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Press Release


May 28, 2008

First State-by-State Health System Scorecard to Focus on Children Finds Wide Differences in Health Care

Report Finds Millions More Children Would Be Insured, Have Health Care, Avoid Developmental Delays If All States Performed as Well as the Top States


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Iowa, Vermont, Maine, Massachusetts, and New Hampshire Lead in State Rankings

New York, NY, May 28, 2008—States vary widely in the quality of health care children receive, as well as children's access to care, family insurance premiums, equity, and the potential to lead long healthy, productive lives, according to a new scorecard issued by The Commonwealth Fund. The scorecard is the first report to assess how the health system is performing for children across these five dimensions on a state-by-state basis.

The striking differences across states add up to real consequences for children and their families. The report estimates that if all states performed as well as the top states:

  • An additional 4.6 million children nationwide would have health insurance;
  • 11.8 million more children would get their recommended yearly medical and dental check-ups;
  • 1.6 million fewer children would be at risk for developmental delays;
  • 10.9 million more children would have a medical home; and
  • Nearly 800,000 more children would be up-to-date on their vaccines.

The report, U.S. Variations In Child Health System Performance: A State Scorecard, by Commonwealth Fund researchers Katherine Shea, M.P.H., Karen Davis, Ph.D., and Edward Schor, M.D., ranked states on 13 indicators for children grouped in categories that include access, quality, costs, equity, and healthy outcomes. While no single state performed at the top across all categories, some states far surpassed others. States in the Northeast and Upper Midwest often rank high in multiple areas. In contrast, states with the lowest rankings tend to be concentrated in the South and Southwest. However, there was room for improvement in even the highest ranked states, which fell short of established standards on some indicators.

The report compares each state to benchmarks that have already been achieved in one or more states, and notes that, because there are limited state-level data on many measures of children's health, there is a pressing need for better data to inform federal and state health policy reform efforts.

"In looking at the country as a whole, we found that, while there are pockets of excellence, there is no one state or region that is doing as well as it could be," said co-author and Commonwealth Fund Vice President Edward Schor, M.D. "This scorecard points to the need to make more information available about children's health care and to improve the health care system for children. The good news is we know improvements can be made because we didn't judge these states based on a pie in the sky standard; we judged them against one another."

Access to Care for Children Consistent Among Top Scorers

While the rate of uninsured children varies widely across states, from 5 percent in Michigan to 20 percent in Texas, the scorecard found that states with the highest rankings on access to care—meaning that they have nearly all of their children insured—were almost uniformly among the best scorers on quality of care and equity measures.

Typically, states that fell in the bottom of the overall ranking lagged well behind their peers on the access to care measure and struggled with other measures. In the overall ranking, Arizona, Florida, Louisiana, Mississippi, New Jersey, Nevada, and Texas all scored in the bottom ten states overall and also were at the bottom on the access measure. Five of the lowest ranked states for access to care (Arizona, Louisiana, Mississippi, New Mexico, Nevada, and Texas) also ranked at the bottom on the quality measures.

In general, scorecard authors found that children in the bottom ranked states are less likely to get the recommended health care, including vaccines, dental care, and regular check-ups. And, children in those states are at greater risk for developmental delays and infant mortality.

Quality of Care for Children Falls Short

Researchers found that, while quality of care for children varied widely across states, even in the highest ranked states, quality falls short of set standards. For example, 75 percent of children in Massachusetts had at least one medical and one dental visit in the past year compared to only 46 percent of children in Idaho. Massachusetts ranked first in that measure yet a full 25 percent of children in Massachusetts didn't get annual preventive medical and dental care.

Quality scores indicate that across the country children aren't receiving the vaccines they need, don't have access to mental health care for emotional problems and are at high risk for developmental delays, aren't getting their regular medical and dental check-ups, don't have a medical home, and are more likely to end up in the hospital if they have asthma. However, states in the South, Southwest, and West ranked lowest on quality while states in the Upper Midwest and Northeast regions ranked the highest.

Wide Variations—Additional Report Findings:


  • Health systems should ensure that families have access to high-quality care while minimizing the costs of care. State per capita health care spending varies from a high of $8,295 a person in Washington, DC to a low of $3,972 a person in Utah. Employer-sponsored family premium costs, the other cost measure used by scorecard authors, range from $8,334 a year in North Dakota to $11,924 a year in Rhode Island. No state data specific to child health expenditures, as opposed to family expenditures, are available.


  • Minority, low-income, and uninsured children received lower quality care across most states. In fact, 65 percent of uninsured and 51 percent of poor children did not receive the recommended medical and dental care while only 37 percent of privately insured children and 30 percent of higher income children did not get those services. And, 77 percent of uninsured children and 70 percent of poor children had no medical home while only 47 percent of privately insured and 42 percent in higher income families lacked a medical home.

Healthy Lives

  • The authors found two-fold difference in rates of children at risk for developmental delays. For instance, 33 percent of young children in Louisiana are at moderate to high risk for developmental delay compared with only 16 percent of young children in Vermont.

Moving Forward

The report points to the need for action in key areas: adequate funding for the state children's health insurance program so that all states can expand health insurance coverage for children; national policies that make sure families can afford the health care they need and that their health insurance benefits meet their children's needs; standards for health care quality that would ensure all children have access to high quality health care; and investing in additional research and data collection to help paint an even clearer and more detailed picture of how states are doing with children's health care.

"The health of our children is paramount to our country's long-term success. This scorecard serves notice that children's health and well-being are at risk," said co-author and Commonwealth Fund President Karen Davis. "We must invest in children's health and health care to ensure that they have the opportunity to become healthy and productive adults. The time to begin is now."

The state scorecard includes 13 indicators grouped into five dimensions of performance: access, quality, costs, equity, and potential to lead long healthy lives. The analysis ranks states on each indicator and then averages the indicator ranks to determine the dimension rank. All five dimension scores are averaged to determine a state's overall rank.