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.



Children's health insurance coverage has expanded in many states, while parents' coverage has eroded. Yet the number of uninsured children continues to vary widely across states.
Currently 10 percent of children are uninsured nationally, and the uninsured rate for children exceeds 16 percent in three states. In contrast, 19 percent of parents are uninsured nationally, and there are nine states in which 23 percent or more of parents are uninsured. The difference between children’s and parents’ coverage rates reflects federal action taken early in the last decade to insure children, as well as continued federal support for children’s coverage. There is no national standard for coverage of parents, however poor. Still, the percent of uninsured children continues to vary widely across states, ranging from a low of 3 percent in Massachusetts to a high of 17 percent to 18 percent in Nevada, Florida, and Texas. The range underscores the importance of state as well as federal action to ensure access and continuity of care.

State Scorecard Summary The passage of the Affordable Care Act will—for the first time—provide health insurance to all low- and middle-income families. To achieve this, the law will expand Medicaid to low-income parents as well as childless adults with incomes up to 133 percent of the federal poverty level, beginning in 2014. This represents a substantial change in Medicaid’s coverage of adults. The law will also assist families with low and moderate incomes to purchase coverage through insurance exchanges and tax credits. These policies will directly benefit children as families gain financial security, and parents’ health improves.

Across states, the extent to which children have access to care is closely related to their receipt of preventive care and treatment. Yet insurance does not guarantee receipt of recommended care or positive health outcomes.
Seven of the 13 leading states in the access and affordability dimension also rank among the top quartile of states in terms of prevention and treatment. Children in states with the lowest uninsured rates are more likely to have a medical home and receive preventive care or referrals to needed care than children in states with the highest uninsured rates. While insurance matters, good care and outcomes are also a function of a well-functioning health care delivery system. Securing coverage and access to affordable care for families is only a first step to ensure that children obtain essential care that is well coordinated and patient-centered.

Children's access to care, health care quality, and health outcomes vary widely across states.
The Scorecard findings show that where a child lives has an impact on his or her potential to lead a healthy life into adulthood. States vary widely in their provision of children’s health care that is effective, coordinated, and equitable. This variability extends to states’ ability to ensure opportunities for children to achieve optimal health.

There is a twofold or greater spread between the best and worst states across important indicators of access and affordability, prevention and treatment, and potential to lead healthy lives (Exhibit 1). The performance gaps are particularly wide on indicators assessing developmental screening rates, provision of mental health care, hospitalizations because of asthma, prevalence of teen smoking, and mortality rates among infants and children. Lagging states would need to improve their performance by 60 percent on average to achieve benchmarks set by leading states.

If all states were to improve their performance to levels achieved by the best states, the cumulative effect would translate to thousands of children’s lives saved because of more accessible and improved delivery of high-quality care. In fact, improving performance to benchmark levels across the nation would mean: 5 million more children would have health insurance coverage, nearly 9 million children would have a medical home to help coordinate care, and some 600,000 more children would receive recommended vaccines by the age of 3 years.

Leading states—those in the top quartile—often do well on multiple indicators across dimensions of performance; public policies and state/local health systems make a difference.
The 14 states at the top quartile of the overall performance rankings generally ranked high on multiple indicators and dimensions (Exhibit 2). In fact, the five top-ranked states—Iowa, Massachusetts, Vermont, Maine, and New Hampshire—performed in the top quartile on each of the four dimensions of performance. Many have been leaders in improving their health systems by taking steps to cover children or families, promote public health, and improve care delivery systems.



Iowa, tied in first place with Massachusetts in terms of overall children’s health system performance, has had a long-standing commitment to children. In the past decade, the state paid particular attention to the needs of its youngest residents, from birth to age 5. After piloting a variety of programs in the early 1990s to identify and serve at-risk children and families, the Iowa legislature established a statewide initiative to fund "local empowerment areas" across the state. The partnerships among clinicians, parents, child care representatives, and educators seek to ensure children receive needed preventive care.

State leaders have focused on child health outcomes by promoting the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. In 1993, an EPSDT Interagency Collaborative was formed with a fourfold purpose: to increase the number of Iowa children enrolled in EPSDT; to increase the percentage of children who receive well-child screenings; to ensure effective linkages to diagnostic and treatment services; and to promote the overall quality of services delivered through EPSDT. As a result of these efforts, the statewide rate of well-child screenings rose from 9 percent to 95 percent in just over five years.

