the Web-based asthma regis- measurable improvements in asthma care achieved at try being designated a “best practice” by the federal the network and practice levels, accelerate practices’ Agency for Healthcare Research and Quality. engagement in improvement work, and support the business case for quality improvement. For more information visit http://www.tristatepho.org and In addition, members of the asthma improvement col- see K. E. Mandel and U. R. Kotagal, “Pay for Performance laborative designed strategies to drive changes at the Alone Cannot Drive Quality,” Archives of Pediatrics and provider level. These included: creation of multidis- Adolescent Medicine, July 2007 161(7):650–54. For outcomes ciplinary quality leadership teams, including a physi- data, see “Improving Asthma Care within a Large Community- Based Pediatric Network,” a poster presented at the National cian, nurse or medical assistant, and office manager, at Initiative for Children’s Healthcare Quality (NICHQ) annual each practice; concurrent data collection during office conference in Orlando, Florida, in March 2008, available at visits through the use of an asthma decision support https://www.tristatepho.org/portal/Uploads/NICHQ_Poster. pdf. 40 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 and supportive services such as rehabilitation, Current federal policies, including Healthy environmental adaptations, personal assistance, People 2010 and the Maternal and Child Health mental health, home health, or respite care play a Bureau Strategic Plan, explicitly target improving pivotal role in decreasing burdens on families and access to services for children with special health promoting maximal health and independence of care needs.66 Successful adoption and spread of the special needs children.64 patient-centered medical home model for children While over 10 million children in the nation would particularly benefit such children. were estimated to have a special health care need in 2005–2006, the parents of nearly 30 percent of CHILDREN’S POTENTIAL TO LEAD such children, on average, reported needing but HEALTHY LIVES not receiving family support services such as family The early years of life offer a critical window of counseling, respite care, and genetic counseling opportunity in which to lay a foundation for good services (Appendix A6).65 The rate of children health, school readiness, and ultimately, success with special health care needs who did not receive in adulthood. Therefore, ensuring that children the support services their families needed ranged have a healthy start in life is fundamental to the from nearly 20 percent in Indiana to more than 40 progress of all states. To do so, states are looking percent in Utah. for comprehensive approaches that emphasize HEALTHY LIVES Exhibit 14 State Ranking on Potential to Lead Healthy Lives Dimension NH WA VT ME MT ND MN OR MA WI NY ID SD MI RI WY PA IA NJ CT NE OH DE NV IN IL WV MD UT CO VA DC CA KS MO KY NC TN OK AR SC AZ NM MS AL GA TX LA FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org41 early childhood health and development as well seven indicators of healthy lives for children.67 (See as prevention of chronic disease. These include box on Minnesota.) For several of the top-ranked policies and programs intended to stem the rise states, performance on at least one of the indicators of obesity, curb smoking, and promote healthy fell in the bottom half of the distribution, pointing lifestyles while ensuring the timely delivery of to areas for further improvement. effective care and resources. Infant and Child Mortality States’ performance in achieving optimal child After decades of substantial decline, the rate of health outcomes reflects the complex interaction infant deaths has leveled off since 2000. The of multiple determinants of health. There is little plateau in the U.S. infant mortality rate is largely question that health outcomes are heavily shaped due to rising numbers of preterm births and low- by forces both outside and inside the health care birthweight infants. More than a third of infant system. Variations in income, education, and deaths are caused by problems related to babies the living environment of a child’s family are being born too early.68 Timely and continuous some of the factors that influence the extent to prenatal care and healthy maternal behaviors which children are able to reach their full health can help improve birth outcomes through early potential. The Scorecard findings of wide variations identification of risk factors and provision of in children’s health outcomes point to targets for advice to encourage healthy lifestyles, treatment improvement, yet effective interventions often of conditions such as diabetes and high blood require comprehensive approaches that address pressure, birth planning, and referrals to promote broader social and public health risk factors as well healthy pregnancies, including nutrition and as the health care system. smoking-cessation counseling.69 The Scorecard uses seven indicators of children’s The chances that infants will survive to their health outcomes to assess state performance in this first birthday vary considerably across states dimension: infant mortality, mortality among chil- (Exhibit 15). Rates in the states with the highest dren ages 1 to 14, children at risk for developmen- infant mortality are twice as high as those in states tal delays, overweight or obese children, children with the lowest rates. In 2006, the infant death with oral health problems, and adolescents who rates in Louisiana, Mississippi, and the District of smoke or do not get the minimum recommended Columbia averaged 10 to nearly 12 per 1,000 live physical activity. births—well above the national average of 6.7 per The analysis found large variation in states’ 1,000 (Appendix A7). Meanwhile, infant death ability to promote healthy lives for their children, rates averaged five per 1,000 live births in the five with distinct regional patterns. States in the highest-rate states (Washington, Massachusetts, South consistently lag on this dimension, while California, Iowa, and Utah). States in the South the top-ranked states were spread across parts and Midwest generally had higher infant mortality of the Upper Midwest, Mountain, and Pacific rates than in other regions. Disturbingly, rates Northwest regions, and New England (Exhibit have increased in some of the worst-performing 14). Minnesota—the leading state in terms of states in recent years. As expected, across states children’s health outcomes—was the only state there is a strong correlation between the number to consistently perform in the top quartile on all of low-birthweight infants and infant mortality 42 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 HEALTHY LIVES Exhibit 15 Infant Mortality by State: Deaths per 1,000 Live Births, 2006 NH ME 15 WA VT MT ND MN OR MA WI NY ID SD MI RI 10.5 WY PA CT 10.0 IA NJ 10 NE OH IN DE NV IL WV VA MD UT CO DC CA KS MO KY 6.8 NC TN OK 4.7 5.0 AZ NM AR SC 5 MS AL GA TX LA FL AK 0 Best Top 5 All states Bottom 5 Worst HI State Rank state states median states state* Top Quartile average average Second Quartile Third Quartile Bottom Quartile * Excludes District of Columbia with 11.9 infant deaths per 1,000 live births. Data: National Vital Statistics System. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. HEALTHY LIVES Exhibit 16 State Rates on Infant Mortality and Low-Birthweight Babies 13.0 12.5 MS 12.0 Births of Low Birthweight Babies as a 11.5 LA DC 11.0 AL Percent of All Births 10.5 SC 10.0 WV GA 9.5 KY DE NC TN CO WY MD AR 9.0 FL OH NM TX VA IL IN 8.5 NJ NV MIPA OK NY HI CT 8.0 MA RI MO 7.5 MT AZ CAIA NE SD KS 7.0 WI UT MN ND ID 6.5 WA ME OR VTNH 6.0 AK 5.5 R2 = 0.61 5.0 4.5 4.0 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5 12.0 12.5 13.0 Infant Mortality, Deaths per 1,000 Live Births Data: Infant mortaility—2006 National Vital Statistics System; Low birthweight—Kaiser statehealthfacts.org (2007 National Vital Statistics System). Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org43 MINNESOTA—PROMOTING LOCAL INITIATIVES TO DRIVE HEALTHY LIVES Minnesota, the leading state on this Scorecard’s funds to: deploy a tobacco-free policy for all students, Healthy Lives dimension, is using community-driven staff, and visitors on all school and university grounds, efforts to create sustainable and systemic changes in student housing, and at all school- and university- that support healthy choices among its population. In sponsored events; increase opportunities to walk and 2009, the Minnesota Department of Health awarded bike to and from school; expand access to recreation 40 grants to Minnesota communities to help lower facilities outside of school hours; promote healthy rates of smoking and obesity. The $47 million ap- food and drink options; and implement policies that propriation for the Statewide Health Improvement support high-quality physical education. Program (SHIP) will contribute to over 80 projects in SHIP is a unique state initiative because it is locally Minnesota that span all 87 counties and eight tribal controlled; grantees establish plans that are best suit- governments. Each community that receives a grant ed to their communities and employ evidence-based is required to make a 10 percent match. Grantees are strategies that result in system-level changes. The pro- required to create community action plans, assemble gram is evaluated at both the state and local levels leadership teams, and establish partnerships. to ensure progress is made toward a set of measur- SHIP is part of Minnesota’s historic health care reform able outcomes. SHIP interventions are expected to de- initiative, signed into law in 2008. To address the lead- crease the state’s health care spending by $1.9 billion ing preventable causes of illness and death in the by 2015. Other states can look to Minnesota’s success United States, SHIP will focus on reducing obesity and on this Scorecard’s Healthy Lives indicators, which is tobacco use through efforts in community, worksite, significantly attributable to its support of a compre- health care, and school settings. Schools in particular hensive public health agenda. are uniquely situated to support children’s healthy be- havior during the years when they are acquiring life- style habits. For example, communities have used SHIP For more information visit http://www.health.state.mn.us/ healthreform/ship/index.html. rates—underscoring the importance of promoting rate among infants up to one year of age, yet healthy pregnancies to maximize the likelihood of ranked second-best for its low child mortality rate. full-term births (Exhibit 16). Such divergence suggests that states may be able to Wide differences across states also exist in the look for benchmarks for improvement within their risk of death for an infant or for a child between own borders to address factors putting children at ages 1 and 14 years. In 2007, there was a threefold risk from birth through adolescence. range across states in such mortality rates—ranging Developmental Delays from more than 30 per 100,000 children in Alaska Developmental, behavioral, or learning delays in and Mississippi to less than 10 per 100,000 in the early years of life can hinder children from Rhode Island. reaching their full potential. Based on parental Massachusetts, Minnesota, and Washington reports, the percentage of young children (ages 4 have among the lowest death rates for both months to 5 years) judged to be at moderate or infants and children (ages 1 to 14 years), whereas high risk of developmental delays ranged from the District of Columbia along with Arkansas, an average of 19 percent in the top five states Louisiana, and Mississippi grapple with the highest (Minnesota, Maine, Colorado, Oregon, and West infant and child death rates in the nation. Virginia) to more than 30 percent in the bottom An individual state’s performance on these two five states (Louisiana, Mississippi, Arkansas, mortality indicators did not always correlate. For Alabama, and Nevada) (Appendix A7). Notably, example, Delaware had a relatively high mortality 44 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 states generally lack registries or other means to expanding access for parents. Parents who do not track and monitor such at-risk children. States obtain dental care for themselves are less likely to with high rates of children with developmental bring their children in for dental care.73 delays appear to be missing opportunities for early Public Health: Smoking, Obesity, and detection and intervention, as evidenced by their Exercise low reported rates of developmental screening. For Cigarette smoking is the leading preventable cause example, Alabama, Arkansas, California, and the of death in the United States, costing an estimated District of Columbia have among the highest rates 443,000 lives a year.74 It is a serious child health of children at risk of developmental delays (30% issue, because dependence begins during childhood or more) and were also the bottom states in terms or adolescence in the majority of cases. Experts of early childhood screening. recommend that physicians counsel adolescents on Oral Health health-related behaviors such as smoking as part As mentioned above, oral health is an integral of multifaceted prevention programs involving component of children’s learning and growth. Yet coordinated effort by families, schools, and the oral health care is often neglected, unavailable, or community.75 unaffordable, especially for low-income children.70 While the rate of youth who smoke began In 2007, more than one-quarter of children ages to decline in the late 1990s, progress has slowed 1 to 17 (27%) had at least one of the following in recent years and smoking rates continue to oral health problems within the past six months: vary widely across states.76 There was a threefold decayed teeth or cavities, toothache, broken teeth, difference in the reported rate of current cigarette or bleeding gums, based on their parents’ reports use among high school students across the 42 states (Appendix A7).71 Even in the state with the lowest reporting data in 2009 (Exhibit 17).77 An average rate of such problems, Minnesota, one of five of 13 percent of high school students smoke children had oral health concerns (Exhibit 17). cigarettes in the five lowest-rate states (Utah, Unmet needs for dental care based on reports of Maryland, Rhode Island, Idaho, and New York), pain and tooth decay or damage were highest in compared with a quarter of students (24%)— Arizona and Mississippi, where nearly one of three double the rate—in the five states with the highest children had such oral health problems. adolescent smoking rates (Kentucky, New Mexico, Combating these largely preventable and Indiana, South Dakota, and Oklahoma) (Appendix treatable dental conditions will require public A7). In fact, only a handful of states have cigarette education, expansion of access to dental care, and use rates among high school students that meet the integration of oral health into routine well-child Healthy People 2010 target of 16 percent or less.78 care. Increasing the availability of dental care for Any further progress is at risk unless states make it children through broader use of midlevel dental more difficult for children to smoke and increase providers will likely be instrumental to ensure funding for tobacco prevention and cessation access to timely, affordable care in all communities, programs. According to the latest estimates, states including rural and low-income areas.72 Strategies have reduced funding for such programs to the to improve will also require raising awareness of lowest level since 1999.79 In 2011, only 2 percent the importance of preventive dental practices and of all revenues from the tobacco settlement and www.commonwealthfund.org45 HEALTHY LIVES Exhibit 17 State Variation: Healthy Lives Percent Best state Top 5 states average All states median Bottom 5 states average Worst state 50 44 39 31 32 31 26 26 24 25 25 22 23 20 18 13 9 0 Children with oral High school students who Children who are health problems* currently smoked cigarettes overweight or obese Top 5 states 1. Minnesota 1. Utah 1. Minnesota 2. Massachusetts 2. Maryland 1. Utah 3. North Dakota 3. Rhode Island 3. Oregon 4. Iowa 4. Idaho 4. Montana 5. Vermont 5. New York 5. Connecticut 5. North Dakota 5. Wyoming * Children who had at least one of the following oral health problems in the past six months: a toothache, decayed teeth/cavities, broken teeth, or bleeding gums. Data: 2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. tobacco taxes will be spent to prevent tobacco use each year, a figure that is bound to increase without among children as well as reduce use among adults. a reversal of trends.82 Targeting the prevention As with smoking, preventing obesity among of obesity prior to adulthood is essential to children and lowering childhood obesity rates overcoming the epidemic and controlling health are national health priorities. Research has found care costs. that overweight children are at increased risk of Nationally, nearly one-third of children ages becoming obese adults and obese parents are, in 10 to 17 (32%) are either overweight or obese, turn, at risk for raising obese children.80 Obesity according to parent-reported height and weight in adolescence raises the likelihood of becoming (Appendix A7).83 The variation across states is severely obese in adulthood.81 Higher rates of wide and startling, ranging from a low of 23 overweight and obesity during childhood increases percent of children who are overweight or obese the likelihood of diabetes, hypertension, stroke, in Utah and Minnesota to a high of 44 percent in and heart disease later in life, as well as emotional Mississippi, as of 2007 (Exhibit 17). Only three problems such as poor self-esteem and depression. states—Minnesota, Utah, and Oregon—had less The consequences place a tremendous financial than one-quarter of children who were overweight strain on our health care system: recent estimates or obese. States