U.S. Variations in Child Health System Performance A State Scorecard Katherine K. Shea, Karen Davis, and Edward L. Schor May 2008 U.S. Variations in Child Health System Performance: A State Scorecard Katherine K. Shea, Karen Davis, and Edward L. Schor May 2008 Note: Portions of this ABSTRACT: This report examines variations among states’ child health care systems, building on the State Scorecard published by The report were revised as of Commonwealth Fund Commission on a High Performance Health System. Focusing on 13 performance indicators of access, quality, June 6, 2008. costs, equity, and the potential to lead healthy lives, the authors find wide variation among states, including distinct regional patterns. Across states, better access to care is closely associated with better quality of care. Top-performing states, such as Iowa and Vermont, have adopted policies to expand children’s access to care and improve the quality of care. While leading states outperform lagging states on multiple indicators, all states have opportunities to improve. National leadership and collaboration across public and private sectors are essential for coherent, strategic reforms to improve child health care in the United States. 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. 1140. Contents List of Figures................................................................................................................................... iv . List of Tables..................................................................................................................................... v About the Authors. ........................................................................................................................... vi . Acknowledgments............................................................................................................................. vi Executive Summary........................................................................................................................... vii Introduction. .................................................................................................................................... 1 . Findings............................................................................................................................................ 3 Access: Medicaid and SCHIP Are Critical................................................................................... 6 Quality: Wide State Variation, with Shortfalls Across Nation...................................................... 9 Costs: A Major Concern in All States.......................................................................................... 13 Equity: Quality Differs by Race/Ethnicity and by Income and Insurance Status.......................... 17 Potential to Lead Healthy Lives: Distinct Regional Patterns........................................................ 21 Cumulative Impact of a Higher-Performing Child Health Care System............................................ 23 A Call to Action: Federal and State Collaboration............................................................................. 25 Appendix: Study Methodology.......................................................................................................... 27 Notes................................................................................................................................................ 55 iii List of Figures Figure ES-1 Indicators of State Child Health System Performance................................................viii Figure ES-2 State Ranking on Child Health System Performance................................................. ix Figure ES-3 Summary of Variations in Child Health System Performance ................................... x Figure ES-4 State Ranking on Access and Quality Dimensions..................................................... xii Figure ES-5 National Cumulative Impact if All States Achieved Top-State Rates...........................xiii Figure 1 Indicators of State Child Health System Performance................................................ 2 Figure 2 Summary of Variations in Child Health System Performance ................................... 4 Figure 3 State Ranking on Child Health System Performance ................................................ 5 Figure 4 Percent of Uninsured Children Declined Since Enactment of SCHIP in 1997, but Gaps Remain ........................................................................... 7 Figure 5 State Ranking on Access Dimension.......................................................................... 8 Figure 6 State Ranking on Quality Dimension........................................................................ 10 Figure 7 State Rates of Hospital Admissions for Pediatric Asthma per 100,000 Children, 2002...................................................................................... 12 Figure 8 State Ranking on Access and Quality Dimensions..................................................... 13 Figure 9 State Ranking on Costs Dimension........................................................................... 14 Figure 10 State Variation: Personal Health Care Spending per Capita, 2004. ............................ 15 . Figure 11 State Variation: Average Family Premium for Employer-Based Health Insurance, 2005............................................................................................. 15 Figure 12 State Ranking on Costs and Quality Dimensions...................................................... 16 Figure 13 State Ranking on Equity Dimension......................................................................... 