Iowa has also been making strides in providing high-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 private providers to develop a sound structure for assessing young children’s social and developmental skills. Under the 1st Five system, a primary care provider screens children and their caregivers when they come in for a visit; if a concern is identified, the provider notifies the 1st Five Child Health Center. The center’s care coordinator then contacts the family to link them to appropriate services in the community or help coordinate referrals.

Iowa also has expansive policies in place to ensure children have health care coverage. The State Children’s Health Insurance Program covers all children under age 19 in families with income levels up to 133 percent of the federal poverty level (FPL). Children ages 6–18 whose family income is between 100 percent and 133 percent of FPL and infants whose family income is between 185 percent and 300 percent of FPL are covered through an expansion of Medicaid. Meanwhile, children in families with income from 133 percent to 300 percent of FPL are covered through private insurance, in a program known as Healthy and Well Kids in Iowa (hawk-i). Iowa contracts with private health plans to provide covered services to children enrolled in the hawk-i program, with little or no cost-sharing for families. Recently, in the spring of 2010, hawk-i implemented a dental-only plan.

Iowa’s innovative policies and public–private partnerships to improve children’s health care serve as evidence-based models that other states can follow to move toward a higher-performing child health system.

For more information see N. Kaye, J. May, and M. K. Abrams, State Policy Options to Improve Delivery of Child Development Services: Strategies from the Eight ABCD States (Portland, Maine, and New York: National Academy for State Health Policy and The Commonwealth Fund, Dec. 2006); and S. Silow-Carroll, Iowa’s 1st Five Initiative: Improving Early Childhood Developmental Services Through Public–Private Partnerships, (New York: The Commonwealth Fund, Sept. 2008). 

In contrast, states at the bottom quartile of overall child health system performance lagged well behind the leaders on multiple indicators of performance. These states had rates of uninsured children and parents that were, on average, more than double those in the top quartile of states. Reflecting the strong association between access to care and the quality and continuity of care, children in the lowest-quartile states were among the least likely to receive routine preventive care visits or mental health services when needed, or to report having a primary care practice that serves as a medical home to provide care and care coordination. Notably, rates of developmental delays and infant mortality are more than 20 percent to 30 percent higher, respectively, in the lowest-quartile states compared with top-quartile states.

These patterns indicate that public policies, as well as state and local health systems, can make a difference to children’s health and health care. But socioeconomic factors also play a role—underscoring the importance of federal and state policies in areas with high rates of poverty.

State Ranking on Child Heath System Performance Regional performance patterns provide valuable insight.
The Scorecard revealed regional patterns in child health system performance (Exhibit 3). Across dimensions, states in New England and the Upper Midwest often rank in the highest quartile of performance, whereas states with the lowest rankings tend to be concentrated in the South and Southwest. Yet within any region, there are exceptions. For example, West Virginia and Tennessee face high rates of poverty, unemployment, and disease yet rank in the top half of performance on indicators of children's health. West Virginia does exceptionally well in ensuring access and high-quality care for its most vulnerable children, ranking fifth in terms of equity. Alabama is in the top quartile for children's insurance, with nearly 94 percent insured. And North Carolina leads in providing developmental screening for young children.

Leading states as well as those that outperform neighboring states within a region have often made concerted efforts to improve through coverage and quality improvement initiatives. Learning about these initiatives can offer insights for other states, particularly those starting with similar health systems or resource constraints.There is room to improve in all states.

There is room to improve in all states. Even in the best states, performance falls short on at least some indicators and state averages are below what should be achievable. 
All states have room to improve. None ranked in the top half of the performance distribution across all indicators. For some indicators, performance was not outstanding even in the high-ranked states. For example, North Carolina ranked first in terms of screening children for developmental or behavioral delays, yet more than half of children in the state were not screened, based on parents’ reports. Nearly a third of children did not have access to care meeting the definitions of a medical home, even in the top-ranked state in this indicator. Conversely, states that performed poorly overall outperformed higher-ranking states on some indicators. There is value in learning from best practices around the nation.

Rising rates of childhood overweight or obesity plague all states. Moreover, many children live with oral health problems that could be addressed with timely, affordable access to effective preventive dental care and treatment. Even in the top-ranked state on this indicator, Minnesota, one of five children has oral health problems such as tooth decay, pain, or bleeding gums.

Inequitable care and outcomes by insurance status, income, and race/ethnicity remain a large concern. Uninsured, low-income, and minority children have less than equal opportunity to thrive in nearly all states. Yet in some higher-performing states, these vulnerable children do nearly as well as the national average and rival performance levels achieved for children in higher-income families, indicating that gains in statewide performance are achievable by focusing on the most vulnerable children.