in the Southeastern region have place obesity-related medical costs at $168 billion the nation’s highest rates of overweight or obese 46 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 children, and parts of the Upper Midwest, the that primary care and pediatric providers play Mountain region, and New England have the in managing obesity, urging them to engage in lowest. Not surprisingly, these geographic patterns BMI measurement as well as counsel parents and closely resemble those for obesity among the adult children on behavioral interventions in the context population.84 of families and communities.88 Concerns about the lack of physical activity Smoking and obesity are serious threats to among youth have been mounting in light of the U.S. population’s quality of life and health. the link between inactivity and obesity and other Nonetheless, they can be overcome through a negative health outcomes during childhood and population-based approach to care, focused on later in life. In 2009, only 37 percent of high disease prevention and health promotion in early school students met recommended levels of childhood. A number of states are integrating physical activity, defined as doing any kind of public health approaches into their reform physical activity (that includes vigorous activity for efforts by developing policies and models of care some of the time) for a total of at least one hour that prioritize prevention and support healthy per day on five or more days per week (Appendix environments and lifestyles, along with improved A7). Idaho was the only state out of 42 states access to care for underserved groups.89 In doing with available survey data where more than half so, states must incorporate public health principles of students (54%) participated in recommended into the day-to-day functioning of health care levels of physical activity. In South Carolina delivery systems. In supporting their children’s and Massachusetts, the same was true for only a ability to lead healthy lives, states also must seek to third of students. Clearly, there are many missed better understand the broader economic and social opportunities to achieve sustained weight loss and conditions in which children live. guard against the risk of premature death through increased physical activity. EQUITY There have been coordinated national efforts A state’s health system should be judged by to reduce childhood obesity. In early 2010, the how well it performs for its youngest and most U.S. Preventive Services Task Force recommended vulnerable residents. By offering public health that clinicians screen children age 6 and older insurance programs such as Medicaid and CHIP, for obesity and offer or refer them to intensive and by funding safety net providers, all states weight-loss programs.85 The Affordable Care Act devote considerable resources to providing care requires private insurance plans to provide obesity for children in disadvantaged or low-income screening for all adults and children at no cost, families. In particular, delivery of preventive including body mass index (BMI) measurements services under Medicaid’s Early and Periodic for children.86 As part of the national Let’s Move! Screening, Diagnosis, and Treatment benefit has campaign, the President’s Task Force on Childhood contributed significantly to the quality of care Obesity outlined an action plan focused on early received by enrolled children, helping to ensure childhood, healthy eating, and physical activity to they are ready for school and able to reach their drive down obesity rates to 5 percent by 2030.87 full potential.90 Policy strategies that continue to The effort further recognizes the integral role support a standard of care for child development www.commonwealthfund.org47 and eliminate barriers to early and preventive better for their entire child population also tend to health care are effective levers to ameliorate health do better for their most vulnerable groups on the disparities among low-income, uninsured, and equity indicators examined. minority populations. The following section examines equity gaps The Scorecard assesses equity by comparing gaps in terms of access to care and prevention and in performance among subgroups of children by treatment, and explores disparities on selected income level, insurance status, and race/ethnicity. health outcomes. The analysis compares performance levels among each state’s most vulnerable child populations to a Health Insurance Coverage: Gaps by Income common benchmark—the national average—for a Extending health insurance to the uninsured is subset of indicators. We call the difference between the most important step to ensuring equitable the state’s most vulnerable group and the national access to health care. Nonetheless, about 16 average the “equity gap.” Up to six indicators percent of children living in families with incomes are examined for each of the relevant subgroups, less than 200 percent of the federal poverty level depending on data availability. In total, there are were uninsured in 2008–09—more than double 14 comparisons included in the equity dimension the uninsured rate among children in higher- of state health system performance for children: income families (Appendix A8). Among the 45 five by income, three by insurance status, and six states with sufficient data, uninsured rates among by race/ethnicity. low-income children (under 200 percent of States ranked at the top of the equity dimension poverty) ranged from an average of 24 percent have the smallest gaps in performance between in the bottom five states (Florida, Nevada, Texas, national averages and levels attained for low- Arizona, and Colorado) to less than 7 percent in income, uninsured, and minority children. The five the top five states (Hawaii, Massachusetts, West top-ranked states for equity—Maine, Vermont, Virginia, Maine, and Michigan). Remarkably, low- Hawaii, Massachusetts, and West Virginia—score income children in these top-ranked states had in the top quartile on this dimension for all three higher insurance rates than the average of all U.S. vulnerable populations (Exhibit 18). Conversely, children. On the other hand, low-income children seven of the 13 states in the bottom quartile score in the bottom-ranked states had uninsured rates up in the bottom quartile for all three groups. Given to 18 percentage points higher than those among its substantial low-income and rural populations, higher-income children in the same states. West Virginia stands out for its performance in Studies estimate that four of five currently providing relatively equitable care for the most- uninsured low-income children are eligible for disadvantaged children, providing an example for public health insurance under either Medicaid or states facing similar demographics. CHIP.91 States’ success in enrolling eligible children States that perform well on overall rankings— in these programs varies greatly, from a 55 percent on measures of access and quality—tend to have participation rate in Nevada to highs of 95 percent smaller performance gaps between the national in the District of Columbia and Massachusetts.92 average and their vulnerable child populations. The majority of states with the lowest participation This relationship indicates that states that do rates (under 80 percent) also had among the 48 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 highest rates of low-income children without any EQUITY Exhibit 18 coverage. In these states, greater effort is needed to Equity Dimension and Equity Type Ranking enroll those who are already eligible for publicly sponsored health insurance through better it y State Rank qu y eE uit outreach and simplified enrollment and renewal Top Quartile Eq ra g Second Quartile it y ve procedures. it y Co nic Third Quartile qu th ce Low-income parents are also at great risk for eE Bottom Quartile /E an om ur ce being uninsured. Nearly 40 percent of parents Inc Ins Ra RANK S TAT E PERFORMANCE BY ages 19–64 earning less than 200 percent of the EQUITY TYPE 1 Maine 3 1 3 federal poverty level were without insurance, 2 Vermont 5 2 1 3 Hawaii 6 4 2 compared with 10 percent of those at 200 percent 4 Massachusetts 2 12 6 5 West Virginia of the poverty level or higher (Appendix A8). 6 Connecticut 1 21 9 3 11 3 As with low-income children, Massachusetts 7 Iowa 3 20 8 8 Alaska 12 7 13 far outperformed the rest of the nation on this 9 Michigan 7 6 23 10 New York 10 10 19 indicator, with 10 percent of parents living below 11 New Hampshire 8 21 13 12 Minnesota 200 percent of the federal poverty level uninsured. 13 Missouri 17 26 10 21 22 5 Hawaii and Maine had the next-lowest uninsured 14 Rhode Island 28 4 21 15 Pennsylvania 9 17 29 rates among low-income parents (12% and 14%, 15 South Carolina 20 25 10 17 Kentucky respectively). Outside of these states, however, rates 17 North Dakota 14 28 36 17 7 12 ranged from 23 percent in Ohio to 59 percent in 19 20 Tennessee Montana 11 35 8 14 39 13 Texas. While parents with higher incomes in Texas 21 Washington 23 31 9 22 Indiana 13 28 23 fare better than their low-income counterparts, 23 Arkansas 22 13 41 23 Nebraska 17 26 33 their uninsured rate (18%) is also the worst among 25 Wisconsin 27 16 35 26 Kansas 17 34 29 high-income parents in the nation. 27 Alabama 16 39 27 These inequities in insurance status have 27 Colorado 43 23 16 27 Ohio 14 32 36 consequences for children’s health and growth. As 27 Virginia 25 23 34 31 Oklahoma 24 27 32 discussed below, children who have no insurance 32 Illinois 32 30 25 face markedly higher risk of lacking a regular 33 District of Columbia 34 Maryland 31 41 17 14 41 37 source of care, not receiving comprehensive care, 35 New Mexico 44 37 18 35 South Dakota 28 28 43 and having unmet needs for health and dental care. 37 Louisiana 37 43 20 38 Florida 46 38 17 39 California Access to Primary Care and Health 39 New Jersey 48 37 35 44 26 28 Outcomes: Gaps by Income and Insurance 41 Wyoming 39 41 31 42 Utah 34 41 38 Providing all children with a medical home can 43 North Carolina 36 33 50 44 Idaho 40 45 39 promote equity and improve their health and 45 Delaware 42 40 48 46 Georgia well-being.93 Yet the likelihood of a child having 47 Oregon 33 47 51 47 49 44 a primary care provider that meets the criteria of 48 49 Mississippi Arizona 44 49 49 46 46 46 a medical home varies significantly by income and 50 Texas 50 49 44 51 Nevada 51 48 51 insurance (Exhibit 19 and Appendix A9). Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org49 Low-income children in all states fare poorly Looking across states, more than 40 percent on this indicator. In 2007, almost half of children of poor children in the five bottom-ranked states in poor families, on average, did not have a medical (Nevada, Oregon, Colorado, Florida, and North home in the five top-ranked states (West Virginia, Dakota) did not receive medical and dental Vermont, Iowa, Montana, and Nebraska). This preventive care visits, compared with 22 percent rate worsens to over 70 percent in the bottom five of poor children in the top four states (Rhode states (Nevada, Utah, Texas, New Mexico, and Island, Hawaii, New York, and West Virginia) and California). West Virginia stands out for being the the District of Columbia. Rates of preventive care only state where children in low-income families visits among uninsured children varied more than are more likely to have a medical home than the twofold across the top- and bottom-ranked five national average rate. In contrast, Texas has one states (24% vs. 61% did not receive both medical of the lowest rates of medical home access among and dental preventive care visits, respectively). poor children (72% did not have a medical home). Among the five states with the largest equity gaps Interestingly, Texas children in higher-income (Oregon, Louisiana, Texas, North Carolina, and families (400% of the federal poverty level or Utah), even children with private insurance did higher) have the highest rate of access to medical worse than the average for all U.S. children on this homes in the nation, indicating a concentration of measure. resources in more affluent communities. Many of these children who have inadequate Among the uninsured, a similar pattern access to primary and preventive care—those appears: uninsured children were far less likely to without any coverage and living in poverty—are have primary care medical homes than children at increased risk of experiencing worse health with private insurance in all states. On average, 45 outcomes than other children. In terms of oral percent to 75 percent of uninsured children did health problems, children in low-income families not have a medical home in the top- and bottom- have more than one-and-a-half times the prevalence ranked states (Exhibit 19). of untreated cavities, pain, bleeding gums, or other Lower incomes and lack of insurance are dental problems than higher-income children in associated with poorer access to primary care and most states (Exhibit 21). Even in the five states preventive services. Nationally, more than a third with the smallest equity gap between low-income of children in families living below the poverty children and the national average (Iowa, Alaska, level (35%) did not have visits for medical and Kansas, Utah, and Alabama), 28 percent of low- dental preventive care in 2007, compared with income children had such preventable oral health 21 percent of children in families with higher concerns in 2007. Likewise, uninsured children incomes (Exhibit 20). The disparity is even wider are far more likely to live with oral health problems by insurance: half of children without insurance than those with insurance: rates of such problems coverage (52%) did not receive these preventive were two times higher among uninsured than care visits, compared with about a quarter of those privately insured children in some states. Moreover, who were privately insured (25%) or publicly the share of uninsured children with unmet dental insured (28%). needs varied more than threefold across states—14 50 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 EQUITY Exhibit 19 Children Without a Medical Home by Income and Insurance Percent of children without a medical home By income By insurance 100 100 400% of poverty or more Less than 100% of poverty Private insurance Uninsured Overall U.S. average = 42.5 75.3 71.4 64.3 60.6 50 45.2 50 45.0 33.5 36.0 30.7 31.9 29.0 27.9 0 0 National Top 5 states Bottom 5 National Top 5 states Bottom 5 average average states average average average states average Note: Top 5 states refer to states with smallest gaps between overall U.S. average and low-income/uninsured groups. Bottom 5 states refer to states with largest gaps between overall U.S. average and low-income/uninsured groups. Data: 2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. EQUITY Exhibit 20 Children Without Both Preventive Medical and Dental Care Visits by Income and Insurance Percent of children without preventive medical and dental care visits By income By insurance 75 75 400% of poverty or more Less than 100% of poverty Private insurance Uninsured 60.9 Overall U.S. average = 28.4 51.8 50 50 43.2 34.7 24.4 25 21.5 26.9 25 30.4 25.3 20.9 16.5 16.0 0 0 National Top 5 states Bottom 5 National Top 5 states Bottom 5 average average states average average average states average Note: Top 5 states refer to states with smallest gaps between overall U.S. average and low-income/uninsured groups. Bottom 5 states refer to states with largest gaps between overall U.S. average and low-income/uninsured groups. Data: 2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org51 percent in Massachusetts and Maine to 47 percent children’s access to dental services and the quality in Pennsylvania. of care.96 Oral health problems are also more prevalent The Children’s Health Insurance Program among children with public insurance than those Reauthorization Act of 2009 requires all CHIP with private insurance (Appendix A10). A report programs to provide a comprehensive dental by the Government Accountability Office found benefit package. In addition, states can draw from that publicly insured children often do not receive CHIP funds to offer dental-only supplemental needed dental care, despite being substantially more coverage for children who lack adequate dental likely to experience dental disease.94 Low dentist coverage.97 However, findings indicate inclusion of participation in Medicaid and CHIP contributes a benefit is not sufficient: states will need to address to reduced dental access for low-income children. the supply of dental care, likely with workforce Some states are increasing the supply of dental innovations to meet children’s preventive and care through higher reimbursement and simplified other oral health needs. administration, in addition to expanding member Gaps by Race and Ethnicity outreach and education.95 Notably, Alaska began The Scorecard compares access to and quality of the Dental Health Aide Therapist program in care by racial and ethnic groups, focusing on states 2003 in response to the high unmet needs of its that have substantial minority populations and rural Alaskan Native population. The successful sufficient data for analysis. Because minorities program has since served as a model of how greater often have lower incomes and are more likely to use of midlevel dental providers can improve be uninsured than whites, the disparities observed EQUITY Exhibit 21 Children with Oral Health Problems by Income and Insurance Percent of children with a toothache, decayed teeth/cavities, broken teeth, or bleeding gums in past six months By income By insurance 75 75 400% of poverty or more Less than 100% of poverty Private insurance Uninsured Overall U.S. average = 26.7 50 50 43.1 40.6 35.9 30.8 27.6 25 25 22.7 18.6 22.7 22.1 20.7 20.1 20.0 0 0 National Top 5 states Bottom 5 National Top 5 states Bottom 5 average average states average average average states average Note: Top 5 states refer to states with smallest gaps between overall U.S. average and low-income/uninsured groups. Bottom 5 states refer