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Stronger Goals Are Needed For Program To Benefit Uninsured Children

Although a glance at recent federal and state legislation suggests impoverished children will receive unprecedented health care in the new millennium, a deeper look reveals flaws that need immediate attention, according to a recent study.

Researchers from Johns Hopkins School of Hygiene and Public Health who took an in-depth look at the State Children's Health Insurance Program (SCHIP) -- a federal program enacted in 1997 that allows states to extend medical coverage for uninsured children not eligible for Medicaid -- say it needs both a broader scope and clearer goals to truly benefit children and families.

"The overall design of SCHIP, with its great flexibility for the states, provides both the benefits of innovation and the risks of inconsistency and inequity," said lead author Leiyu Shi, DrPH.

According to the researchers, states are not lacking for good intentions or money with regard to SCHIP. Most states assert reducing the number of uninsured children as a major strategic objective of SCHIP, and the federal government is granting them approximately $40 billion from 1997 to 2007 to achieve this objective.

Under SCHIP, states may cover children with family incomes up to approximately 200 percent of the federal poverty level, according to the study.

In the short term, states should expect higher patient satisfaction, reduced illness and hospitalization, and greater well-being among children with special needs, as a result of SCHIP. Also, the health-related costs of both families and the government should stabilize.

However, the researchers point out that focusing simply on extending medical coverage to uninsured children is not a far-reaching enough goal for SCHIP. What's missing is focus on the quality of that coverage, according to the researchers.

"An evaluation of the benefits of SCHIP should consider not only expanded insurance coverage for eligible children but also the extent to which children receive high quality care," said Shi.

High quality care entails regular physician office visits along with preventive and specialist care, as opposed to emergency room visits and hospitalization, according to the study. Enhancing primary care services is another important quality issue, including strengthening accessibility to care, continuity of care, comprehensiveness of services, and coordination of care.

States are also neglecting to plan ahead to provide for the pediatricians and family practitioners who are needed, along with clinics and hospital emergency departments, to care for these uninsured children.

"Including these individuals and services in the design and financing of services is critical to building a seamless system of primary care for low income children," said Shi.

A third problem: many states have no system in place to evaluate the short and long-term effects of SCHIP, and to measure SCHIP achievements against objectives. States can choose from a wealth of both government and private database agencies to help them track progress, according to the study.

In the end, the success of SCHIP should be a measure of its long-term effect on children's health, said the researchers, noting that although U.S. infant and child mortality rates have fallen in the second half of the 20th century, they remain high compared to other developed countries.

To help remedy the flaws of SCHIP's current design, Shi and colleagues developed a "framework" to help evaluate SCHIP. This framework is broadly defined to account for economic and other variations among states.

They published their research in the September issue of The Milbank Quarterly.

"We hope such a framework can assist federal and state leaders in discussions of SCHIP performance and in developing a consistent approach for SCHIP evaluation," said Shi.

"A broader perspective and stronger goals are essential to design a health care system for improving the quality of care and children's health," Shi added.

The study was supported by the Bureau of Primary Health Care, Health Resources and Services Administration, and the Johns Hopkins Primary Care Policy Center for the Underserved Populations. The opinions expressed in the study are those of the authors and do not necessarily represent the Bureau of Primary Health Care.

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The Milbank Quarterly is a journal of public health and health care policy published by the Milbank Memorial Fund. For information about the journal, contact Bradford H. Gray, PhD, at (212) 822-7287.