Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011

February 2, 2011

Authors: Sabrina K. H. How, M.P.A., Ashley-Kay Fryer, Douglas McCarthy, M.B.A., Cathy Schoen, M.S., and Edward L. Schor, M.D.
Contact: Sabrina K. H. How, M.P.A., Senior Research Associate, Commonwealth Fund Health System Scorecard and Research Project,
Editor: Martha Hostetter


Child health map Use this map to view state-specific rankings and results compared to benchmarks and to view the potential gains in terms of healthy lives and access to coverage and care. Also check out the comparison tool to select performance indicators, and states and then generate custom tables and bar charts.



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.

Executive Summary

 A child’s health, ability to participate fully in school, and capacity to lead a productive, healthy life depend on access to preventive and effective health care—starting well before birth and continuing throughout early childhood and adolescence. Since healthy children are key to the well-being and economic prosperity of families and society, investing in child health has long been a high priority for federal and state policy. This State Scorecard on Child Health System Performance, 2011, finds that federal action to extend insurance to children has made a critical difference in reducing the number of uninsured children across states and maintaining children’s coverage during the recent recession. However, the report also finds that where children live and their parent’s incomes significantly affect their access to affordable care, receipt of preventive care and treatment, and opportunities to survive past infancy and thrive. Better and more equitable results will require improving the quality of children’s health care across the continuum of their needs as well as holding health care systems accountable for preventing health problems and promoting health, not just caring for children when they are sick or injured.

The Scorecard’s findings on children’s health insurance attest to the pivotal role of federal and state partnerships. Until the start of this decade, the number of uninsured children had been rising rapidly as the levels of employer-sponsored family coverage eroded for low- and middle-income families. This trend was reversed across the nation as a result of state-initiated Medicaid expansions and enactment and renewal of the Children’s Health Insurance Program (CHIP). Currently, Medicaid, CHIP, and other public programs fund health care for more than one-third of all children nationally. Children’s coverage has expanded in 35 states since the start of the last decade and held steady even in the middle of a severe recession. At the same time, coverage for parents—lacking similar protection—deteriorated in 41 states.

Indicators of State Child Health System Performance With the goal of identifying opportunities to improve, this Scorecard examines state performance on 20 key health system indicators for children clustered into three dimensions: access and affordability, prevention and treatment, and potential to lead healthy lives. It also examines state performance by family income, insurance status, and race/ethnicity to assess the equity of the child health care system—the fourth dimension of performance. The analysis ranks states and the District of Columbia on each indicator and the four dimensions. The analysis finds wide variation in system performance, with often a two- to threefold difference across states, as illustrated in Exhibit 1. Benchmark levels set by leading states show there are abundant opportunities to improve health system performance to benefit children. If all states achieved top levels on each dimension of performance, over 5 million more children would be insured and 10 million more children would receive at least one medical and dental preventive care visit per year. Eight hundred thousand more children ages 19 to 35 months would be up to date on all recommended doses of six key vaccines, and nearly 370,000 fewer children with special health care needs would have problems getting referrals to specialty care services. Likewise, nearly 9 million additional children would have a medical home to help coordinate their care.

The 14 states in the top quartile of the overall performance ranking—Iowa, Massachusetts, Vermont, Maine, New Hampshire, Rhode Island, Hawaii, Minnesota, Connecticut, North Dakota, Pennsylvania, Wisconsin, Kansas, and Washington—often perform well on multiple indicators and across dimensions (Exhibit 2). At the same time, the Scorecard finds that even the leading states have opportunities to improve: no state ranks in the top half of the performance distribution on all indicators. At the other end of the spectrum, states in the bottom quartile generally lag in multiple areas, with worse access to care, lower rates of recommended prevention and treatment, poorer health outcomes, and wide disparities related to income, race/ethnicity, and insurance status.

Throughout, the findings underscore the importance of policy action to sustain children's access to care in the midst of rising health care costs and financial stress on families. Access to care must be coupled with statewide initiatives and community efforts to improve health care system performance for children.

The State Scorecard on Child Health System Performance, 2011, finds that some states do markedly better than others in promoting the health and development of their youngest residents, and in ensuring that all children are on course to lead healthy and productive lives. As states, clinicians, and hospitals prepare to implement health reforms, the Scorecard provides a framework to take stock of where they stand today and what they could gain by reaching and raising benchmark performance levels.

The findings reveal crucial areas in which comprehensive federal, state, and community policies are needed to improve child health system performance for all families. States that invest in children’s health reap the benefits of having children who are able to learn in school and become healthy, productive adults. Other states can learn from models of high performance to shape policies that ensure all children are given the opportunity to lead long, healthy lives and realize their potential.

Greater investment in measurement and data collection at the state level could enrich understanding of variations in child health system performance. For many dimensions, only a limited set of indicators is available. Moreover, there is often a time lag in the availability of data. National surveys of children’s health care are conducted at four-year intervals, for example. Hence, a large number of indicators discussed in this Scorecard date from 2007. The indicators of child health care quality presented here are also largely parent-reported. The collection of more robust clinical data on children’s health care quality is integral to future state and federal child health policy reform and could modify the state rankings provided in this report. The CHIP program reauthorization has begun to lead the way by creating a set of standardized quality measures for use by CHIP, Medicaid, and health plans. The availability of core measures and information on community-level variation will enable states to learn from innovative models. Work under way in many states as well as efforts supported by CHIP and the Affordable Care Act should lay a foundation for public and private action.