to states with largest gaps between overall U.S. average and low-income/uninsured groups. Data: 2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 52 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 among minorities also reflect concerns related to other ethnicities in New Mexico and Alaska placed income and insurance status. these states at the bottom—more than 70 percent Overall, Hispanic children have the highest of these children did not have a medical home. uninsured rate: 18 percent were without any Some minority children fare relatively better coverage in 2008–09, compared with only 7 than white children in terms of receipt of medical percent of white children. Across the 29 states with and dental preventive visits, with black children sufficient data to generate uninsured estimates more likely to receive preventive visits in two- among Hispanic children, uninsured rates ranged thirds of the states for which data are available. from a low of 5 percent in Massachusetts to a This was not the case for Hispanic children, who high of 28 percent in North Carolina. Uninsured were much more likely than other children to go rates among black children—varying from 2 without routine preventive care. In several cases, percent in Massachusetts to more than 20 percent states ranked low on measures of equitable care as in Florida—were generally lower than among a result of shortfalls for selected minority groups Hispanic children, and at times white children, that comprise relatively small shares of these states’ within the same state. Meanwhile, the highest total child populations. For example, Minnesota uninsured rate among white children in any state and North Carolina performed poorly for a racial/ was 14 percent (Mississippi). ethnic category that included Asian Americans and The variation in coverage levels among minority Native Americans. For these states, improvement parents is even wider. Overall, 22 percent of black efforts focused on these populations could parents and 41 percent of Hispanic parents were substantially reduce health disparities.98 without health insurance—two and four times The racial/ethnic disparities in an infant’s higher than their white counterparts, respectively. chance of survival are a striking example of the In fact, Hispanic parents had the highest uninsured human toll that can result from failure to reduce rate in all 24 states with available data. In the five inequities in health. The rate of infant deaths states with the largest equity gaps (North Carolina, among blacks was above the national average for Georgia, Texas, Oregon, and Maryland), more all states in 2006, ranging from eight per 1,000 than half of Hispanic parents (53%), on average, live births in Washington State to more than 20 were without insurance. per 1,000 live births in Hawaii (Appendix A11). Black, Hispanic, and other minority children Death rates were above the national average are at higher risk of lacking a primary care medical among American Indian or Alaska Native infants home to coordinate their care: medical home as well. Moreover, racial disparities persist in all rates among minority children were about 20 states: on average, death rates among black infants percentage points to 40 percentage points lower are two-and-one-half times higher than the rate of than among white children in the majority of white infants in states with reliable data, reaching states. As an exception, minority children in West more than five times as high in the District of Virginia and Vermont had more favorable rates Columbia and Hawaii. The large racial inequity is compared with the U.S. average for all children. largely due to a high incidence among blacks of Meanwhile, the low rates among Hispanic children very premature births.99 Ensuring that high-risk in Pennsylvania, Utah, and Nevada and children of mothers and newborns have insurance and receive www.commonwealthfund.org53 coordinated care and support services could would be nearly 6,000 fewer deaths per year improve health outcomes to the levels that should among children ages of 1 to 14. The prevalence of be attainable for all infants.100 Without a healthy childhood illnesses and developmental disabilities start to life, these children will be at greater risk for could also be reduced through improved access ill health as adults. and timely delivery of care. If all states performed at the levels achieved by IMPACT OF IMPROVED the top states: PERFORMANCE There are many ways to improve child health • about 16 million more children and parents system performance, involving stakeholders at all would have health insurance coverage— levels of the system. This section illustrates the reducing the number of uninsured by 70 potential gains in terms of healthy lives and access percent; to coverage and care if all states were able to meet • approximately 9 million more children would the levels of performance achieved by top states. have a medical home to help coordinate care Exhibit 22 shows the estimated impact if all and an additional 11 million children would states were to improve their performance to the receive preventive care visits, including rate of the best-performing state for eight key routine dental care and immunizations; indicators of child health system performance. If • over 300,000 fewer children with special all states could approach the low levels of child health care needs would have problems mortality achieved by the top state in 2007, there getting needed referrals; and Exhibit 22 National Cumulative Impact If All States Achieved Top State Rate If all states improved their performance to the level of the best-performing state Indicator for this indicator, then: more children ages 0–18 would be covered by health insurance (public or private), Insured Children 5,568,435 and therefore would be more likely to receive health care when needed. more parents ages 19–64 would be covered by health insurance (public or private), Insured Parents 10,394,481 and therefore would be more likely to receive health care when needed. more children ages 0–17 would have a medical home to help ensure that care is Medical Home 8,791,965 coordinated and accessible when needed. more young children (ages 19–35 months) would be up-to-date on all Vaccinations 592,963 recommended doses of six key vaccines. more children ages 0–17 would receive both routine preventive medical and Preventive Care Visits 10,170,287 dental care visits. fewer children with special health care needs ages 0–17 who needed a referral to Specialty Referrals 366,637 see another doctor or receive services would have problems getting such referrals. Child Mortality 5,749 fewer deaths among children ages 1–14 might occur. fewer children ages 1–17 would be suffering from oral health problems, including Oral Health Problems 4,691,470 toothaches, decayed teeth/cavities, broken teeth, and bleeding gums. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 54 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 • 4.7 million fewer children would have oral populations, and socioeconomic challenges that health problems. may limit their capacity for improvement.101 The formula for determining federal funding of state These examples illustrate only a few of the Medicaid programs recognizes this inequality many important opportunities for improvement. among states. Likewise, the recent economic Because some indicators would affect the same recession illustrates how federal funding can play individuals, some of these numbers cannot be a countercyclical role to help all states maintain combined. Yet across states over the course of coverage during times of fiscal duress. several years, the numbers add up to substantial Looking forward, a coherent set of national and gains in value for the nation. The Web resource state policies and innovations at the delivery system at http://www.commonwealthfund.org/Charts- level will be essential to sustain improvements in and-Maps/State-Data-Center/Child-Health.aspx children’s health care across the nation and raise provides state-specific estimates of potential gains benchmarks of performance. of achieving benchmark rates of performance on Federal health reform provides the common the Scorecard indicators. foundation on which states can build to address the variations, gaps, and disparities in children’s coverage and care documented in the Scorecard. POLICY IMPLICATIONS: Notably for children, the Affordable Care Act MOVING FORWARD TO IMPROVE strengthens and extends the successful federal– CHILDREN’S HEALTH, ACCESS, AND state partnership renewed in the Children’s Health CARE EXPERIENCES AND ADDRESS Insurance Program Reauthorization Act of 2009 to COSTS CONCERNS expand coverage to parents as well as children and The State Scorecard on Child Health System improve the quality of care for children. Performance, 2011, reveals that—in the period prior State action and leadership will be essential to the enactment of federal health care reform— to implement reforms effectively and support the U.S. health care system failed to ensure that initiatives tailored to specific state circumstances. all children received the timely, effective, and well- Actions that states can take include: coordinated care they need for their health and development. The Scorecard documents variations 1. Ensure continuous insurance coverage for in risk factors such as developmental delays and all children. obesity, pointing to the need for comprehensive medical and public health interventions to support 2. Strengthen Medicaid and CHIP provider children and their families in obtaining services networks with support of care systems that and adopting healthy lifestyles. provide high-quality care and superior While top-performing states provide examples outcomes for children and their families. for other states, no state performed well on all 3. Align provider incentives to promote access indicators and many performed at levels that are far and high-value care. from optimal—highlighting the need for systemic 4. Promote accountable, accessible, patient- change across the nation. Poorly performing centered, and coordinated care for children. states often have fewer resources, larger uninsured www.commonwealthfund.org55 5. Support information systems to inform from the Supplemental Nutrition Assistance and guide efforts to improve quality, health Program to determine eligibility. Families affirm outcomes, and efficiency. their enrollment when they use the Medicaid card 6. Participate in statewide initiatives to provide to access services.105 accountable leadership and collaboration, Going forward, states will play a critical role in which are essential to set and achieve implementing key pieces of comprehensive reform, national goals. such as designing health insurance exchanges to offer affordable private coverage to families of Ensure Continuous Insurance Coverage workers in small businesses. Expansion of family for All Children coverage under the Affordable Care Act is critical States can make progress toward achieving near- to the health and well-being of children. universal coverage for children as they take The Affordable Care Act’s expansion of advantage of enhanced federal matching funds coverage to all families has the potential to for CHIP and forthcoming Medicaid expansions dramatically alter the map of insurance coverage under the Affordable Care Act. Despite the across the country (Exhibits 23 and 24). When economic recession, more than half the states the law is fully implemented, rates of coverage expanded eligibility or made it easier for families among parents will rival the rates among the top to apply for and renew children’s enrollment in states today. Moreover, by 2019 no states will have CHIP or Medicaid since CHIPRA was enacted, more than 12 percent of children uninsured, and indicating their commitment to children’s only three states will have uninsured rates among health.102 Research finds that children who gain children above 10 percent. CHIP coverage are more likely to have a regular By 2019, only three states (Nevada, New provider and receive preventive care and are less Mexico, and Texas) are expected to have more likely to have unmet needs.103 Almost half the than 14 percent of their parental population ages states are promoting continuous eligibility in 19–64 uninsured. This contrasts with 34 states in Medicaid and CHIP to reduce coverage losses that 2008–09 (Exhibit 23). And 28 states are expected lead to gaps in essential care.104 to have less than 7 percent of parents uninsured, In September 2009, the federal government compared with just one state in 2008–09. When awarded $40 million of the $100 million parents are insured, their children are more likely authorized by CHIPRA to help states, safety-net to obtain the health care they need. States have organizations, and local communities expand the opportunity to make family coverage more and improve outreach efforts to enroll more affordable and efficient through complementary children in CHIP and Medicaid. As of December reforms in health insurance markets outside of the 2009, nine states had earned almost $73 million exchanges and through value-based purchasing of in performance bonuses for using innovative coverage for state employees. strategies to meet enrollment targets. For example, States also can take independent action to fill Louisiana automatically enrolled more than coverage gaps before (and after) federal subsidies 10,000 children in its Medicaid program under become available in 2014 for families to purchase “Express Lane Eligibility” procedures using data coverage through the exchanges. Oregon enacted 56 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Exhibit 23 Post-Reform: Percent of Children Ages 0–18 Uninsured by State 2008–2009 2019 (estimated) NH ME NH ME WA VT WA VT MT ND MT ND MN MN OR NY MA OR NY MA WI WI ID SD RI ID SD RI MI MI WY CT WY CT PA NJ PA NJ IA IA NE OH NE OH IN DE IN DE NV IL NV IL WV VA MD WV VA MD UT CO UT CO DC DC CA KS MO KY CA KS MO KY NC NC TN TN OK AR SC OK AR SC AZ NM AZ NM MS AL GA MS AL GA TX TX LA LA FL FL AK AK HI HI 16% or more 10%–15.9% 7%–9.9% Less than 7% Data: 2009–10 Current Population Survey ASEC Supplement; estimates for 2019 by Jonathan Gruber and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. Exhibit 24 Post-Reform: Percent of Parents Ages 19–64 Uninsured by State 2008–2009 2019 (estimated) NH ME NH ME WA VT WA VT MT ND MT ND MN MN OR NY MA OR NY MA WI WI ID SD RI ID SD RI MI MI WY CT WY PA NJ PA CT IA IA NJ NE OH NE OH IN DE IN DE NV NV IL WV VA MD IL MD UT CO UT WV VA DC CO DC CA KS MO KY CA KS MO KY NC NC TN TN OK AR SC OK SC AZ NM AZ NM AR MS AL GA MS AL GA TX TX LA LA FL FL AK AK HI HI 23% or more 19%–22.9% 14%–18.9% 7%–13.9% Less than 7% Data: 2009–10 Current Population Survey ASEC Supplement; estimates for 2019 by Jonathan Gruber and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org57 OREGON’S HEALTHY KIDSCONNECT—THE FIRST HEALTH EXCHANGE FOR CHILDREN In January 2010, five health plans in Oregon came to- age of the child and the carrier. Healthy KidsConnect gether to form the first-ever health exchange for chil- is designed to serve as many as 34,000 children with dren. Under the state’s new health care program for benefits similar to those offered through the Oregon children, called Healthy Kids, children are given com- Health Plan. The five carriers participating in the ex- prehensive coverage, including medical, dental, vision, change are PacificSource, the statewide carrier, and mental health care, and prescription benefits. There four regional carriers: Clear One Health Plans, Kaiser is one streamlined application for the Healthy Kids Foundation Health Plan of the Northwest, Samaritan program, but three different means of coverage: 1) Health Plans, and a partnership between local plans Oregon Health Plan Plus, the state’s Medicaid pro- Trillium Community Health and Lane Individual gram; 2) employer-sponsored insurance; or 3) Healthy Practice Association. Exchanges are a promising model KidsConnect. for states, offering a way to increase children’s access Healthy KidsConnect is a private-market insurance to care, drive down costs, and create incentives for option for families who earn too much to qualify for quality improvement through competition. the Oregon Health Plan, but can’t afford private in- surance—those with incomes between 201 percent For more information see D. Mooradian, “Up to 34,000 Chil- and 300 percent of the federal poverty level (FPL). dren May Get Benefits in New Oregon Exchange,” Health- If a family makes more than 300 percent FPL, it can Leaders–InterStudy, Oregon and Washington Health Plan buy Healthy KidsConnect coverage for the full cost Analysis, Winter 2010 7(1), available at http://www.oregon. of $165 to $475 a month per child, depending on the gov/OPHP/kidsconnect/docs/orwa_upto34000.pdf. reform legislation in 2009 that will cover up to Medicaid programs to learn from each other about 80,000 uninsured children through a Medicaid ways to improve the provision of developmental expansion and a new Healthy KidsConnect services for children. (See box on North Carolina.) exchange that offers a choice of private plans with A growing number of multipayer, public–private sliding-scale premiums based on family income. collaborations are focusing on improving quality, The expansion is funded by a tax on insurers as coordination, and accountability of children’s well as federal matching funds. Several states have care. In Pennsylvania, for example, commercial instituted buy-in programs that enable moderate- payers are participating in a state-led collaboration income families to purchase Medicaid and CHIP targeting care for childhood asthma (along with coverage for their children—often those with adult diabetes) within medical group practices.107 disabilities—who do not have access to affordable CHIPRA allocates $225 million over five years private coverage.106 (See box on Oregon.) for initiatives to improve care for children enrolled in CHIP and Medicaid. In February 2010, the Strengthen Medicaid and CHIP to Department of Health and