18 Figure 14 Equity Dimension: Disparities by Income, Insurance Status, and Race/Ethnicity ................................................................................................... 19 Figure 15 State Ranking on Potential to Lead Healthy Lives. .................................................... 21 . Figure 16 Infant Mortality by State, 2002................................................................................. 22 Figure 17 National Cumulative Impact if All States Achieved Top-State Rates........................... 23 iv List of Tables Table 1.1 State Ranking on Health System Performance by Dimension.................................... 29 Table 2.1 Access: Adequate Health Coverage for Children........................................................ 30 Table 2.2 Percent of Children at or Below 200% of Poverty Who Are Uninsured, Two-Year Average, Ages 0–17.................................................................................... 31 Table 2.3 Percent of Children Who Are Uninsured, Two-Year Average, Ages 0–17. .................. 32 . Table 3.1 Quality: Getting Right Care, Coordinated Care, and Family-Centered Care............. 34 Table 3.2 Percent of Children Ages 19–35 Months Receiving All Recommended Doses of Five Key Vaccines........................................................................................ 36 Table 3.3 Percent of Children Ages 0–17 with Both a Medical and Dental Preventive Care Visit in the Past Year............................................................. 36 Table 3.4 Percent of Children Ages 1–17 with Emotional, Behavioral, or Developmental Problems Receiving Some Mental Health Care in the Past Year................................. 38 Table 3.5 Percent of Children Ages 0–17 with a Medical Home............................................... 38 . Table 3.6 Percent of Children Ages 0–17 Whose Personal Doctor or Nurse Follows up After They Get Specialty Care Services................................................................. 40 . Table 3.7 Percent of Children Ages 0–17 with Special Health Care Needs Who Have Problems Getting Referrals to Specialty Care Services, 2002..................................................... 40 Table 3.8 Hospital Admissions for Pediatric Asthma Per 100,000 Children Ages 0–17............. 42 Table 4.1 Family Costs of Health Care...................................................................................... 42 Table 4.2 Personal Health Care Spending Per Capita, 2004...................................................... 44 Table 4.3 Average Family Premium Per Enrolled Employee For Employer-Based Health Insurance, FY 2005........................................................................................ 45 Table 5.1 Equitable Care: Disparities by Income, Insurance Status, and Race/Ethnicity............ 46 Table 5.2 Equity: Insurance...................................................................................................... 48 . Table 5.3 Equity: Income.......................................................................................................... 49 Table 5.4 Equity: Race/Ethnicity.............................................................................................. 50 . Table 6.1 Potential to Lead Healthy Lives................................................................................. 51 Table 6.2 Infant Mortality, Deaths per 1,000 Live Births.......................................................... 52 Table 6.3 Percent of Children Ages 1–5 at Moderate/High Risk for Developmental Delay....... 52 v About the Authors Katherine K. Shea, M.P.H., is research associate on health and social policy issues, including the to The Commonwealth Fund’s president, having landmark books Health Care Cost Containment; served previously as program associate for the Medicare Policy; National Health Insurance: Benefits, Fund’s Child Development and Preventive Care Costs, and Consequences; and Health and the War on program and the Patient-Centered Primary Care Poverty. She can be e-mailed at kd@cmwf.org. Initiative. As of June 2008, she will be a health policy analyst in the Executive Office of Health Edward L. Schor, M.D., vice president, leads The and Human Services for the Commonwealth of Commonwealth Fund’s Child Development and Massachusetts under Secretary Judith Bigby. Prior Preventive Care program. Dr. Schor, a pediatrician, to joining the Fund, Ms. Shea worked as a session has held many important positions in pediatrics, assistant at Memorial Sloan-Kettering Cancer health outcomes, and child development and Center in an ambulatory hematology clinic. She pediatric care prior to joining the Fund at the holds a B.A. in art history from Columbia University beginning of 2002. He is editor of the book, Caring and an M.P.H. in health policy from Columbia’s for Your School-Age Child, and has chaired both the Mailman School of Public Health. Ms. Shea can be Committee on Early Childhood, Adoption and e-mailed at ks@cmwf.org. Dependent Care and the national Task Force on the Family for the American Academy of Pediatrics. Karen Davis, Ph.D., is president of The Dr. Schor received his medical degree from the Commonwealth Fund. She is a nationally Chicago Medical School. He can be e-mailed at recognized economist with a distinguished career els@cmwf.org. in public policy and research. In recognition of her work, Ms. Davis received the 2006 AcademyHealth Distinguished Investigator Acknowledgments Award. Before joining the Fund, she served as The authors are grateful to Joel Cantor, Cathy chairman of the Department of Health Policy and Schoen, Sabrina