Human Services Support Care Systems That Provide High- Quality Care and Superior Outcomes for awarded $100 million in grants to 10 projects Children and Families involving 18 states that will test new quality Collaborative learning and technical assistance measures, promote health information technology, can help states create the necessary infrastructure evaluate provider-based delivery models, and and information systems to inform efforts to demonstrate a model electronic health record for improve. The Assuring Better Child Health and children. For example, Colorado and New Mexico Development (ABCD) program sponsored by The are collaborating to form an Interstate Alliance Commonwealth Fund has enabled several state of School-Based Health Centers to improve care 58 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 for underserved children using a medical home Support Information Systems to Inform approach.108 and Guide Efforts to Improve Quality, Health Outcomes, and Efficiency Promote Accountable, Accessible, Information is critical to guide and drive change, Patient-Centered, and Coordinated Care and to set targets and monitor progress over time. Under federal health reform legislation, state Yet the nation lacks comprehensive data on the Medicaid programs may elect to provide benefits child health system to assess performance across through a “health home” that uses health all payers, including Medicaid and CHIP. Not information technology to improve coordination all states participate in the voluntary federal– of care for beneficiaries with chronic illnesses. The state partnership that produces the national Affordable Care Act also provides funds for several Healthcare Cost and Utilization Project (HCUP) pilots, demonstrations, and grant opportunities database, for example, limiting the ability to for states and community organizations to compare potentially preventable hospitalization promote prevention and wellness and to improve rates such as pediatric asthma admissions across coordination and quality of care for children as all states. Likewise, state reporting on CHIP has well as adults.109 Notable among these are grant not yet been fully standardized and the voluntary programs to establish and support: nature of quality reporting limits its potential for comparative evaluation. A few states such as • interdisciplinary community-based health California, New York, Pennsylvania, and Utah have teams, such as those being deployed through led robust efforts to develop public reporting and Vermont’s Blueprint for Health, that data monitoring systems that serve as models for support patient-centered medical homes for other states, though additional focus on children individuals with chronic conditions; may be warranted. • evidence-based maternal, infant, and early Better uniform data on the performance of the childhood home visitation programs serving child health care system will become available as at-risk communities identified by states; states conform to federal CHIPRA and Medicaid • cooperative community care networks, such requirements to measure and report on the quality as those developed by Community Care of of care. A core pediatric quality measurement North Carolina, that promote integrated set, building on existing Healthcare Effectiveness health care services for low-income Data and Information Set (HEDIS) measures, populations; and has been adopted and additional measures are being considered and developed. However, many • primary care extension program state hubs of the existing measures focus on care processes or and agencies that provide educational utilization and will need to be expanded to include support and assistance to primary care child health outcomes. Further, much as we have providers to implement quality improvement found substantial variability among states in terms programs and establish patient-centered of child health system performance, there likely is medical homes. equal or greater variability within states. Methods www.commonwealthfund.org59 to identify and reduce that variation remain to be Participate in Statewide Initiatives to developed and adopted. Provide the Accountable Leadership Widespread adoption of electronic health and Collaboration Essential to Set and Achieve Goals records and health information exchange among Several leading states have histories of a providers would promote more effective and collaborative culture of quality improvement efficient care delivery.110 The federal Health focused on improving leadership, transparency, Information Technology for Economic and and sustainability of results. Such efforts tend Clinical Health Act (HITECH) has provided to focus on expanding access as well as quality, state planning grants and loans to support and with a goal of improving health outcomes. For expand the effective statewide use and exchange example, Kansas set a goal that 85 percent of the of electronic information.111 CHIPRA builds state’s children have a medical home. In addition, on this effort by funding the development of a the state has achieved agreement on indicators of model electronic medical record for children and quality, access, cost, and public health—including encouraging adoption of electronic record systems several measures of the quality of care provided in for children in Medicaid and CHIP. Ongoing Medicaid managed care organizations—and has diligence will be needed to ensure that the new started publicly reporting results. Kansas also has information systems are capable of supporting created a consumer Web site for comparing the cost clinicians and generating robust and comparable and quality of health care plans and providers.114 data to measure and improve performance at both the micro and macro levels. Some states such as Arizona are incorporating CONCLUSION health information exchange into Medicaid The overall picture that emerges from the State programs to promote efficient, patient-centered Scorecard on Child Health System Performance, care. Starting in pilot regions in 2008, Arizona 2011, is the clear potential for improvement providers are exchanging patients’ demographic, across dimensions of performance. Our national eligibility, and clinical information. The state is values emphasize that we are one nation, yet also creating a group-purchasing arrangement where children live affects their health care in for providers to acquire systems that will support nearly every respect. The view across states reveals statewide objectives for the effective use of health startlingly wide gaps between leading and lagging information technology.112 Alabama is using a states on multiple indicators. Gaps between health information system to provide clinicians actual and achievable performance represent with free electronic access to medical claims lost opportunities to foster children’s health and history, including laboratory test results, and development. Exemplary initiatives in the top- to enable electronic prescribing to pharmacies. performing states and models of excellence in Federal funds support the initiative.113 health care delivery that exist within many states can help set the pace for change. 60 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Continuing variation in state performance achieved by top-performing states become realistic and state capacity to effect change also provides targets for all states to meet and exceed. compelling evidence of the need for concerted With costs rising faster than incomes and and complementary federal and state policies pressuring families and businesses, it is urgent that to improve health system performance. The states join together to aim higher—to take action interdependency of federal and state policy was locally to enhance the value of health care and amply demonstrated during the recent recession, ensure that everyone can participate in the health when the federal government enabled states to care system according to their needs. Investing in maintain coverage by providing a temporary children’s health yields long-term payoffs: healthy increase in funding for public programs to counter children are better able to learn in school and are the loss of state tax revenue and the decline in more likely to become healthy, productive adults. private coverage. Enactment of national reform Individuals, families, and society as a whole benefit provides a common foundation and shared from reduced dependency and disability, a healthier resources for states to build a more coherent health future workforce, and a stronger economy. system infrastructure, so that benchmark levels www.commonwealthfund.org61 NOTES 11 Health and Human Services, “Children’s Health Insurance Program,” 2010; and M. Heberlein, J. 1 E. Fielding and S. M. Teutsch, “Integrating Clinical Guyer, and D. Horner, Weathering the Storm: Care and Community Health: Delivering Health,” States Move Forward on Child and Family Coverage Journal of the American Medical Association, July Despite Tough Economic Climate (Washington, D.C.: 15, 2009 302(3):317–19. Georgetown University Center for Children and 2 M. K. Abrams, R. Nuzum, S. Mika, and G. Lawlor, Families, Sept. 2009). Realizing Health Reform’s Potential: How the 12 Institute of Medicine, Board on Health Care Services, Affordable Care Act Will Strengthen Primary Care Committee on the Consequences of Uninsurance, and Benefit Patients, Providers, and Payers (New Health Insurance Is a Family Matter (Washington, York: The Commonwealth Fund, Jan. 2011). D.C.: National Academies Press, 2002); J. M. Lambrew, 3 D. M. Berwick, T. W. Nolan, and J. Whittington, “The Health Insurance: A Family Affair (New York, The Triple Aim: Care, Health, and Cost,” Health Affairs, Commonwealth Fund May 2001). May/June 2008 27(3):759–69. 13 M. Heberlein, T. Brooks, J. Guyer et al., Holding 4 G. Moody and S. Silow-Carroll, High- and Low- Steady, Looking Ahead: Annual Findings of a Scoring States: Lessons to Raise Health System 50-State Survey of Eligibility Rules, Enrollment and Performance (New York: The Commonwealth Fund, Renewal Procedures, and Cost Sharing Practices in forthcoming). Mediciad and CHIP, 2010–2011 (Menlo Park, Calif.: Kaiser Family Foundation, Jan. 2011), available at 5 E. I. Knudsen, J. J. Heckman, J. Cameron et al., http://www.kff.org/medicaid/upload/8130.pdf. “Economic, Neurobiological, and Behavioral Perspectives on Building America’s Future 14 L. Ku and M. Broaddus, The Importance of Family- Workforce,” Proceedings of the National Academy Based Insurance Expansions: New Research Findings of Sciences, July 5, 2006 103(27):10155–62. About State Health Reforms (Washington, D.C.: Center on Budget and Policy Priorities, 2000); and L. 6 The Commonwealth Fund Commission on a High Dubay and G. M. Kenney, Expanding Public Health Performance Health System, Why Not the Best? Insurance to Parents: Effects on Children’s Coverage Results from the National Scorecard on U.S. Under Medicaid (Washington, D.C.: Urban Institute, Health System Performance, 2008 (New York: The 2002). Commonwealth Fund, July 2008). 15 R2 = 0.69 7 J. K. Rajaratnam, J. R Marcus, A. D. Flaxman et al., “Neonatal, Postneonatal, Childhood, and 16 M. Kogan, P. Newacheck, S. Blumberg et al.,“ Under-5 Mortality for 187 Countries, 1970–2010: A “Underinsurance Among Children in the United Systematic Analysis of Progress Towards Millennium States,” New England Journal of Medicine, Aug. 26, Development Goal 4,” The Lancet, June 5, 2010 2010 363(9):841–51. 375(9730):1988–2008. 17 According to the National Bureau of Economic 8 Commonwealth Fund Commission on a High Research’s Business Cycle Dating Committee, the Performance Health System, Why Not the Best? recession officially began December 2007 and Results from a National Scorecard on U.S. Health ended in June 2009. For more information, see the System Performance (New York: The Commonwealth following announcement: http://www.nber.org/ Fund, Sept. 2006); and D. McCarthy, S. K. H. How, C. cycles/sept2010.pdf. Schoen, J. C. Cantor, and D. Belloff, Aiming Higher: 18 G. Fairbrother and A. Carle, “The Impact of Parental Results from a State Scorecard on Health System Job Loss on Children’s Health Insurance Coverage,” Performance (New York: The Commonwealth Fund Health Affairs, July 2010 29(7):1343–49. Commission on a High Performance Health System, June 2007). 19 D. Horner, J. Guyer, C. Mann et al., The Children’s Health Insurance Program Reauthorization Act of 9 K. K. Shea, K. Davis, and E. L. Schor, U.S. Variations in 2009 (Washington, D.C.: Georgetown University Child Health System Performance: A State Scorecard Center for Children and Families, Feb. 2009); and (New York: The Commonwealth Fund, May 2008). Kaiser Commission on Medicaid and the Uninsured, 10 CHIP Statistical Enrollment Data System (2/01/10) as Health Coverage of Children: The Role of Medicaid reported in U.S. Department of Health and Human and CHIP (Menlo Park, Calif.: Kaiser Family Services, “Children’s Health Insurance Program Foundation, Aug. 2010). Reauthorization Act One Year Later: Connecting 20 C. Schoen, K. Stremikis, S. K. H. How, and S. R. Kids to Coverage,” Feb. 4, 2010; and G. Kenney and Collins, State Trends in Premiums and Deductibles, J. Yee, “SCHIP at a Crossroads: Experiences to Date 2003–2009: How Building on the Affordable Care Act and Challenges Ahead,” Health Affairs, March/April Will Help Stem the Tide of Rising Costs and Eroding 2007 26(2):356–69. Benefits (New York: The Commonwealth Fund, Dec. 2010). 62 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 21 K. Baiker and A. Chandra, The Labor Market Effects 33 S. W. Roush, T. V. Murphy, and the Vaccine- of Rising Health Insurance Premiums, NBER Working Preventable Disease Table Working Group, “Historical Paper No. 11160 (Cambridge, Mass.: National Bureau Comparisons of Morbidity and Mortality for Vaccine- of Economic Research, Feb. 2005); D. Goldman, N. 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Home, March 2007, available at http://www.aafp. 41 Ibid. org/pcmh/principles.pdf. 42 U.S. Department of Health and Human Services, Oral 31 Abrams, Nuzum, Mika, and Lawlor, Realizing Health Health, objective 2 in: Healthy People 2010. Available Reform’s Potential, 2011. at http://www.healthypeople.gov/Document/pdf/ 32 F. Zhou, J. Santoli, M. L. Messonnier et al., “Economic Volume2/21Oral.pdf. Evaluation of the 7-Vaccine Routine Childhood 43 Pourat and Finocchio, “Racial and Ethnic Disparities,” Immunization Schedule in the United States, 2001,” 2010. Archives of Pediatric and Adolescent Medicine, Dec. 2005 159(12):1136–44. www.commonwealthfund.org63 44 American Academy of Pediatrics, Council on 56 L. Wang, Y. Zhong, and L. Wheeler, “Direct and Children with Disabilities, Section on Developmental Indirect Costs of Asthma in School-Age Children,” Behavioral Pediatrics, Bright Futures Steering Preventing Chronic Disease, Jan. 2005 2(1):A11, Committee, and Medical Home Initiatives for available at http://www.cdc.gov/pcd/issues/2005/ Children with Special Needs, “Identifying Infants and jan/04_0053.htm. Young Children with Developmental Disorders in the 57 L. J. Akinbami, J. E. Moorman, P. L. Garbe et al., Medical Home: An Algorithm for Developmental “Status of Childhood Asthma in the United States, Surveillance and Screening,” Pediatrics, July 2006 1980–2007,” Pediatrics, March 2009 123(Suppl. 3): 118(1):405–20. S131–S145. 45 H. Hix-Small, K. Marks, J. Squires et al., “Impact of 58 Office of Child Advocacy, “Spotlight on Asthma,” Implementing Developmental Screening at 12 and (Boston: Children’s Hospital, July 2009), available at 24 months in a Pediatric Practice,” Pediatrics, Aug. http://www.childrenshospital.org/about/Site1394/ 2007 120(2):381–89. Documents/Asthma spotlight FINAL.pdf. 46 American Academy of Pediatrics Policy Statement, 59 U.S. Department of Health and Human Services, Committee on School Health, “School-Based Mental Health Resources and Services Administration, Health Services,” Pediatrics, June 2004 113(6):1839– Maternal and Child Health Bureau, The National 45. Survey of Children with Special Health Care 47 J. Williams, K. Klinepeter, G. Palmes et al., “Diagnosis Needs Chartbook 2005–2006 (Rockville, Md.: U.S. and Treatment of Behavioral Health Disorders in Department of Health and Human Services, 2008). Pediatric Practice,” Pediatrics, Sept. 2004 114(3): 60 Z. J. Huang, M. D. Kogan, S. M. Yu et al., “Delayed 601–06; and C. Weitzman and J. Leventhal, or Forgone Care Among Children with Special “Screening for Behavioral Health Problems in Health Care Needs: An Analysis of the 2001 National Primary Care,” Current Opinion in Pediatrics, Dec. Survey of Children with Special Health Care Needs,” 2006 18(6):641–48. Ambulatory Pediatrics, Jan.–Feb. 2005 5(1):60–67. 48 J. DeSocio and J. Hootman, “Children’s Mental 61 S. Silow-Carroll and G. Hagelow, Systems of Care Health and School Success,” Journal of School Coordination for Children: Lessons Learned Across Nursing, Aug. 2004 20(4):189–96. State Models (New York: The Commonwealth Fund, 49 C. C. Weitzman and J. M. Leventhal, “Screening Sept. 2010). for Behavioral Health Problems in Primary Care,” 62 Antonelli, McAllister, and Popp, Making Care Current Opinion in Pediatrics, Dec. 2006 18(6):641– Coordination, 2009; and J. Palfrey, L. Sofis, E. 48. Davidson et al., “The Pediatric Alliance for 50 Williams, Klinepeter, and Palmes, “Diagnosis and Coordinated Care: Evaluation of a Medical Home Treatment,” 2004. Model,” Pediatrics, May 2004 113(5):1507–16. 51 DeSocio and Hootman, “Children’s Mental Health,” 63 M. Ganz and S. Tendulkar, “Mental Health Care 2004. Services for Children with Special Health Care 52 P. Wellstone and P. Domenci, “Mental Health Needs and Their Family Members: Prevalence and Parity and Addition Equity Act of 2008.” Correlates of Unmet Needs,” Pediatrics, June 2006 For more information, see: https://www. 117(6):2138–48. cms.gov/healthinsreformforconsume/04_ 64 R. Benedict, “Quality Medical Homes: Meeting thementalhealthparityact.asp. Children’s Needs for Therapeutic and Supportive 53 Medical Home Initiatives for Children with Special Services,” Pediatrics, published online Dec. 3, 2007. Needs Project Advisory Committee, American 65 Support services in this measure include respite care, Academy of Pediatrics, “The Medical Home,” family genetic counseling, and family mental health Pediatrics, July 2002 110(1 Pt. 1):184–86. care or counseling. All services are those needed 54 R. C. Antonelli, J. W. McAllister, and J. Popp, because of a child’s medical, behavioral, or other Making Care Coordination a Critical Component health conditions. of the Pediatric Health System: A Multidisciplinary 66 U.S. Department of Health and Human Services, Framework (New York: The Commonwealth Fund, Healthy People 2010: Understanding and Improving May 2009). Health, 2nd ed. (Washington D.C.: U.S. Government 55 J. Tom, C. Tseng, J. Davis et al., “Missed Well- Printing Office, 2000); U.S. Department of Health Child Visits, Low Continuity of Care, and Risk of and Human Services, MCHB Vision and Mission Ambulatory Care–Sensitive Hospitalizations in Young Statement and Strategic Plan, 1998–2003 (Rockville, Children,” Archives of Pediatric and Adolescent Md.: Maternal and Child Health Bureau, Health Medicine, Nov. 2010 164(11):1052–58. Resources and Service Administration, 1999). 67 Minnesota had data for five of the seven indicators included in the healthy lives dimension. It did not participate in the 2009 Youth Risk Behavior Survey. 64 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 68 T. J. Mathews and M. F. MacDorman, “Infant 80 R. C. Whitaker, J. A. Wright, M. S. Pepe et al., Mortality from the 2006 Period Linked Birth/Infant “Predicting Obesity in Young Adulthood from Death Data Set,” National Vital Statistics Reports, Childhood and Parental Obesity,” New England April 30, 2010 58(17):1–31. Journal of Medicine, Sept. 25, 1997 337(13):869–73. 69 G. R. Alexander and C. C. Korenbrot, “The Role of 81 N. S. The, C. Suchindran, K. E. North et al., Prenatal Care in Preventing Low Birth Weight,” “Association of Adolescent Obesity with Risk of Future Child, Spring 1995 5(1):103–20; M. C. Severe Obesity in Adulthood,” Journal of the McCormick and J. E. Siegel, “Recent Evidence on American Medical Association, Nov. 10, 2010 the Effectiveness of Prenatal Care,” Ambulatory 304(18):2042–47. Pediatrics, Nov./Dec. 2001 1(6):321–25. 82 J. Cawley and C. Meyerhoefer, The Medical Care 70 U.S. Department of Health and Human Services, Costs of Obesity: An Instrumental Variables Oral Health in America: A Report of the Surgeon Approach (Cambridge, Mass.: National Bureau of General—Executive Summary (Rockville, Md.: Health Economic Research, Oct. 2010). and Human Services, National Institute of Dental and 83 Overweight means that the child’s Body Mass Index Craniofacial Research, National Institutes of Health, (BMI) is at or above the 85th percentile for sex and 2000). age. Obesity is 95th percentile of BMI or higher. 71 According to the Child and Adolescent Health Overweight and obesity were only reported among Measurement Initiative, it appears that the variable children ages 10 to 17 because parent-reported on decayed teeth/cavities is driving this indicator, height and weight are more reliable for this age with approximately 16 percent of children having group than they are for younger children. decayed teeth/cavities in the past six months. 84 G. K. Singh, M. D. Kogan, and P. C. van Dyck, 72 S. Wetterhall, J. Bader, B. Burrus et al, “Evaluation of “Changes in State-Specific Childhood Obesity and the Dental Health Aide Therapist Workforce Model Overweight Prevalence in the United States from in Alaska, Final Report,” Prepared for W. K. Kellogg 2003 to 2007,” Archives of Pediatric and Adolescent Foundation, Rasmuson Foundation, and Bethel Medicine, May 3, 2010 164(7):598–607. Community Services Foundation, Oct. 2010. 85 U.S. Preventive Services Task Force, “Screening for 73 I. A. Isong, K. E. Zuckerman, S. R. Rao et al., Obesity in Children and Adolescents: U.S. Preventive “Association Between Parents’ and Children’s Use Services Task Force Recommendation Statement,” of Oral Health Services,” Pediatrics, Feb. 1, 2010 Pediatrics, Jan. 18, 2010 125(2):361–67. 125(3):502–08. 86 C. M. Clancy, “Focus on Obesity,” Navigating the 74 Centers for Disease Control and Prevention, Health Care System: Advice Columns from Dr. Carolyn “Smoking-Attributable Mortality, Years of Potential Clancy (Rockville, Md.: Agency for Healthcare Life Lost, and Productivity Losses—United States, Research and Quality, Oct. 5, 2010), available at 2000–2004,” Morbidity and Mortality Weekly Report, http://www.ahrq.gov/consumer/cc/cc100510.htm. Nov. 14, 2008 57(45):1226–28. 87 White House Task Force on Childhood Obesity Report 75 American Academy of Pediatrics, Committee on to the President, Solving the Problem of Childhood Substance Abuse, “Tobacco, Alcohol, and Other Obesity Within a Generation, May 11, 2010. Drugs: The Role of the Pediatrician in Prevention 88 J. C. Lumeng, V. P. Castle, and C. N. Lumeng, “The and Management of Substance Abuse,” Pediatrics, Role of Pediatricians in the Coordinated National Jan. 1998 101(1):125–28. Effort to Address Childhood Obesity,” Pediatrics, 76 Centers for Disease Control and Prevention, Sept. 2010 126(3):574–75. “Cigarette Use Among High School Students— 89 G. Moody and S. Silow-Carroll, “Public Health in the United States, 1991–2009,” Morbidity and Mortality State Reform Spotlight,” States in Action (New York: Weekly Report, July 9, 2010 59(26):797–801. The Commonwealth Fund, June/July 2009). 77 Current cigarette use was defined as smoking 90 E. L. Schor, M. K. Abrams, and K. Shea, “Medicaid: cigarettes on at least one day during the past Health Promotion and Disease Prevention for 30 days. School Readiness,” Health Affairs, March/April 2007 78 U.S. Department of Health and Human Services, 26(2):420–29. Healthy People 2010, 2nd ed. With Understanding 91 G. Kenney, A. Cook, and L. Dubay, Progress Enrolling and Improving Health and Objectives for Improving Children in Medicaid/CHIP: Who Is Left and What Health, 2 vols., Objective 27-02 (Washington, D.C.: Are the Prospects for Covering More Children? U.S. Government Printing Office, Nov. 2000). (Washington, D.C.: Urban Institute, 2009). 79 A Broken Promise to Our Children: The 1998 State 92 G. M. Kenney, V. Lynch, A. Cook et al., “Who and Tobacco Settlement 12 Years Later (Washington, Where Are the Children Yet to Enroll in Medicaid D.C.: Campaign for Tobacco Free Kids, Nov. 17, 2010). and the Children’s Health Insurance Program?” Health Affairs, Oct. 2010 29(10):1920–29. www.commonwealthfund.org65 93 Starfield and Shi, “Medical Home,” 2004. 105 S. Silow-Carroll, G. Moody, and D. Rodin, “The Children’s Health Insurance Program Reauthorization 94 Medicaid: Extent of Dental Disease in Children Act: Progress After One Year,” States in Action (New Has Not Decreased and Millions are Estimated to York: The Commonwealth Fund, May/June 2010). Have Untreated Tooth Decay (Washington, D.C.: Government Accountability Office, GAO-08-1121, 106 Center for Children and Families, Program Design Sept. 2008). Snapshot: State Buy-In Programs for Children (Washington, D.C.: Georgetown University Health 95 Strides in Dental Access for Low-Income Children: Policy Institute, March 2009). Lessons Learned from Six States with Major Dental- Medicaid Reforms (Washington, D.C.: Children’s 107 M. Takach, The Role of Federally Qualified Health Dental Health Project/Doral, 2007). Centers in State-Led Medical Home Collaboratives (Portland, Maine: National Academy for State Health 96 Oral Health: Efforts Under Way to Improve Children’s Policy, June 2009). Access to Dental Services, but Sustained Attention Needed to Address Ongoing Concerns, GAO-11- 108 Silow-Carroll, Moody, and Rodin, “Children’s Health 96 (Washington, D.C.: Government Accountability Insurance Program,” 2010; and Centers for Medicare Office, Nov. 2010). and Medicaid Services, State Demo Grants: Children’s Health Insurance Program Reauthorization Act of 97 Kaiser Commission on Medicaid and the Uninsured, 2009 (Washington, D.C.: U.S. Department of Health CHIP TIPS: Children’s Oral Health Benefits (Menlo and Human Services, 2009), available at http://www. Park, Calif.: Kaiser Family Foundation, Aug. 2010). cms.hhs.gov/CHIPRA/15_StateDemo.asp. 98 The analysis of racial and ethnic disparities focuses 109 Georgia Health Policy Center, Policy Brief: on subgroups for which there were sufficient data Implications of Health Reform for Community-Based in each state for valid comparisons. Sample sizes Organizations (Atlanta: Georgia State University, were too small to report data separately for Asian May 2010), available at http://aysps.gsu.edu/ghpc/. Americans, Native Americans, and other subgroups whose experiences are combined in an “other” 110 C. Schoen, S. Guterman, A. Shih, J. Lau, S. Kasimow, category. Some states (such as Vermont, Maine, A. Gauthier, and K. Davis, Bending the Curve: Options and West Virginia) with relatively homogenous for Achieving Savings and Improving Value in U.S. populations often had no subgroups for ranking Health Spending (New York: The Commonwealth other than multiracial children. Fund, Dec. 2007). 99 Mathews and MacDorman, “Infant Mortality,” 2010. 111 S. Silow-Carroll and G. Moody, “Early Federal Action on Health Policy: The Impact on States,” States in 100 E. Eckholm, “Trying to Explain a Drop in Infant Action (New York: The Commonwealth Fund, Feb./ Mortality,” New York Times, Nov. 27, 2009. March 2009). 101 G. Moody and S. Silow-Carroll, Aiming Higher for 112 “Arizona’s Statewide HIE Utility” (New York: The Health System Performance: A Profile of Seven States Commonwealth Fund, Sept. 15, 2008); and A. D. That Perform Well on the Commonwealth Fund’s Rodgers, Arizona Health Care Cost Containment 2009 State Scorecard (New York: The Commonwealth System, “States ‘HITting’ Back at Escalating Health Fund, Oct. 2009); and G. Moody and S. Silow-Carroll, Care Costs and Poor Quality: The Science and Art High and Low-Scoring States: Lessons to Raise Health of Health Information Technology Deployment and System Performance (New York: The Commonwealth Adoption,” presentation at the AcademyHealth Fund, forthcoming). State Quality Improvement Institute, Denver, Colo., 102 U.S. Department of Health and Human Services, May 27, 2009. CHIPRA One Year Later (Washington, D.C.: Health 113 State of Alabama, E-Prescribing Capability Added and Human Services, Feb. 4, 2010), available at http:// to QTool Electronic Health Record (Montgomery, www.insurekidsnow.gov/chip/report.html. Ala.: Alabama Medicaid Agency, 2009), available at 103 Children’s Health Insurance Research Initiative, http://www.medicaid.alabama.gov/documents/News/ “What Has Been Learned About Expanding Children’s MM_E-Prescribe_4-22-09.pdf. Health Insurance? Highlights from The Child Health 114 J. Rosenthal and C. Hanlon, State Partnerships to Insurance Research Initiative,” Issue Brief No. 10 Improve Quality: Models and Practices from Leading (Washington, D.C.: Agency for Healthcare Research States (Portland, Maine: National Academy for State and Quality, Sept. 2009), available at www.ahrq.gov/ Health Policy, June 2009). chiri. 104 L. M. Olson, S. F. Tang, and P. W. Newacheck, “Children in the U.S. with Discontinuous Health Insurance Coverage,” New England Journal of Medicine, July 28, 2005 353(4):382–91. 66 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 APPENDICES Appendix A APPENDIX A1 State Ranking on Health System Performance by Dimension APPENDIX A2 Summary of Indicator Rankings by State APPENDIX A3 Access and Affordability: Dimension Ranking and Performance on Indicators APPENDIX A4 Health Insurance Coverage Rates for Children and Parents, 1999–2000 to 2008–09 APPENDIX A5 Percent of Currently Insured Children Ages 0–17 Whose Health Insurance Coverage Is Adequate to Meet Needs, by Insurance Type, 2007 APPENDIX A6 Prevention and Treatment: Dimension Ranking and Performance on Indicators APPENDIX A7 Potential to Lead Healthy Lives: Dimension Ranking and Performance on Indicators APPENDIX A8 Equity: Uninsured Rates for Children and Parents, by Income, 2008–09 APPENDIX A9 Equity: Percent of Children Without a Medical Home, by Income and Insurance Type, 2007 APPENDIX A10 Equity: Percent of Children with Oral Health Problems, by Income and Insurance Type, 2007 APPENDIX A11 Equity: Infant Mortality, by Race/Ethnicity, 2004–2006 APPENDIX A12 State Characteristics: Poverty and Health Status APPENDIX A13 State Characteristics: Child Population by Race/Ethnicity, 2008–2009 Appendix B APPENDIX B1 State Scorecard Data Years and Databases APPENDIX B2 State Scorecard Indicator Descriptions APPENDIX B3 Complete References for Data Sources www.commonwealthfund.org67 Appendix A1. State Ranking on Health System Performance by Dimension = State in top quartile Potential to Lead Overall Access & Affordability Prevention & Treatment Healthy Lives Equity Rank* State Rank Rank Rank Rank 37 Alabama 29 32 48 27 30 Alaska 34 38 40 8 49 Arizona 47 45 38 49 42 Arkansas 41 37 49 23 44 California 44 42 27 39 20 Colorado 28 28 4 27 9 Connecticut 8 26 6 6 31 Delaware 13 33 32 45 39 District of Columbia 20 39 51 33 47 Florida 49 44 35 38 43 Georgia 29 34 42 46 7 Hawaii 3 12 23 3 41 Idaho 38 50 17 44 28 Illinois 33 22 31 32 25 Indiana 31 15 33 22 1 Iowa 6 1 2 7 13 Kansas 19 6 20 26 36 Kentucky 40 30 46 17 40 Louisiana 43 21 47 37 4 Maine 7 5 10 1 18 Maryland 4 18 26 34 1 Massachusetts 1 4 7 4 15 Michigan 14 29 21 9 8 Minnesota 18 11 1 12 50 Mississippi 51 43 50 48 21 Missouri 26 19 30 13 34 Montana 42 49 17 20 16 Nebraska 22 16 14 23 51 Nevada 48 51 43 51 5 New Hampshire 2 2 13 11 29 New Jersey 23 41 16 39 46 New Mexico 46 40 37 35 21 New York 27 34 17 10 32 North Carolina 35 20 28 43 10 North Dakota 16 23 11 17 19 Ohio 14 8 36 27 45 Oklahoma 36 47 41 31 38 Oregon 39 46 9 47 10 Pennsylvania 11 17 24 15 6 Rhode Island 9 2 14 14 33 South Carolina 44 23 45 15 27 South Dakota 25 13 33 35 26 Tennessee 32 7 44 19 48 Texas 50 48 29 50 23 Utah 17 25 5 42 3 Vermont 9 8 3 2 24 Virginia 4 34 25 27 13 Washington 12 26 12 21 17 West Virginia 24 10 39 5 12 Wisconsin 21 14 8 25 35 Wyoming 36 31 22 41 * Final rank for overall health system performance across four dimensions. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 68 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Appendix A2. Summary of Indicator Rankings by State Overall No. of main Top 5 Top 2nd 3rd Bottom Bottom 5 Rank* State indicators States Quartile Quartile Quartile Quartile States 37 Alabama 19 1 4 1 6 8 4 30 Alaska 19 0 1 5 7 6 3 49 Arizona 20 0 1 3 7 9 4 42 Arkansas 20 0 1 3 6 10 4 44 California 18 1 3 2 5 8 4 20 Colorado 20 1 7 5 3 5 1 9 Connecticut 20 6 10 4 2 4 0 31 Delaware 19 2 5 3 6 5 1 39 District of Columbia 17 1 4 2 1 10 5 47 Florida 20 0 2 2 9 7 5 43 Georgia 20 1 3 5 6 6 3 7 Hawaii 20 5 7 5 7 1 1 41 Idaho 19 2 3 4 6 6 1 28 Illinois 20 0 0 9 7 4 0 25 Indiana 20 1 2 9 5 4 1 1 Iowa 18 9 14 3 1 0 0 13 Kansas 20 2 10 4 5 1 0 36 Kentucky 20 0 0 7 5 8 3 40 Louisiana 19 1 2 5 2 10 4 4 Maine 20 3 12 5 1 2 1 18 Maryland 20 2 7 4 4 5 1 1 Massachusetts 20 9 14 3 1 2 1 15 Michigan 20 1 4 9 7 0 0 8 Minnesota 18 4 10 6 0 2 1 50 Mississippi 19 0 1 3 1 14 8 21 Missouri 20 1 5 5 6 4 2 34 Montana 19 1 2 5 5 7 1 16 Nebraska 18 1 6 7 5 0 0 51 Nevada 20 0 1 3 3 13 7 5 New Hampshire 20 5 11 7 2 0 0 29 New Jersey 20 1 4 4 9 3 2 46 New Mexico 19 1 4 2 3 10 5 21 New York 20 2 6 5 5 4 2 32 North Carolina 20 2 4 7 7 2 0 10 North Dakota 19 3 9 4 3 3 1 19 Ohio 18 2 3 10 5 0 0 45 Oklahoma 20 0 1 4 5 10 3 38 Oregon 18 3 5 1 5 7 2 10 Pennsylvania 19 1 5 8 4 2 2 6 Rhode Island 20 6 9 5 4 2 0 33 South Carolina 20 0 2 3 8 7 1 27 South Dakota 20 0 4 9 3 4 2 26 Tennessee 20 2 5 5 4 6 2 48 Texas 20 0 0 4 6 10 5 23 Utah 20 3 7 9 2 2 1 3 Vermont 20 7 12 4 3 1 1 24 Virginia 18 2 3 7 7 1 1 13 Washington 18 1 6 5 5 2 0 17 West Virginia 20 2 6 4 4 6 0 12 Wisconsin 20 2 8 7 4 1 1 35 Wyoming 19 3 3 5 9 2 0 * Final rank for overall health system performance across four dimensions. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org69 Appendix A3. Access and Affordability: Dimension Ranking and Performance on Indicators Indicator Performance Family Premiums as Percent Currently Insured Percent of Median Income Percent Children Percent Parents Children Whose Coverage for Family Household Ages 0–18 Insured Ages 19–64 Insured Is Adequate (Under Age 65) Dimension State Rank 2008–09 Rank 2008–09 Rank 2007 Rank 2009 Rank United States 89.6 80.9 76.5 19.0 Alabama 29 93.5 12 80.0 37 77.3 24 20.9 41 Alaska 34 87.6 45 80.0 37 76.6 31 17.0 14 Arizona 47 85.0 47 76.8 44 75.1 38 21.4 44 Arkansas 41 89.0 36 75.7 48 78.1 18 20.9 41 California 44 88.9 39 76.5 47 75.1 38 19.2 31 Colorado 28 88.6 41 82.8 31 76.7 30 16.4 10 Connecticut 8 93.2 13 88.8 9 76.9 28 13.9 1 Delaware 13 90.5 28 86.6 15 79.9 6 17.4 19 District of Columbia 20 92.5 18 89.5 8 79.3 9 21.5 46 Florida 49 82.2 50 73.6 49 72.8 46 19.9 35 Georgia 29 88.5 42 77.4 42 81.6 2 19.0 28 Hawaii 3 95.4 3 92.6 2 83.8 1 17.4 19 Idaho 38 90.3 30 81.3 33 72.8 46 18.2 24 Illinois 33 91.9 23 83.6 28 73.2 42 19.3 32 Indiana 31 92.3 22 84.5 21 73.5 41 19.9 35 Iowa 6 94.2 8 88.1 11 78.1 18 16.6 11 Kansas 19 90.0 32 84.3 23 78.8 11 16.9 13 Kentucky 40 90.4 29 79.7 39 77.0 26 21.4 44 Louisiana 43 89.7 33 77.0 43 77.5 23 22.2 48 Maine 7 94.7 5 91.5 3 78.6 14 18.9 27 Maryland 4 93.2 13 84.6 20 79.5 8 14.8 4 Massachusetts 1 96.7 1 95.6 1 81.5 3 15.2 6 Michigan 14 94.4 7 86.6 15 77.9 21 18.6 26 Minnesota 18 93.9 9 89.9 6 68.7 51 16.7 12 Mississippi 51 87.7 44 76.6 46 72.7 48 24.9 51 Missouri 26 91.5 25 83.7 26 75.3 36 17.9 22 Montana 42 88.9 39 79.1 40 68.8 50 17.1 16 Nebraska 22 91.6 24 86.4 17 75.5 35 17.2 18 Nevada 48 83.4 49 76.7 45 73.1 44 20.1 37 New Hampshire 2 96.1 2 88.3 10 80.2 5 14.5 3 New Jersey 23 89.6 34 83.9 25 75.7 34 14.0 2 New Mexico 46 84.4 48 71.2 50 78.8 11 22.3 49 New York 27 92.4 21 84.1 24 77.2 25 20.4 40 North Carolina 35 89.0 36 81.3 33 78.6 14 21.5 46 North Dakota 16 92.7 15 89.9 6 73.2 42 16.1 9 Ohio 14 92.5 18 88.0 12 78.0 20 17.4 19 Oklahoma 36 89.6 34 77.9 41 75.9 33 18.2 24 Oregon 39 88.1 43 80.8 36 76.9 28 19.0 28 Pennsylvania 11 92.7 15 88.0 12 78.7 13 17.9 22 Rhode Island 9 92.6 17 87.4 14 79.6 7 17.0 14 South Carolina 44 87.1 46 81.9 32 73.7 40 20.1 37 South Dakota 25 90.1 31 84.4 22 75.3 36 17.1 16 Tennessee 32 91.4 26 83.3 29 77.0 26 20.2 39 Texas 50 82.0 51 65.5 51 76.6 31 23.0 50 Utah 17 89.0 36 85.6 18 78.6 14 15.5 7 Vermont 9 95.1 4 91.4 5 79.2 10 19.4 33 Virginia 4 92.5 18 85.0 19 80.4 4 14.8 4 Washington 12 93.9 9 83.7 26 77.7 22 15.9 8 West Virginia 24 93.8 11 81.0 35 78.2 17 20.9 41 Wisconsin 21 94.5 6 91.5 3 72.6 49 19.7 34 Wyoming 36 90.7 27 83.1 30 73.0 45 19.1 30 State Variation Best State Rate 96.7 95.6 83.8 13.9 All States Median Rate 91.4 83.7 77.0 18.6 Worst State Rate 82.0 65.5 68.7 24.9 Data: See Part B in Appendix for years, databases, and descriptions for each indicator. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 70 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Appendix A4. Health Insurance Coverage Rates for Children and Parents, 1999–2000 to 2008–09 Percent Children Percent Parents Ages 0–18 Insured Ages 19–64 Insured Actual Percent Actual Percent State 2008–09 1999–2000 Change Change 2008–09 1999–2000 Change Change United States 89.6 87.6 2.0 2.3% 80.9 84.3 –3.4 –4.0% Alabama 93.5 90.2 3.3 3.7% 80.0 84.4 –4.4 –5.2% Alaska 87.6 83.9 3.7 4.4% 80.0 81.7 –1.7 –2.1% Arizona 85.0 82.9 2.1 2.5% 76.8 77.4 –0.6 –0.8% Arkansas 89.0 88.4 0.6 0.7% 75.7 84.7 –9.0 –10.6% California 88.9 83.7 5.2 6.2% 76.5 78.1 –1.6 –2.0% Colorado 88.6 85.0 3.6 4.2% 82.8 86.2 –3.4 –3.9% Connecticut 93.2 92.4 0.8 0.9% 88.8 91.3 –2.5 –2.7% Delaware 90.5 93.2 –2.7 –2.9% 86.6 90.5 –3.9 –4.3% District of Columbia 92.5 87.7 4.8 5.5% 89.5 84.2 5.3 6.3% Florida 82.2 82.8 –0.6 –0.7% 73.6 79.5 –5.9 –7.4% Georgia 88.5 88.9 –0.4 –0.5% 77.4 85.1 –7.7 –9.0% Hawaii 95.4 91.1 4.3 4.7% 92.6 92.7 –0.1 –0.1% Idaho 90.3 82.9 7.4 8.9% 81.3 80.1 1.2 1.5% Illinois 91.9 89.2 2.7 3.0% 83.6 85.9 –2.3 –2.7% Indiana 92.3 90.8 1.5 1.7% 84.5 90.1 –5.6 –6.2% Iowa 94.2 93.8 0.4 0.4% 88.1 92.9 –4.8 –5.2% Kansas 90.0 88.5 1.5 1.7% 84.3 87.4 –3.1 –3.5% Kentucky 90.4 90.0 0.4 0.4% 79.7 85.9 –6.2 –7.2% Louisiana 89.7 80.8 8.9 11.0% 77.0 77.5 –0.5 –0.6% Maine 94.7 92.6 2.1 2.3% 91.5 87.4 4.1 4.7% Maryland 93.2 91.2 2.0 2.2% 84.6 88.5 –3.9 –4.4% Massachusetts 96.7 92.7 4.0 4.3% 95.6 91.3 4.3 4.7% Michigan 94.4 93.1 1.3 1.4% 86.6 90.0 –3.4 –3.8% Minnesota 93.9 94.0 –0.1 –0.1% 89.9 93.0 –3.1 –3.3% Mississippi 87.7 88.4 –0.7 –0.8% 76.6 83.4 –6.8 –8.2% Missouri 91.5 94.8 –3.3 –3.5% 83.7 92.9 –9.2 –9.9% Montana 88.9 82.9 6.0 7.2% 79.1 81.4 –2.3 –2.8% Nebraska 91.6 92.0 –0.4 –0.4% 86.4 92.1 –5.7 –6.2% Nevada 83.4 81.8 1.6 2.0% 76.7 80.0 –3.3 –4.1% New Hampshire 96.1 94.2 1.9 2.0% 88.3 89.8 –1.5 –1.7% New Jersey 89.6 91.6 –2.0 –2.2% 83.9 87.6 –3.7 –4.2% New Mexico 84.4 77.5 6.9 8.9% 71.2 67.5 3.7 5.5% New York 92.4 89.1 3.3 3.7% 84.1 82.9 1.2 1.4% North Carolina 89.0 89.0 0.0 0.0% 81.3 86.1 –4.8 –5.6% North Dakota 92.7 90.0 2.7 3.0% 89.9 88.4 1.5 1.7% Ohio 92.5 90.8 1.7 1.9% 88.0 88.6 –0.6 –0.7% Oklahoma 89.6 83.3 6.3 7.6% 77.9 76.8 1.1 1.4% Oregon 88.1 88.1 0.0 0.0% 80.8 85.6 –4.8 –5.6% Pennsylvania 92.7 93.5 –0.8 –0.9% 88.0 90.9 –2.9 –3.2% Rhode Island 92.6 95.4 –2.8 –2.9% 87.4 93.6 –6.2 –6.6% South Carolina 87.1 87.5 –0.4 –0.5% 81.9 86.1 –4.2 –4.9% South Dakota 90.1 91.3 –1.2 –1.3% 84.4 91.1 –6.7 –7.4% Tennessee 91.4 92.2 –0.8 –0.9% 83.3 89.8 –6.5 –7.2% Texas 82.0 77.0 5.0 6.5% 65.5 72.9 –7.4 –10.2% Utah 89.0 90.7 –1.7 –1.9% 85.6 88.9 –3.3 –3.7% Vermont 95.1 94.6 0.5 0.5% 91.4 92.3 –0.9 –1.0% Virginia 92.5 88.8 3.7 4.2% 85.0 87.7 –2.7 –3.1% Washington 93.9 89.6 4.3 4.8% 83.7 87.0 –3.3 –3.8% West Virginia 93.8 88.1 5.7 6.5% 81.0 78.5 2.5 3.2% Wisconsin 94.5 92.8 1.7 1.8% 91.5 91.7 –0.2 –0.2% Wyoming 90.7 86.9 3.8 4.4% 83.1 83.1 0.0 0.0% Number of States: Rate Improved (+) 35 9 Rate Worsened (–) 14 41 No Change in Rate 2 1 Data: U.S. Census Bureau, 2000–01 and 2009–10 Current Population Survey ASEC Supplement. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org71 Appendix A5. Percent of Currently Insured Children Ages 0–17 Whose Health Insurance Coverage Is Adequate to Meet Needs, by Insurance Type, 2007 Insurance Type Currently Insured Public Private State Rate Rank Rate Rate United States 76.5 81.4 74.2 Alabama 77.3 24 83.9 73.8 Alaska 76.6 31 83.5 73.7 Arizona 75.1 38 80.4 72.3 Arkansas 78.1 18 83.9 72.7 California 75.1 38 75.7 75.0 Colorado 76.7 30 82.5 75.1 Connecticut 76.9 28 83.8 74.7 Delaware 79.9 6 88.5 75.7 District of Columbia 79.3 9 82.3 76.6 Florida 72.8 46 78.0 70.2 Georgia 81.6 2 87.0 78.1 Hawaii 83.8 1 83.5 83.8 Idaho 72.8 46 82.1 69.2 Illinois 73.2 42 77.6 71.1 Indiana 73.5 41 84.0 69.1 Iowa 78.1 18 85.9 75.3 Kansas 78.8 11 89.2 75.5 Kentucky 77.0 26 86.4 71.2 Louisiana 77.5 23 83.9 71.0 Maine 78.6 14 88.1 73.7 Maryland 79.5 8 82.7 78.5 Massachusetts 81.5 3 87.6 79.4 Michigan 77.9 21 81.5 75.9 Minnesota 68.7 51 83.0 64.8 Mississippi 72.7 48 77.3 68.3 Missouri 75.3 36 82.9 71.7 Montana 68.8 50 82.9 64.3 Nebraska 75.5 35 89.7 70.9 Nevada 73.1 44 75.8 72.7 New Hampshire 80.2 5 87.1 78.5 New Jersey 75.7 34 78.4 75.1 New Mexico 78.8 11 83.6 75.5 New York 77.2 25 79.8 75.9 North Carolina 78.6 14 86.5 74.0 North Dakota 73.2 42 82.0 71.3 Ohio 78.0 20 83.7 76.3 Oklahoma 75.9 33 80.5 72.1 Oregon 76.9 28 81.9 75.2 Pennsylvania 78.7 13 82.0 77.3 Rhode Island 79.6 7 86.9 76.2 South Carolina 73.7 40 83.8 68.1 South Dakota 75.3 36 80.7 73.2 Tennessee 77.0 26 80.1 75.0 Texas 76.6 31 82.0 73.7 Utah 78.6 14 82.0 78.2 Vermont 79.2 10 85.4 75.0 Virginia 80.4 4 87.9 78.0 Washington 77.7 22 83.7 75.3 West Virginia 78.2 17 86.2 72.5 Wisconsin 72.6 49 76.1 71.6 Wyoming 73.0 45 86.6 67.0 Data: 2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 72 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Appendix A6. Prevention and Treatment: Dimension Ranking and Performance on Indicators Indicator Performance Percent Children Ages Percent Children with Percent Children with Percent Children with a 19–35 Months Received Preventive Medical Preventive Dental Care Dimension Medical Home Key Vaccines Care Visit Visit State Rank 2007 Rank 2009 Rank 2007 Rank 2007 Rank United States 57.5 75.7 88.5 78.4 Alabama 32 56.1 39 77.9 11 87.4 27 78.4 32 Alaska 38 52.3 44 64.6 49 85.1 36 80.5 16 Arizona 45 50.0 47 73.4 30 83.9 40 75.5 45 Arkansas 37 60.7 26 66.7 43 83.5 42 74.7 48 California 42 49.6 49 78.2 10 87.2 29 78.4 32 Colorado 28 59.3 30 69.2 42 88.2 23 77.0 39 Connecticut 26 62.4 18 71.4 36 95.2 5 84.9 4 Delaware 33 59.9 28 73.5 29 92.8 10 76.8 40 District of Columbia 39 49.7 48 75.5 23 97.6 2 81.7 11 Florida 44 56.8 37 77.4 15 91.5 12 68.5 51 Georgia 34 58.5 35 76.7 19 88.3 21 80.3 18 Hawaii 12 60.1 27 73.2 33 90.2 17 86.9 1 Idaho 50 56.1 39 73.3 32 76.7 51 76.6 41 Illinois 22 55.9 41 73.4 30 90.3 16 80.5 16 Indiana 15 61.7 21 69.9 40 86.3 33 79.4 23 Iowa 1 66.9 4 84.1 1 87.8 26 84.8 5 Kansas 6 61.3 24 80.5 6 90.4 15 78.7 29 Kentucky 30 61.8 20 76.8 18 88.1 24 78.4 32 Louisiana 21 55.3 43 80.7 5 88.6 19 76.5 42 Maine 5 65.5 7 69.5 41 92.2 11 80.9 13 Maryland 18 58.6 34 64.6 49 93.5 8 79.1 25 Massachusetts 4 66.2 5 81.1 3 96.6 3 83.8 7 Michigan 29 62.5 17 80.8 4 88.6 19 83.0 8 Minnesota 11 63.0 14 76.9 16 83.6 41 79.5 21 Mississippi 43 51.6 45 77.7 14 82.3 44 75.5 45 Missouri 19 64.8 8 64.6 49 87.1 31 75.4 47 Montana 49 61.5 22 65.9 45 80.5 45 76.5 42 Nebraska 16 69.1 2 74.3 27 84.8 37 79.5 21 Nevada 51 45.4 51 65.8 46 79.1 49 73.1 50 New Hampshire 2 69.3 1 78.7 8 94.5 7 84.2 6 New Jersey 41 56.8 37 70.2 38 95.0 6 78.7 29 New Mexico 40 49.0 50 74.3 27 87.2 29 79.3 24 New York 34 56.9 36 77.9 11 96.2 4 80.8 14 North Carolina 20 60.9 25 78.3 9 88.3 21 78.3 35 North Dakota 23 64.0 10 77.8 13 78.9 50 77.2 38 Ohio 8 66.2 5 74.8 25 89.7 18 78.7 29 Oklahoma 47 55.7 42 76.5 21 83.5 42 78.2 36 Oregon 46 63.4 12 73.0 34 79.7 48 75.7 44 Pennsylvania 17 61.9 19 74.4 26 93.0 9 82.7 9 Rhode Island 2 63.6 11 70.0 39 97.7 1 86.5 2 South Carolina 23 58.8 32 76.7 19 87.0 32 82.0 10 South Dakota 13 63.3 13 76.9 16 80.0 47 80.7 15 Tennessee 7 61.4 23 81.8 2 87.4 27 78.8 28 Texas 48 50.3 46 66.7 43 85.6 34 74.0 49 Utah 25 63.0 14 75.8 22 80.2 46 79.1 25 Vermont 8 67.2 3 65.1 48 91.3 14 86.1 3 Virginia 34 58.8 32 75.0 24 88.1 24 79.0 27 Washington 26 59.9 28 70.3 37 84.2 38 81.3 12 West Virginia 10 64.6 9 65.8 46 91.4 13 80.3 18 Wisconsin 14 62.9 16 80.0 7 84.2 38 80.2 20 Wyoming 31 59.3 30 72.5 35 85.3 35 78.0 37 State Variation Best State Rate 69.3 84.1 97.7 86.9 All States Median Rate 60.7 74.4 87.8 79.1 Worst State Rate 45.4 64.6 76.7 68.5 CSHCN = children with special health care needs Data: See Part B in Appendix for years, databases, and descriptions for each indicator. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org73 Appendix A6. Prevention and Treatment: Dimension Ranking and Performance on Indicators (continued) Indicator Performance Percent Children Ages 10 Months–5 Years Hospital Admissions Percent CSHCN Percent CSHCN Percent Children Ages Received Standardized for Pediatric Asthma Needing Referrals Whose Families 2–17 Received Needed Developmental per 100,000 Children Had No Problems Received All Needed Mental Health Care Screening Ages 2–17 Receiving Them Support Services State 2007 Rank 2007 Rank 2006 Rank 2005–06 Rank 2005–06 Rank United States 60.0 19.5 144.1 78.9 72.1 Alabama 61.7 32 12.1 48 * * 85.3 9 80.7 4 Alaska 63.0 26 20.7 18 * * 79.7 29 61.6 50 Arizona 62.1 31 17.3 36 123.1 19 70.3 51 71.3 30 Arkansas 56.5 38 15.9 41 105.1 16 84.9 10 68.8 37 California 53.5 43 14.0 45 92.3 12 72.4 49 71.2 31 Colorado 64.8 22 25.9 8 186.6 38 75.1 43 73.6 20 Connecticut 78.8 2 16.6 39 172.4 33 76.0 40 64.0 46 Delaware 76.9 3 10.9 50 * * 75.7 41 78.4 11 District of Columbia 56.5 38 14.3 44 * * 74.8 44 63.3 49 Florida 52.0 47 17.1 37 147.2 25 73.1 47 67.8 39 Georgia 51.2 48 22.7 12 116.1 18 82.6 21 63.7 47 Hawaii 62.8 28 27.2 7 61.0 3 78.6 33 70.8 32 Idaho 63.4 25 18.1 32 * * 77.9 34 65.5 42 Illinois 53.0 46 21.1 15 131.4 21 83.3 19 73.1 24 Indiana 64.3 23 19.4 22 99.1 13 80.0 28 83.0 1 Iowa 74.5 5 18.7 28 65.7 5 87.3 3 81.7 2 Kansas 72.3 8 24.7 11 171.3 32 88.6 2 79.9 8 Kentucky 65.5 21 15.5 42 174.1 35 84.1 16 73.3 22 Louisiana 55.3 40 28.7 6 * * 84.2 15 74.1 19 Maine 70.8 12 21.5 14 78.4 8 84.5 13 76.0 17 Maryland 59.4 37 22.3 13 163.2 30 79.1 32 77.1 15 Massachusetts 66.6 19 16.4 40 154.6 28 86.1 6 77.2 14 Michigan 60.4 36 18.2 30 151.6 27 77.1 37 69.6 34 Minnesota 67.0 17 41.6 2 103.1 15 81.1 23 80.3 6 Mississippi 43.0 50 20.0 21 * * 81.2 22 79.0 10 Missouri 73.9 6 19.0 25 173.3 34 85.7 7 79.2 9 Montana 67.9 15 16.7 38 * * 76.6 38 65.9 41 Nebraska 71.0 11 18.8 26 75.1 7 79.6 30 77.7 13 Nevada 53.1 45 18.6 29 89.8 10 72.5 48 64.7 45 New Hampshire 63.0 26 18.1 32 61.8 4 84.0 17 76.4 16 New Jersey 55.2 41 12.7 47 176.4 36 77.8 35 72.8 25 New Mexico 53.5 43 29.6 4 * * 74.1 46 65.0 43 New York 61.1 35 11.7 49 251.0 39 77.3 36 75.2 18 North Carolina 61.7 32 47.0 1 109.5 17 86.7 4 72.8 25 North Dakota 72.4 7 17.6 35 * * 84.4 14 80.7 4 Ohio 66.2 20 20.8 16 128.7 20 86.2 5 69.3 36 Oklahoma 53.6 42 20.8 16 181.6 37 80.2 27 67.1 40 Oregon 46.2 49 13.5 46 44.1 1 76.5 39 69.7 33 Pennsylvania 81.5 1 10.7 51 * * 72.0 50 73.2 23 Rhode Island 76.0 4 14.5 43 139.1 23 89.8 1 78.3 12 South Carolina 62.7 29 19.1 24 150.4 26 85.5 8 64.8 44 South Dakota 69.3 13 18.8 26 85.4 9 83.4 18 73.4 21 Tennessee 64.1 24 29.0 5 146.1 24 84.7 12 80.1 7 Texas 41.7 51 19.2 23 163.0 29 74.6 45 71.8 29 Utah 66.8 18 20.6 19 74.0 6 81.0 24 56.7 51 Vermont 69.3 13 17.9 34 46.2 2 82.7 20 72.1 28 Virginia 72.2 9 18.2 30 136.2 22 79.2 31 63.4 48 Washington 62.4 30 25.6 10 90.3 11 75.4 42 69.4 35 West Virginia 72.0 10 31.9 3 165.3 31 80.3 26 72.2 27 Wisconsin 61.4 34 25.9 8 100.8 14 84.9 10 68.5 38 Wyoming 67.6 16 20.2 20 * * 80.8 25 80.9 3 State Variation Best State Rate 81.5 47.0 44.1 89.8 83.0 All States Median Rate 63.0 18.8 128.7 80.3 72.8 Worst State Rate 41.7 10.7 251.0 70.3 56.7 CSHCN = children with special health care needs Data: See Part B in Appendix for years, databases, and descriptions for each indicator. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 74 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Appendix A7. Potential to Lead Healthy Lives: Dimension Ranking and Performance on Indicators Indicator Performance Percent Children Ages Child Mortality, Deaths 4 Months–5 Years at Infant Mortality, Deaths per 100,000 Children Moderate/High Risk for Dimension per 1,000 Live Births Ages 1–14 Developmental Delays State Rank 2006 Rank 2007 Rank 2007 Rank United States 6.7 19.0 26.4 Alabama 48 9.0 48 23.0 40 32.0 48 Alaska 40 7.0 28 31.0 50 27.3 36 Arizona 38 6.4 22 21.0 27 27.7 40 Arkansas 49 8.5 46 28.0 46 32.1 49 California 27 5.0 3 16.0 11 30.5 46 Colorado 4 5.8 13 16.0 11 19.2 3 Connecticut 6 6.2 18 12.0 3 22.7 13 Delaware 32 8.1 42 10.0 2 25.8 26 District of Columbia 51 11.9 51 29.0 47 30.1 45 Florida 35 7.3 32 21.0 27 27.6 38 Georgia 42 8.1 42 21.0 27 26.6 33 Hawaii 23 5.9 14 21.0 27 27.6 38 Idaho 17 6.8 25 22.0 36 23.3 18 Illinois 31 7.3 32 19.0 19 26.2 27 Indiana 33 7.9 39 21.0 27 22.5 12 Iowa 2 5.1 4 19.0 19 21.2 6 Kansas 20 7.2 31 19.0 19 27.4 37 Kentucky 46 7.5 35 22.0 36 26.2 27 Louisiana 47 10.0 49 29.0 47 35.2 51 Maine 10 6.3 21 16.0 11 18.6 1 Maryland 26 8.0 40 21.0 27 27.7 40 Massachusetts 7 4.9 2 12.0 3 22.1 9 Michigan 21 7.3 32 18.0 15 23.7 21 Minnesota 1 5.2 6 15.0 6 18.6 1 Mississippi 50 10.5 50 34.0 51 32.8 50 Missouri 30 7.5 35 23.0 40 24.2 23 Montana 17 6.0 17 22.0 36 22.1 9 Nebraska 14 5.5 9 20.0 24 23.6 20 Nevada 43 6.6 24 22.0 36 31.2 47 New Hampshire 13 5.9 14 15.0 6 22.1 9 New Jersey 16 5.4 7 15.0 6 26.7 34 New Mexico 37 5.7 11 24.0 42 22.7 13 New York 17 5.6 10 15.0 6 28.6 43 North Carolina 28 8.1 42 21.0 27 26.9 35 North Dakota 11 5.9 14 19.0 19 22.7 13 Ohio 36 7.8 38 18.0 15 22.9 17 Oklahoma 41 8.0 40 29.0 47 26.2 27 Oregon 9 5.4 7 17.0 14 19.4 4 Pennsylvania 24 7.7 37 18.0 15 26.2 27 Rhode Island 14 6.2 18 9.0 1 26.5 31 South Carolina 45 8.3 45 25.0 44 26.5 31 South Dakota 33 6.9 27 27.0 45 28.5 42 Tennessee 44 8.7 47 20.0 24 28.9 44 Texas 29 6.2 18 21.0 27 25.5 24 Utah 5 5.1 4 20.0 24 21.9 8 Vermont 3 5.7 11 12.0 3 21.8 7 Virginia 25 7.1 29 18.0 15 25.7 25 Washington 12 4.7 1 15.0 6 23.3 18 West Virginia 39 7.1 29 24.0 42 20.4 5 Wisconsin 8 6.4 22 19.0 19 22.8 16 Wyoming 22 6.8 25 21.0 27 24.0 22 State Variation Best State Rate 4.7 9.0 18.6 All States Median Rate 6.8 20.0 25.8 Worst State Rate 11.9 34.0 35.2 Data: See Part B in Appendix for years, databases, and descriptions for each indicator. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org75 Appendix A7. Potential to Lead Healthy Lives: Dimension Ranking and Performance on Indicators (continued) Indicator Performance Percent High School Percent High School Percent Children Percent Children Ages Students Who Students Not Meeting Ages 10–17 Who are 1–17 with Oral Health Currently Smoked Recommended Physical Overweight or Obese Problems Cigarettes Activity Level State 2007 Rank 2007 Rank 2009 Rank 2009 Rank United States 31.6 26.7 19.5 63.0 Alabama 36.1 46 26.3 27 20.8 31 62.7 38 Alaska 33.9 40 24.7 17 15.7 7 57.6 25 Arizona 30.6 25 31.6 50 19.7 28 53.2 9 Arkansas 37.5 50 27.5 37 20.3 29 58.0 27 California 30.5 24 30.5 47 * * * * Colorado 27.2 10 24.3 14 17.7 17 53.0 8 Connecticut 25.7 5 23.6 9 17.8 19 54.8 18 Delaware 33.2 36 26.4 28 19.0 26 59.6 32 District of Columbia 35.4 43 30.6 48 * * * * Florida 33.1 35 25.8 26 16.1 9 59.2 30 Georgia 37.3 49 27.5 37 16.9 10 57.2 24 Hawaii 28.5 15 25.3 20 15.2 6 65.6 40 Idaho 27.5 11 27.9 41 14.5 4 46.4 1 Illinois 34.9 42 26.5 31 18.1 20 55.3 20 Indiana 29.9 21 25.5 24 23.5 40 59.4 31 Iowa 26.5 8 22.3 4 * * * * Kansas 31.1 30 23.6 9 16.9 10 51.1 2 Kentucky 37.1 48 29.4 44 26.1 42 61.1 36 Louisiana 35.9 45 26.8 32 17.6 15 60.5 35 Maine 28.2 13 23.2 7 18.1 20 63.2 39 Maryland 28.8 16 23.7 11 11.9 2 61.2 37 Massachusetts 30.0 22 21.1 2 16.0 8 66.5 41 Michigan 30.6 25 25.4 22 18.8 24 53.2 9 Minnesota 23.1 1 20.0 1 * * * * Mississippi 44.4 51 31.6 50 19.6 27 60.3 33 Missouri 31.0 27 27.4 35 18.9 25 51.7 5 Montana 25.6 4 27.2 34 18.7 23 54.0 13 Nebraska 31.5 31 22.9 6 * * * * Nevada 34.2 41 31.3 49 17.0 13 55.9 21 New Hampshire 29.4 17 25.7 25 20.8 31 54.7 17 New Jersey 31.0 27 25.0 18 17.0 13 58.5 29 New Mexico 32.7 33 29.4 44 24.0 41 54.2 16 New York 32.9 34 23.9 12 14.8 5 57.7 26 North Carolina 33.5 38 23.9 12 17.7 17 54.0 13 North Dakota 25.7 5 21.7 3 22.4 37 56.3 23 Ohio 33.3 37 27.4 35 * * * * Oklahoma 29.5 18 28.9 43 22.6 38 52.6 6 Oregon 24.3 3 30.0 46 * * * * Pennsylvania 29.7 20 26.4 28 18.4 22 54.1 15 Rhode Island 30.1 23 26.4 28 13.3 3 56.0 22 South Carolina 33.7 39 25.3 20 20.5 30 66.7 42 South Dakota 28.4 14 24.6 16 23.2 39 53.3 11 Tennessee 36.5 47 23.5 8 20.9 33 60.3 33 Texas 32.2 32 28.8 42 21.2 34 53.4 12 Utah 23.1 1 27.0 33 8.5 1 52.7 7 Vermont 26.7 9 22.5 5 17.6 15 55.1 19 Virginia 31.0 27 25.4 22 * * * * Washington 29.5 18 27.8 40 * * * * West Virginia 35.5 44 25.2 19 21.8 35 58.2 28 Wisconsin 27.9 12 24.3 14 16.9 10 51.5 4 Wyoming 25.7 5 27.5 37 22.1 36 51.1 2 State Variation Best State Rate 23.1 20.0 8.5 46.4 All States Median Rate 30.6 25.8 18.3 56.0 Worst State Rate 44.4 31.6 26.1 66.7 Data: See Part B in Appendix for years, databases, and descriptions for each indicator. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 76 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Appendix A8. Equity: Uninsured Rates for Children and Parents, by Income, 2008–09 Percent Children Ages 0–18 Uninsured Percent Parents Ages 19–64 Uninsured By Income as Share of Federal Poverty Level By Income as Share of Federal Poverty Level State Income Gap Rank 0–199% FPL 200%+ FPL Income Gap Rank 0–199% FPL 200%+ FPL United States -5.4 15.8 6.5 -19.5 38.6 10.1 Alabama 0.9 6 9.5 3.4 -19.1 26 38.2 7.8 Alaska * * * 10.6 * * * 13.1 Arizona -12.2 42 22.6 7.5 -22.5 32 41.6 11.4 Arkansas -2.1 17 12.5 9.4 -23.0 34 42.1 12.4 California -5.0 27 15.4 7.8 -22.4 31 41.5 13.7 Colorado -10.6 41 21.0 6.2 -22.5 32 41.6 8.1 Connecticut -2.3 18 12.7 4.8 -8.4 9 27.5 7.6 Delaware -7.8 35 18.2 4.8 * * * 7.4 District of Columbia * * * * * * * * Florida -17.5 45 27.9 10.1 -31.1 40 50.2 14.3 Georgia -6.9 33 17.3 6.9 -27.2 37 46.3 9.8 Hawaii 5.7 1 4.7 4.5 6.7 2 12.4 5.6 Idaho -3.8 26 14.2 6.0 -17.8 23 36.9 8.5 Illinois -3.7 25 14.1 4.0 -14.9 15 34.0 8.6 Indiana -0.1 9 10.5 5.5 -11.4 12 30.5 8.3 Iowa -0.2 10 10.6 3.1 -11.6 13 30.7 5.8 Kansas -6.0 31 16.4 5.4 -15.9 17 35.0 7.1 Kentucky -1.8 16 12.2 7.5 -15.9 17 35.0 11.7 Louisiana -5.3 30 15.7 5.8 -28.0 38 47.1 10.1 Maine 3.4 4 7.0 4.2 5.6 3 13.5 6.5 Maryland -3.1 22 13.5 4.0 -21.5 30 40.6 8.6 Massachusetts 4.9 2 5.5 2.3 9.1 1 10.0 2.9 Michigan 1.2 5 9.2 3.3 -8.6 10 27.7 7.3 Minnesota -1.3 13 11.7 3.2 -5.7 7 24.8 5.4 Mississippi -3.4 24 13.8 10.6 -19.3 27 38.4 11.5 Missouri -3.2 23 13.6 4.9 -18.5 24 37.6 6.8 Montana -5.2 29 15.6 7.4 * * * 11.3 Nebraska -5.0 27 15.4 4.4 -14.1 14 33.2 6.4 Nevada -15.2 44 25.6 10.3 -24.9 36 44.0 13.9 New Hampshire * * * 3.5 * * * 7.4 New Jersey -8.5 39 18.9 6.7 -20.6 29 39.7 9.1 New Mexico -10.5 40 20.9 9.8 -28.6 39 47.7 15.3 New York -0.2 10 10.6 5.3 -8.0 8 27.1 10.4 North Carolina -8.3 38 18.7 5.1 -23.2 35 42.3 7.1 North Dakota * * * 4.8 * * * 4.7 Ohio -2.3 18 12.7 3.9 -3.9 4 23.0 7.0 Oklahoma -1.7 15 12.1 9.0 -19.0 25 38.1 14.1 Oregon -8.0 37 18.4 6.9 -19.8 28 38.9 9.5 Pennsylvania -1.2 12 11.6 5.0 -5.2 6 24.3 7.7 Rhode Island -2.6 20 13.0 3.7 * * * 8.2 South Carolina -7.8 35 18.2 8.9 -16.5 21 35.6 9.8 South Dakota -6.6 32 17.0 4.9 * * * 6.7 Tennessee -1.5 14 11.9 5.7 -16.2 20 35.3 6.3 Texas -12.5 43 22.9 13.0 -40.1 41 59.2 18.2 Utah -7.6 34 18.0 7.7 -10.4 11 29.5 9.4 Vermont * * * 2.4 * * * 5.1 Virginia -3.0 21 13.4 4.7 -17.1 22 36.2 8.7 Washington 0.6 7 9.8 4.0 -16.0 19 35.1 8.9 West Virginia 4.0 3 6.4 6.1 -15.6 16 34.7 11.6 Wisconsin 0.1 8 10.3 3.0 -4.8 5 23.9 3.8 Wyoming * * * 7.3 * * * 9.7 Note: Income gap is the difference between the US average for this indicator (10.4) and each state’s low-income (0–199% FPL) group. A positive or negative value indicates that this state’s most vulnerable group is that much better or worse than the US average for the indicator. Data: U.S. Census Bureau, 2009–10 Current Population Survey ASEC Supplement. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org77 Appendix A9. Equity: Percent of Children Without a Medical Home, by Income and Insurance Type, 2007 Percent Children Without a Medical Home Percent Children Without a Medical Home By Income as Share of Federal Poverty Level By Insurance Type Income 100–199% 200–399% Insurance State Gap Rank 0–99% FPL FPL FPL 400%+ FPL Gap Rank Public Private Uninsured United States -18.1 60.6 50.6 37.5 30.7 -21.8 54.6 33.5 64.3 Alabama -19.7 37 62.2 54.9 33.8 28.8 -26.2 43 54.2 33.7 68.7 Alaska -17.6 31 60.1 54.7 45.7 32.3 -16.3 24 55.9 41.3 58.8 Arizona -20.7 40 59.8 63.2 46.9 33.9 -31.3 49 55.3 40.6 73.8 Arkansas -8.3 10 48.0 50.8 31.5 25.7 -12.1 17 46.3 30.8 54.6 California -25.9 47 68.4 64.0 44.4 36.9 -23.7 35 65.8 38.5 66.2 Colorado -20.4 39 62.9 45.1 39.0 30.2 -24.1 36 59.4 31.0 66.6 Connecticut -23.7 45 66.2 51.1 36.8 27.4 -12.8 19 54.2 31.0 55.3 Delaware -18.4 35 60.9 50.4 35.2 30.1 -13.1 21 52.7 32.8 55.6 District of Columbia -23.1 43 65.6 61.7 44.7 31.1 -20.1 31 61.9 37.4 62.6 Florida -12.7 17 47.3 55.2 40.8 33.9 -24.5 38 46.2 37.4 67.0 Georgia -16.1 25 58.6 47.6 35.5 30.8 -25.1 40 52.6 30.3 67.6 Hawaii -16.8 27 59.3 45.9 35.7 30.8 -16.6 26 53.2 34.9 59.1 Idaho -19.9 38 62.4 48.0 37.2 35.7 -25.1 40 52.4 36.3 67.6 Illinois -23.0 42 65.5 52.2 42.0 30.8 -18.6 29 58.6 36.2 61.1 Indiana -7.9 8 50.4 40.4 38.3 27.2 -25.7 42 44.7 32.0 68.2 Iowa -4.1 3 46.6 42.6 27.7 27.0 -2.9 3 43.0 28.5 45.4 Kansas -19.1 36 61.6 41.1 35.2 28.5 -17.6 27 50.2 31.3 60.1 Kentucky -7.0 7 49.5 38.1 37.7 27.2 -23.1 34 41.7 33.4 65.6 Louisiana -21.0 41 63.5 51.4 35.0 29.3 -26.4 44 55.1 31.4 68.9 Maine -6.7 6 49.2 37.0 33.5 24.2 -5.2 6 46.2 27.0 47.7 Maryland -17.5 30 60.0 48.4 40.7 34.8 -10.1 12 57.3 35.4 52.6 Massachusetts -12.8 18 55.3 40.0 33.1 26.5 -31.5 50 45.3 28.6 74.0 Michigan -14.0 21 56.5 46.9 29.9 26.7 -3.8 4 50.3 30.3 46.3 Minnesota -12.8 18 55.3 42.5 32.1 32.8 -9.2 11 48.7 32.0 51.7 Mississippi -23.2 44 65.7 49.4 39.3 29.7 -28.4 46 56.7 35.9 70.9 Missouri -8.2 9 50.7 38.2 30.7 26.8 -8.8 10 43.5 29.3 51.3 Montana -4.6 4 47.1 43.4 34.1 33.1 -7.8 9 45.1 33.2 50.3 Nebraska -6.6 5 49.1 37.0 23.6 23.6 -6.7 8 41.4 24.4 49.2 Nevada -32.0 51 74.5 65.4 50.0 41.0 -40.9 51 65.3 43.1 83.4 New Hampshire -9.0 12 51.5 32.2 30.3 25.9 -1.1 2 41.3 26.9 43.6 New Jersey -25.3 46 67.8 58.2 38.7 34.3 -30.5 48 60.2 34.3 73.0 New Mexico -27.6 48 70.1 51.7 45.5 29.9 -26.5 45 60.6 37.9 69.0 New York -17.7 32 60.2 48.2 36.9 36.2 -12.9 20 56.8 34.9 55.4 North Carolina -14.5 23 57.0 38.0 36.0 30.6 -20.9 32 43.9 32.6 63.4 North Dakota -8.5 11 51.0 38.5 34.6 27.7 -10.8 14 40.1 33.4 53.3 Ohio -9.7 14 52.2 43.3 24.1 25.2 -12.0 16 47.9 25.8 54.5 Oklahoma -17.7 32 60.2 50.4 38.2 27.0 -16.5 25 53.3 34.3 59.0 Oregon -15.7 24 58.2 45.3 28.9 25.1 -21.3 33 51.5 26.6 63.8 Pennsylvania -16.6 26 59.1 44.9 30.8 30.1 -4.2 5 52.5 30.9 46.7 Rhode Island -18.2 34 60.7 44.6 30.4 26.1 -10.6 13 50.5 29.2 53.1 South Carolina -13.4 20 55.9 40.9 41.1 27.6 -13.4 22 48.3 34.6 55.9 South Dakota -16.8 27 59.3 38.1 33.6 25.7 -19.7 30 47.2 29.6 62.2 Tennessee -11.0 15 53.5 47.8 30.3 25.4 -11.0 15 50.6 28.7 53.5 Texas -29.1 49 71.6 61.2 46.4 22.6 -29.8 47 67.1 33.4 72.3 Utah -29.8 50 72.3 38.4 29.8 29.2 -24.5 38 47.6 30.2 67.0 Vermont -2.1 2 44.6 38.4 29.8 27.3 -0.7 1 37.4 28.5 43.2 Virginia -12.2 16 53.4 54.7 38.6 32.3 -18.5 28 47.5 37.3 61.0 Washington -14.3 22 56.8 43.2 43.5 27.8 -16.1 23 47.4 33.7 58.6 West Virginia 3.8 1 38.7 38.3 35.0 28.3 -5.5 7 37.7 32.4 48.0 Wisconsin -16.9 29 59.4 47.8 32.6 25.0 -24.1 36 50.7 30.8 66.6 Wyoming -9.5 13 52.0 47.8 39.2 31.7 -12.5 18 45.4 36.0 55.0 Note: Income gap is the difference between the US average for this indicator (42.5 in 2007) and each state’s most vulnerable low-income (0–99% or 100–199% FPL) group. Insurance gap is the difference between the US average and each state’s uninsured group. A positive or negative value indicates that this state’s most vulnerable group is that much better or worse than the US average for the indicator. Data: 2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 78 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Appendix A10. Equity: Percent of Children with Oral Health Problems, by Income and Insurance Type, 2007 Percent Children Ages 1–17 With Oral Health Problems Percent Children Ages 1–17 With Oral Health Problems By Income as Share of Federal Poverty Level By Insurance Type Income 100–199% 200–399% Insurance State Gap Rank 0–99% FPL FPL FPL 400%+ FPL Gap Rank Public Private Uninsured United States -9.2 35.9 31.9 24.0 20.1 -4.1 34.1 22.7 30.8 Alabama -3.0 5 29.7 29.7 26.1 19.7 -4.9 36 30.9 22.5 31.6 Alaska -1.0 2 24.1 27.7 24.5 21.9 1.0 12 30.5 22.0 25.7 Arizona -16.7 48 43.4 33.2 26.8 26.2 -8.8 42 39.8 27.4 35.5 Arkansas -5.3 14 32.0 28.5 26.7 22.0 0.2 13 31.7 23.8 26.5 California -18.8 50 39.9 45.5 24.5 21.3 -3.3 27 41.4 24.3 30.0 Colorado -3.6 6 28.4 30.3 23.5 19.9 2.8 8 27.6 23.6 23.9 Connecticut -9.8 33 24.4 36.5 24.6 18.5 -0.8 15 33.3 20.3 27.5 Delaware -8.7 28 35.4 32.1 25.6 20.3 -8.0 39 35.3 22.0 34.7 District of Columbia -11.5 38 38.2 37.9 26.3 20.2 -3.9 33 38.4 22.3 30.6 Florida -8.0 25 34.7 26.7 27.2 18.2 -2.4 23 25.1 25.7 29.1 Georgia -9.1 29 35.8 30.1 26.0 20.9 -12.8 49 35.4 20.6 39.5 Hawaii -6.8 20 33.5 26.5 24.2 21.7 3.6 5 32.3 23.3 23.1 Idaho -9.1 29 35.8 27.6 27.7 22.7 -5.4 37 31.4 25.6 32.1 Illinois -10.5 35 37.2 32.4 22.3 21.5 -8.1 41 32.6 23.7 34.8 Indiana -9.8 33 36.5 29.3 20.8 20.5 3.3 6 32.5 23.1 23.4 Iowa -0.2 1 26.9 26.5 21.7 17.8 -12.8 49 23.9 20.6 39.5 Kansas -1.4 3 28.1 28.1 23.8 17.0 -9.4 43 26.3 20.9 36.1 Kentucky -12.9 42 39.6 31.9 26.2 21.0 -11.3 46 38.7 23.2 38.0 Louisiana -4.3 8 30.0 31.0 25.5 20.6 2.4 11 31.9 21.6 24.3 Maine -5.0 12 31.7 30.4 20.9 14.9 11.9 2 36.2 17.1 14.8 Maryland -12.1 40 31.4 38.8 21.5 18.4 -3.4 29 30.1 21.4 30.1 Massachusetts -4.5 9 31.2 21.0 19.5 19.2 12.4 1 27.6 19.4 14.3 Michigan -3.8 7 30.5 28.1 23.7 22.0 -2.2 21 31.2 21.7 28.9 Minnesota -11.1 36 37.8 19.7 17.4 17.0 -3.5 30 15.4 20.2 30.2 Mississippi -14.9 47 41.6 32.7 25.7 22.1 -8.0 39 37.2 26.2 34.7 Missouri -8.1 26 34.8 29.3 28.3 19.1 -2.9 24 32.6 24.9 29.6 Montana -12.5 41 39.2 29.7 24.0 20.1 -1.6 17 35.0 24.1 28.3 Nebraska -9.4 32 36.1 19.6 20.6 20.3 -7.1 38 25.0 20.7 33.8 Nevada -20.1 51 46.8 38.3 26.7 22.5 -11.6 47 43.3 26.5 38.3 New Hampshire -6.6 18 33.3 29.6 30.1 18.8 -11.9 48 31.3 23.1 38.6 New Jersey -4.6 11 31.1 31.3 25.9 20.7 -4.1 34 32.2 22.0 30.8 New Mexico -7.5 24 34.2 33.5 27.7 19.8 -3.3 27 36.1 22.9 30.0 New York -6.6 18 32.1 33.3 19.6 17.1 -3.0 26 31.4 19.7 29.7 North Carolina -7.4 22 34.1 25.3 23.3 15.7 3.0 7 33.8 18.4 23.7 North Dakota -7.4 22 34.1 24.1 20.2 15.7 -1.8 19 24.9 20.3 28.5 Ohio -12.9 42 39.6 30.0 24.8 21.1 -3.8 31 38.8 23.2 30.5 Oklahoma -9.1 29 32.5 35.8 25.5 20.9 2.8 8 35.6 24.7 23.9 Oregon -14.3 46 41.0 32.7 28.6 23.0 -10.7 45 39.5 25.9 37.4 Pennsylvania -6.2 17 32.9 29.1 27.9 19.1 -20.6 51 30.3 22.5 47.3 Rhode Island -17.0 49 43.7 30.2 24.6 18.4 -2.3 22 37.7 22.0 29.0 South Carolina -8.2 27 34.9 25.5 22.3 19.8 4.8 4 31.6 23.0 21.9 South Dakota -5.9 16 32.6 27.3 23.2 18.9 -2.9 24 32.5 20.9 29.6 Tennessee -5.0 12 31.7 24.8 22.2 15.6 -2.1 20 33.6 16.4 28.8 Texas -13.1 44 39.8 33.3 19.8 23.1 -4.5 35 37.2 23.1 31.2 Utah -2.5 4 29.2 27.6 27.9 23.6 -1.3 16 26.6 27.0 28.0 Vermont -5.5 15 32.2 24.5 21.6 18.0 -0.3 14 26.1 19.6 27.0 Virginia -7.2 21 33.9 28.9 25.6 20.2 2.8 8 32.4 23.5 23.9 Washington -11.2 37 37.9 36.3 28.8 17.6 -1.7 18 42.4 22.0 28.4 West Virginia -4.5 9 27.3 31.2 22.1 20.9 -3.8 31 28.3 22.4 30.5 Wisconsin -14.0 45 40.7 25.2 22.2 18.7 7.9 3 38.7 20.6 18.8 Wyoming -11.9 39 25.7 38.6 26.5 20.6 -10.3 44 31.8 24.2 37.0 Note: Income gap is the difference between the US average for this indicator (26.7 in 2007) and each state’s most vulnerable low-income (0–99% or 100– 199% FPL) group. Insurance gap is the difference between the US average and each state’s uninsured group. A positive or negative value indicates that this state’s most vulnerable group is that much better or worse than the US average for the indicator. Data: 2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org79 Appendix A11. Equity: Infant Mortality, by Race/Ethnicity, 2004–2006 Deaths per 1,000 Live Births By Race/Ethnicity American lndian/ Asian/ State Race/Ethnic Gap Rank White Black Hispanic Alaskan Native Pacific Islander United States -6.7 5.7 13.5 5.5 8.3 4.7 Alabama -7.0 26 7.0 13.8 7.4 * * Alaska -3.0 8 5.0 * * 9.8 * Arizona -5.5 18 6.1 12.3 6.7 7.2 6.0 Arkansas -7.2 30 7.0 14.0 6.3 * * California -4.6 12 4.7 11.4 4.9 6.3 4.1 Colorado -7.2 30 5.2 14.0 7.0 * 5.6 Connecticut -6.6 25 4.0 13.4 7.8 * 3.2 Delaware -8.2 37 6.3 15.0 5.5 * * District of Columbia -11.7 46 3.2 18.5 * * * Florida -6.0 21 5.9 12.8 5.1 * 5.5 Georgia -6.2 23 6.1 13.0 5.2 * 5.9 Hawaii -14.1 47 3.7 20.9 6.1 * 6.4 Idaho -0.5 1 6.0 * 7.3 * * Illinois -7.6 34 5.9 14.4 6.2 * 5.1 Indiana -9.3 44 7.0 16.1 6.7 * * Iowa -1.8 4 5.0 8.2 5.0 * 8.6 Kansas -7.7 35 6.8 14.5 6.4 * 6.4 Kentucky -5.7 20 6.5 12.5 7.4 * * Louisiana -7.9 36 7.0 14.7 5.7 * 6.3 Maine * * 6.2 * * * * Maryland -6.1 22 5.6 12.9 5.3 * 4.6 Massachusetts -3.5 11 4.0 10.3 6.4 * 3.6 Michigan -8.9 40 5.7 15.7 7.3 * 4.9 Minnesota -2.8 7 4.4 9.6 4.3 9.5 4.1 Mississippi -8.6 39 6.8 15.4 5.7 * * Missouri -7.0 26 6.5 13.8 6.2 * 5.5 Montana -3.1 10 5.0 * * 9.9 * Nebraska -5.4 17 5.3 12.2 5.8 * * Nevada -7.5 32 5.5 14.3 5.1 * 5.6 New Hampshire * * 5.3 * * * * New Jersey -5.0 15 3.7 11.8 5.1 * 4.7 New Mexico -0.8 2 6.8 * 5.4 7.6 * New York -4.7 14 4.6 11.5 5.3 * 3.8 North Carolina -8.9 40 6.4 15.7 6.2 10.6 6.1 North Dakota -3.0 8 5.4 * * 9.8 * Ohio -9.1 42 6.4 15.9 5.6 * 4.4 Oklahoma -6.3 24 7.7 13.1 5.4 8.3 6.3 Oregon -2.6 6 5.5 9.4 5.4 8.3 5.2 Pennsylvania -7.0 26 5.8 13.8 7.7 * 5.6 Rhode Island -4.6 12 4.0 11.4 8.0 * * South Carolina -7.5 32 6.3 14.3 7.4 * 6.1 South Dakota -5.5 18 6.2 * * 12.3 * Tennessee -9.1 42 6.9 15.9 6.5 * 7.4 Texas -5.3 16 5.8 12.1 5.5 * 4.2 Utah -0.9 3 4.7 * 5.3 * 7.7 Vermont * * 5.6 * * * * Virginia -7.0 26 5.7 13.8 5.3 * 4.0 Washington -2.5 5 4.5 8.1 4.8 9.3 4.4 West Virginia -8.3 38 7.3 15.1 * * * Wisconsin -10.1 45 5.0 16.9 5.7 8.1 5.6 Wyoming * * 7.3 * * * * * Indicates data value is missing because there were fewer than 20 deaths. Note: Race/ethnic gap is the difference between the US average for this indicator (6.8 in 2004–06) and each state’s most vulnerable non-white group. A positive or negative value indicates that this state’s most vulnerable group is that much better or worse than the US average for the indicator. Data: National Vital Statistics System—Linked Birth and Infant Death Data. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011 80 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 Appendix A12. State Characteristics: Poverty and Health Status Percent Parents Ages Percent Children Ages Percent Children with 19–64 Living Below Percent Children with 0–18 Living Below 200% Special Health Care 200% of Federal Poverty Asthma Problems of Federal Poverty Level Needs Level State 2008–09 Rank 2008–09 Rank 2005–06 Rank 2007 Rank United States 41.5 31.7 13.9 9.0 Alabama 51.4 48 40.1 48 17.1 45 12.3 49 Alaska 31.6 7 24.2 9 11.9 5 6.4 4 Arizona 49.7 45 39.2 46 12.5 9 8.5 20 Arkansas 50.9 47 40.3 49 17.7 48 10.2 35 California 43.7 36 35.3 41 9.9 1 8.0 15 Colorado 35.0 13 27.0 19 12.5 9 7.9 14 Connecticut 25.2 2 17.9 2 16.0 36 11.8 47 Delaware 35.4 15 24.9 13 17.5 47 11.4 45 District of Columbia 52.4 49 36.3 44 14.7 25 14.4 51 Florida 43.4 35 33.7 37 13.4 15 8.3 17 Georgia 44.0 37 35.0 39 13.9 18 10.0 34 Hawaii 37.5 21 26.5 16 12.0 6 11.2 43 Idaho 45.4 41 36.1 43 11.4 4 5.3 2 Illinois 40.6 24 30.6 25 13.9 18 8.4 18 Indiana 44.1 38 32.6 32 16.6 43 8.7 23 Iowa 35.8 18 24.5 11 14.2 20 8.6 22 Kansas 41.5 29 30.7 26 16.0 36 9.1 28 Kentucky 45.6 43 36.6 45 18.5 51 11.9 48 Louisiana 45.5 42 35.0 39 14.8 26 9.0 26 Maine 37.4 20 28.3 20 17.7 48 9.0 26 Maryland 29.3 3 21.2 3 15.5 34 9.6 32 Massachusetts 30.7 4 21.2 3 16.4 40 10.8 39 Michigan 38.7 22 29.7 23 15.4 32 9.5 30 Minnesota 33.7 11 24.3 10 14.4 22 6.0 3 Mississippi 54.9 51 44.4 51 15.0 27 10.6 37 Missouri 41.0 25 30.7 26 16.2 38 10.8 39 Montana 45.0 39 34.1 38 13.6 16 6.6 5 Nebraska 36.7 19 26.7 18 14.6 24 6.6 5 Nevada 41.1 26 31.4 29 10.4 2 8.8 24 New Hampshire 23.2 1 17.4 1 16.6 43 8.8 24 New Jersey 30.7 4 22.9 5 13.3 14 8.4 18 New Mexico 52.6 50 41.9 50 12.1 7 7.7 13 New York 42.7 32 32.7 33 12.7 13 11.1 42 North Carolina 43.2 33 33.0 34 15.4 32 9.2 29 North Dakota 35.5 16 26.5 16 12.2 8 6.9 7 Ohio 41.1 26 30.9 28 16.2 38 12.3 49 Oklahoma 45.0 39 33.2 36 16.5 42 11.7 46 Oregon 43.2 33 33.0 34 13.6 16 7.4 12 Pennsylvania 35.0 13 25.7 15 15.3 30 10.6 37 Rhode Island 39.9 23 28.3 20 17.2 46 11.2 43 South Carolina 42.4 30 32.2 31 15.2 29 8.5 20 South Dakota 41.3 28 30.5 24 12.6 11 5.2 1 Tennessee 46.6 44 35.8 42 16.4 40 9.5 30 Texas 50.4 46 40.0 47 12.6 11 6.9 7 Utah 31.6 7 24.8 12 11.0 3 7.0 11 Vermont 34.9 12 25.1 14 15.0 27 9.6 32 Virginia 32.4 9 23.0 6 15.8 35 10.3 36 Washington 35.5 16 28.4 22 14.3 21 6.9 7 West Virginia 42.6 31 32.0 30 18.3 50 10.8 39 Wisconsin 33.5 10 23.2 8 15.3 30 8.1 16 Wyoming 31.1 6 23.1 7 14.4 22 6.9 7 Data: Children/Parents income less than 200% of poverty—2009 and 2010 Current Population Survey ASEC Supplement; Special health care needs—2005–2006 National Survey of Children with Special Health Care Needs; Asthma problems—2007 National Survey of Children’s Health. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. www.commonwealthfund.org81 Appendix A13. State Characteristics: Child Population by Race/Ethnicity, 2008–2009 Distribution of Children Ages 0–18 State White Black Hispanic Other United States 55.5 14.3 22.2 7.9 Alabama 62.2 30.7 4.0 3.1 Alaska 63.2 4.0 5.3 27.5 Arizona 41.1 4.8 44.0 10.1 Arkansas 66.4 19.1 8.4 6.1 California 29.8 5.8 51.5 12.8 Colorado 63.3 4.0 26.2 6.4 Connecticut 68.7 10.5 14.4 6.4 Delaware 60.3 24.5 8.9 6.3 District of Columbia 20.3 60.6 14.7 4.4 Florida 50.3 20.9 24.7 4.1 Georgia 50.8 32.1 11.7 5.4 Hawaii 9.0 1.5 14.3 75.2 Idaho 81.4 1.5 14.0 3.1 Illinois 56.0 17.0 20.1 7.0 Indiana 76.5 12.3 8.0 3.2 Iowa 81.1 3.7 9.1 6.2 Kansas 72.6 7.9 13.4 6.1 Kentucky 84.2 9.2 4.2 2.5 Louisiana 55.1 38.4 3.4 3.2 Maine 90.9 1.6 2.6 4.9 Maryland 49.4 31.6 9.9 9.1 Massachusetts 70.0 7.4 13.9 8.8 Michigan 69.9 17.5 5.4 7.3 Minnesota 78.8 6.7 6.9 7.6 Mississippi 52.3 42.8 2.9 2.1 Missouri 76.9 13.7 4.8 4.5 Montana 79.9 1.0 4.5 14.6 Nebraska 74.5 4.7 15.9 4.9 Nevada 45.1 9.1 34.0 11.9 New Hampshire 90.2 1.3 4.4 4.1 New Jersey 51.5 14.7 23.2 10.5 New Mexico 30.8 2.3 53.0 14.0 New York 50.9 17.6 23.3 8.2 North Carolina 58.6 23.8 10.2 7.4 North Dakota 78.3 0.4 2.5 18.8 Ohio 76.1 14.1 3.8 6.0 Oklahoma 54.2 9.0 14.2 22.6 Oregon 70.0 2.4 17.5 10.2 Pennsylvania 74.2 12.6 9.3 4.0 Rhode Island 66.7 6.0 21.2 6.1 South Carolina 60.4 32.8 2.3 4.6 South Dakota 77.8 1.7 4.0 16.5 Tennessee 69.0 20.1 7.3 3.6 Texas 30.3 12.3 51.6 5.9 Utah 81.5 1.3 13.2 4.0 Vermont 92.3 1.7 2.0 4.0 Virginia 61.9 22.3 8.0 7.8 Washington 64.4 5.0 12.7 17.9 West Virginia 88.3 5.2 2.5 4.1 Wisconsin 76.6 7.9 9.6 5.8 Wyoming 81.8 1.9 11.7 4.6 Data: 2009 and 2010 Current Population Survey ASEC Supplement. Source: Commonwealth Fund State Scorecard on Child Health System Performance, 2011. 82 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 APPENDIX B1. State Scorecard Data Years and Databases Current Year Database Access & Affordability 1. Children ages 0–18 insured 2008–2009 CPS ASEC 2. Parents ages 19–64 insured 2008–2009 CPS ASEC 3. Currently insured children whose health insurance coverage is adequate 2007 NSCH to meet needs 4. Average total premium for employer-based family coverage as percent 2009 of median income for family household (all members under age 65) (premiums)/ MEPS-IC (premiums)/ 2008–09 CPS ASEC (household (household income) income) Prevention & Treatment 5. Children with a medical home 2007 NSCH 6. Young children (ages 19–35 months) received all recommended doses 2009 NIS of six key vaccines 7. Children with a preventive medical care visit in the past year 2007 NSCH 8. Children ages 1–17 with a preventive dental care visit in the past year 2007 NSCH 9. Children ages 2–17 needing mental health treatment/counseling who 2007 NSCH received mental health care in the past year 10. Young children (ages 10 months–5 years) received standardized 2007 NSCH developmental screening during visit 11. Hospital admissions for pediatric asthma per 100,000 children ages 2–17 2006 HCUP 12. Children with special health care needs who had no problems receiving 2005–06 NS-CSHCN referrals when needed 13. Children with special health care needs whose families received all 2005–06 NS-CSHCN needed family support services Potential to Lead Healthy Lives 14. Infant mortality, deaths per 1,000 live births 2006 NVSS-I 15. Child mortality, deaths per 100,000 children ages 1–14 2007 NVSS-M 16. Young children (ages 4 months–5 years) at moderate/high risk for 2007 NSCH developmental or behavioral delays 17. Children ages 10–17 who are overweight or obese 2007 NSCH 18. Children ages 1–17 with oral health problems 2007 NSCH 19. High school students who currently smoked cigarettes 2009 YRBS 20. High school students not meeting recommended physical activity level 2009 YRBS Definition of Databases CPS ASEC = Annual Social and Economic Supplement to the Current Population Survey HCUP = Healthcare Cost and Utilization Project MEPS-IC = Medical Expenditure Panel Survey-Insurance Component NIS = National Immunization Survey NSCH = National Survey of Children’s Health NS-CSHCN = National Survey of Children with Special Health Care Needs NVSS-I = National Vital Statistics System, Linked Birth and Infant Death Data NVSS-M = National Vital Statistics System, Mortality Data YRBS = Youth Risk Behavior Survey www.commonwealthfund.org83 APPENDIX B2. State Scorecard Indicator Descriptions 1 Children ages 0–18 insured: Employee 6 Young children (ages 19–35 months) received Benefits Research Institute analysis of Current all recommended doses of six key vaccines: Population Survey ASEC Supplement (U.S. Percent of children ages 19–35 months who Census Bureau, 2009, 2010). received 4+ doses of diphtheria, tetanus, and accellular pertussis (DTap); 3+ doses of 2 Parents ages 19–64 insured: Employee poliovirus vaccine; 1+ doses of measles-mumps- Benefits Research Institute analysis of Current rubella (MMR) vaccine; > 2 or >3 doses of Population Survey ASEC Supplement (U.S. Haemophilus influenzae type b (Hib) vaccine Census Bureau, 2009, 2010). for the primary series, depending on brand 3 Currently insured children whose health type; 3+ doses of hepatitis B vaccine (HepB), insurance coverage is adequate to meet and 1+ doses of varicella vaccine. Data from needs: Percent of children ages 0–17 who were the National Immunization Survey (NCHS, NIS currently insured and parents responded that 2009). the child’s health insurance: usually or always 7 Children with a preventive medical care visit offers benefits or covers services that meet in the past year: Percent of children ages child’s needs; usually or always allows child to 0–17 who saw a health care professional for see health care providers he/she needs; and preventive medical care one or more times in that out-of-pocket costs are usually or always the past year. Data from the National Survey reasonable (including no out-of-pocket costs). of Children’s Health, assembled by the Child For more information, see www.nschdata.org. and Adolescent Health Measurement Initiative Data from the National Survey of Children’s (CAHMI 2009). Health, assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2009). 8 Children ages 1–17 with a preventive dental care visit in the past year: Percent of children 4 Average total premium for employer-based ages 1–17 who saw a dentist for preventive family coverage as percent of median income dental care one or more times in the past year. for family household (all members under age Data from the National Survey of Children’s 65): Average total premiums for employer- Health, assembled by the Child and Adolescent based family health insurance plans— Health Measurement Initiative (CAHMI 2009). Medical Expenditure Panel Survey-Insurance Component (AHRQ, MEPS-IC, 2009); Median 9 Children ages 2–17 needing mental health incomes for family households (all members treatment/counseling who received mental under age 65)—Columbia University Mailman health care in the past year: Percent of children School of Public Health analysis of Current ages 2–17 who had any kind of emotional, Population Survey ASEC Supplement (U.S. developmental, or behavioral problem that Census Bureau, 2009, 2010). required treatment or counseling and who received treatment from a mental health 5 Children with a medical home: Percent of professional (as defined) during the past year. children ages 0–17 who received health care For more information, see www.nschdata.org. that meets criteria of having a medical home: Data from National Survey of Children’s Health, child had a personal doctor/nurse; had a assembled by the Child and Adolescent Health usual source for sick care; received family- Measurement Initiative (CAHMI 2009). centered care from all health care providers; had no problems getting needed referrals; 10 Young children (ages 10 months–5 years) and received effective care coordination when received standardized developmental needed. For more information, see www. screening during visit: Percent of children nschdata.org. Data from the National Survey ages 10 months–5 years who had a health of Children’s Health, assembled by the Child care visit in the past year and parents and Adolescent Health Measurement Initiative completed a questionnaire about specific (CAHMI 2009). concerns and observations they had about their child’s development, communication or social behavior. The questionnaire was required to cover aspects of language or social development as appropriate for the child’s age. For more information, see www.nschdata.org. Data from the National Survey of Children’s Health, assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2009). 84 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 11 Hospital admissions for pediatric asthma 16 Young children (ages 4 months–5 years) per 100,000 children ages 2–17: Data from at moderate/high risk for developmental the Healthcare Cost and Utilization Project or behavioral delays: Percent of children (HCUP) databases and AHRQ Quality Indicators, ages 4 months–5 years whose risk for delay version 3.1. State estimates are from the State in learning, development, or behavior is Inpatient Databases (SID), and not all states moderate or high. Level of risk is based on a participate in HCUP. Estimates for the total U.S. set of questions asking parents if they have are from the Nationwide Inpatient Sample. concerns about their child’s development as (AHRQ, HCUP-SID 2006). Reported in National appropriate for the child’s age. These parental Healthcare Quality Report (AHRQ 2009). concerns were identified by the Maternal and Child Health Bureau as predictive of a child’s 12 Children with special health care needs who risk for delays based on the standardized had no problems receiving referrals when screening tool, Parents Evaluation of needed: Percent of children with special health Developmental Status (PEDS). The National care needs ages 0–17 who needed a referral Survey of Children’s Health uses a non-clinical to see other doctors or receive services during version of the PEDS. If parents replied “a little” the past year and had no problem getting or “a lot” they qualified as having a concern. referrals. For more information, see www. Those with 2 or more predictive concerns, cshcndata.org. Data from the National Survey which are given more weight than non- of Children with Special Health Care Needs, predictive concerns, were considered as “high assembled by the Child and Adolescent Health risk”; 1 concern, as “moderate risk.” For more Measurement Initiative (CAHMI 2008). information, see www.nschdata.org. Data 13 Children with special health care needs whose from the National Survey of Children’s Health, families received all needed family support assembled by the Child and Adolescent Health services: Percent of children with special Measurement Initiative (CAHMI 2009). health care needs ages 0–17 who received all 17 Children (ages 10–17) who are overweight or needed services which include respite care, obese: Overweight is defined as an age- and family genetic counseling, and family mental gender-specific body mass index (BMI-for- health care or counseling. All services are those age) between the 85th and 94th percentile of needed due to child’s medical, behavioral or the CDC growth charts. Obese is defined as a other health conditions. For more information, BMI-for-age at or above the 95th percentile. see www.cshcndata.org. Data from the BMI was calculated based on parent-reported National Survey of Children with Special height and weight. For more information, see Health Care Needs, assembled by the Child www.nschdata.org. Data from the National and Adolescent Health Measurement Initiative Survey of Children’s Health, assembled by the (CAHMI 2008). Child and Adolescent Health Measurement 14 Infant mortality, deaths per 1,000 live births: Initiative (CAHMI 2009). Data from the National Vital Statistics System– 18 Children ages 1–17 with oral health problems: Linked Birth and Infant Death Data (NCHS, Percent of children ages 1–17 who had at least NVSS n.d.), reported in National Vital Statistics one of the following oral health problems Reports, Volume 58, Number 17, April 30, 2010. in the past six months: a toothache, decayed 15 Child mortality, deaths per 100,000 children teeth/cavities, broken teeth, or bleeding gums. ages 1–14: Data from the National Vital For more information, see www.nschdata.org. Statistics System Multiple Cause-of-Death Data from the National Survey of Children’s Mortality Data (NCHS, NVSS n.d.), assembled by Health, assembled by the Child and Adolescent the National KIDS COUNT Program (The Annie Health Measurement Initiative (CAHMI 2009). Casey Foundation, 2010). www.commonwealthfund.org85 19 High school students who currently smoked cigarettes: Percent of high school students who smoke cigarettes on at least 1 day during the 30 days before the survey. Results are not available from every state because some states do not participate in the Youth Risk Behavior Survey and some states that do participate do not achieve a high enough overall response rate to receive weighted results. Data from the Youth Risk Behavior Survey (CDC, 2010). 20 High school students not meeting recommended physical activity level: Percent of high school students who were not physically active at least 60 minutes/day on 5 or more days (doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time during the 7 days before the survey). Results are not available from every state because some states do not participate in the Youth Risk Behavior Survey and some states that do participate do not achieve a high enough overall response rate to receive weighted results. Data from the Youth Risk Behavior Survey (CDC, 2010). 86 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 APPENDIX B3. Complete References for Data Sources AHRQ (Agency for Healthcare Research and Quality). CAHMI (Child and Adolescent Health Measurement (2009). National Healthcare Quality Report, 2009. Initiative). (2009). National Survey of Children’s Health, AHRQ Publication No. 10-0003. Rockville, MD: U.S. 2007. Portland, OR: Data Resource Center on Child Department of Health and Human Services. and Adolescent Health, Oregon Health and Science University. http://www.nschdata.org. AHRQ, HCUP-SID (Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project-State CAHMI (Child and Adolescent Health Measurement Inpatient Databases). (2006). Rockville, MD: Center for Initiative). (2008). National Survey of Children with Delivery, Organization, and Markets, U.S. Department Special Health Care Needs, 2005–2006. Portland, OR: of Health and Human Services. Data Resource Center on Child and Adolescent Health, Oregon Health and Science University. http://www. AHRQ, MEPS-IC (Agency for Healthcare Research and cshcndata.org. Quality, Medical Expenditure Panel Survey-Insurance Component). (2009). Washington, DC: U.S. Department NCHS, NIS (National Center for Health Statistics, of Health and Human Services. http://www.meps.ahrq. National Immunization Survey). (2009). Hyattsville, MD: gov. Centers for Disease Control and Prevention. The Annie E. Casey Foundation. (2010). Baltimore, MD: NCHS, NVSS (National Center for Health Statistics, KIDS COUNT Data Center. http://datacenter.kidscount. National Vital Statistics System). (n.d.). Hyattsville, MD: org. Centers for Disease Control and Prevention. CDC (Centers for Disease Control and Prevention). U.S. Census Bureau, Current Population Survey, Annual (2010). Surveillance Summaries, June 4, 2010. MMWR Social and Economic (ASEC) Supplement. (2009, 2010). 2010;59 (No. SS-5). Washington, DC: U.S. Department of Commerce. www.commonwealthfund.org87 FURTHER READING The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment Publications listed below can be found on in Primary Care (March 2010). W. Holt. The Commonwealth Fund’s Web site at www.commonwealthfund.org. “Implementing Developmental Screening and Referrals: Lessons Learned from a National Project,” Pediatrics, Feb. 2010 125(2):350–60. Realizing Health Reform’s Potential: How the T. M. King, S. D. Tandon, M. M. Macias et al. Affordable Care Act Will Strengthen Primary “Improving Asthma Outcomes in Minority Care and Benefit Patients, Providers, and Payers Children: A Randomized, Controlled Trial (Jan. 2011). M. K. Abrams, R. Nuzum, S. Mika, of Parent Mentors,” Pediatrics, Dec. 2009 and G. Lawlor. 124(6):1522–32. G. Flores, C. Bridon, S. Torres State Trends in Premiums and Deductibles, et al. 2003–2009: How Building on the Affordable Aiming Higher: Results from a State Scorecard Care Act Will Help Stem the Tide of Rising Costs on Health System Performance, 2009 (Oct. and Eroding Benefits (Dec. 2010). C. Schoen, K. 2009). D. McCarthy, S. K. H. How, C. Schoen, J. Stremikis, S. K. H. How, and S. R. Collins. C. Cantor, and D. Belloff. How to Develop a Statewide System to Link Aiming Higher for Health System Performance: Families with Community Resources: A Manual A Profile of Seven States That Perform Well for Replication of the Help Me Grow System on the Commonwealth Fund’s 2009 State (Sept. 2010). P. Dworkin, J. Bogin, M. Carey Scorecard (Oct. 2009). G. Moody and S. Silow- et al. Carroll. State Case Studies of Infant and Early “Implementing Electronic Health Record- Childhood Mental Health Systems: Strategies Based Quality Measures for Developmental for Change (July 2010). D. R. Lyman, W. Holt, Screening,” Pediatrics, Oct. 2009 124(4):e648– and R. H. Dougherty. e654. R. E. Jensen, K. S. Chan, J. P. Weiner et al. Mirror, Mirror on the Wall: How the Perfor- Implementation Choices for the Children’s mance of the U.S. Health Care System Compares Health Insurance Reauthorization Act of Internationally, 2010 Update (June 2010). 2009 (Sept. 2009). L. Simpson, G. Fairbrother, K. Davis, C. Schoen, and K. Stremikis. J. Touschner et al. Colorado Children’s Healthcare Access Program: North Carolina’s ABCD Program: Using Helping Pediatric Practices Become Medical Community Care Networks to Improve Homes for Low-Income Children (June 2010). the Delivery of Childhood Developmental S. Silow-Carroll. Screening and Referral to Early Intervention “The Children’s Health Insurance Program Re- Services (Aug. 2009). S. Klein and D. McCarthy. authorization Act: Progress After One Year,” “Pediatricians’ Roles in the Provision of Devel- States in Action, May/June 2010. S. Silow-Car- opmental Services: An International Study,” roll, G. Moody, and D. Rodin. Journal of Developmental and Behavioral Evidence-Based Health Care for Children: What Pediatrics, Aug. 2009, 30(4):331–39. A. A. Kuo, Are We Missing? (April 2010). R. D. Sege and M. Inkelas, M. Maidenberg et al. E. De Vos. Medicaid and CHIP Strategies for Improving Measuring the Quality of Developmental Child Health (July 2009). V. Smith, J. Edwards, Services for Young Children: A New Approach E. Reagan et al. (April 2010). N. Halfon, L. Stanley, and H. DuPlessis. 88 Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011 “The Use of Internet-Based Technology to “Medicaid: Health Promotion and Disease Pre- Tailor Well-Child Care Encounters,” Pediatrics, vention for School Readiness,” Health Affairs, July 2009 140(1):e37-e43. D. Bergman, A. Beck, March/April 2007 26(2):420–29. E. L. Schor, and A. K. Rahm. M. K. Abrams, and K. K. Shea. “Public Health in the State Reform Spotlight,” Why Not the Best? Results from the National States in Action, June/July 2009. G. Moody and Scorecard on U.S. Health System Performance S. Silow-Carroll. (Sept. 2006). The Commonwealth Fund Com- mission on a High Performance Health System. Building Medical Homes in State Medicaid and CHIP Programs (June 2009). N. Kaye and Primary Care Services: Promoting Optimal Child M. Takach. Development from Birth to Three Years (Sept. 2002). M. Regalado and N. Halfon. “Using Implementation and Dissemination Concepts to Spread 21st-Century Well-Child Health Insurance: A Family Affair (May 2001). Care at a Health Maintenance Organiza- J. M. Lambrew. tion,” The Permanente Journal, Summer 2009 13(3):10–17. A. Beck, D. Bergman, A. K. Rahm et al. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework (May 2009). R. C. Antonelli, J. W. McAllister, and J. Popp. “Early Federal Action on Health Policy: The Impact on States,” States in Action, Feb./March 2009. S. Silow-Carroll and G. Moody. Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008 (July 2008). The Commonwealth Fund Commission on a High Performance Health System. U.S. Variations in Child Health System Perfor- mance: A State Scorecard (May 2008). K. K. Shea, K. Davis, and E. L. Schor. Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending (Dec. 2007). C. Schoen, S. Guterman, A. Shih, J. Lau, S. Kasimow, A. Gauthier, and K. Davis. Aiming Higher: Results from a State Scorecard on Health System Performance (June 2007). J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy. www.commonwealthfund.org89 1150 17th Street NW One East 75th Street Suite 600 New York, NY 10021 Washington, DC 20036 Tel 212.606.3800 Tel 202.292.6700 www.commonwealthfund.org