How, and Douglas McCarthy for Management at The Johns Hopkins Bloomberg their work on The Commonwealth Fund’s State School of Public Health, where she also held an Scorecard on Health System Performance, which appointment as professor of economics. She served informed this report. For their thoughtful review as deputy assistant secretary for health policy in and comments, we also thank Brett Brown at the Department of Health and Human Services Child Trends, Inc., Catherine Hess at the National from 1977 to 1980, and was the first woman to Academy for State Health Policy, and Christina head a U.S. Public Health Service agency. A native Bethell and the team at the Child and Adolescent of Oklahoma, she received her doctoral degree in Health Measurement Initiative. We thank Michelle economics from Rice University, which recognized Doty for her diligence in verifying the accuracy of her achievements with a Distinguished Alumna the data. Lastly, we thank Martha Hostetter and Award in 1991. Ms. Davis has published a number Chris Hollander for their editorial guidance. of significant books, monographs, and articles vi U.S. Variations In Child Health System Performance: A State Scorecard Executive Summary Investing in child health is a high priority for goal of focusing on opportunities to improve, this state officials. More than one-third of children analysis assesses performance relative to what is nationally receive health care funded by the federal achievable, based on benchmarks drawn from the government as well as the 50 states and the District range of state health system performance. of Columbia. Twenty-eight million children are covered by Medicaid, and 6 million are covered The analysis focuses on 13 indicators of child by the State Children’s Health Insurance Program health system performance along the dimensions (SCHIP), which was enacted in 1997 to expand of access, quality, costs, and the “potential to lead coverage of children in low-income families.1 Yet, healthy lives.” In addition, for two indicators, some states do better than others in promoting gaps in performance by income, race/ethnicity, the health and development of their youngest and insurance are used to gauge equity. Six of residents, and in ensuring that all children are on the 13 indicators were included in the previously course to lead healthy and productive lives. published State Scorecard; others were added from government data sources. All 50 states, plus the The recent State Scorecard on Health System District of Columbia, are ranked on each indicator Performance, prepared for The Commonwealth and the five dimensions of performance—access, Fund Commission on a High Performance Health quality, costs, equity, and potential to lead healthy System, found that access to health care, as well as lives—using the same methodology employed health care quality, costs, outcomes, and equity, in the State Scorecard. The rankings for each vary widely across the states.2 This report examines dimension are then summed to derive an overall performance variations among states’ child ranking for child health system performance. health systems, building on many of the State Figure ES-1 shows the indicators included, the Scorecard indicators as well as other key indicators range in variation across states, and the highest- of children’s health. It finds similar variation achieving state on each indicator. (See “Appendix: in performance among states—and abundant Study Methodology” for further details.) opportunities for all states to improve. With a Executive Summary vii Figure ES-1. Indicators of State Child Health System Performance Range of State All States Best Access Year Performance Median State (Bottom–Top) Children uninsured 2005– 2006 9.1 20.1–4.9 MI Low-income children uninsured 2005– 2006 16.6 34.5–7.0 DC Quality Children ages 19–35 months received all 2005 81.6 66.7–93.5 MA recommended doses of five key vaccines Children with both medical and dental preventive 2003 59.2 45.7–74.9 MA care visits Children with emotional, behavioral, or developmental problems received mental 2003 61.9 43.4–77.2 WY health care Children with a medical home 2003 47.6 33.8–61.0 NH Children needing specialty care, those whose personal doctor or nurse follows up after they get 2003 57.9 49.8–68.0 WV specialty care services Children with special health care needs who needed specialist care with problems getting referrals to 2001 22.0 33.5–13.5 SD specialty care services Hospital admissions for pediatric asthma 2002 176.7 314.2–54.9 VT per 100,000 children Costs State total personal health spending 2004 $5,327 $8,295–3,972 UT Family premium for employer-based health insurance 2005 $10,637 $8,334–11,924 ND Potential to Lead Healthy Lives Young children at moderate/high risk for 2003 23.6 32.9–16.4 VT developmental delay Infant mortality: deaths per 1,000 live births 2002 7.1 11.0–4.3 ME Equity Income 2003 -11 point gap -33.7–6.4 gap VT Race/Ethnicity 2003 -14.2 point gap -29.3–13.2 gap VT Insurance coverage 2003 -19.2 point gap -36.2–3.9 gap MA Source: State Variations in Child Health System Performance, The Commonwealth Fund, May 2008. viii U.S. Variations In Child Health System Performance: A State Scorecard Highlights • Leading states consistently outperform Variations in state child health system performance lagging states on multiple child health point to six important findings: indicators and dimensions. Thirteen states— Iowa, Vermont, Maine, Massachusetts, Ohio, • High performance is possible. Iowa and Hawaii, New Hampshire, Rhode Island, Vermont have created children’s health care Kentucky, Kansas, Wisconsin, Michigan, and systems that are accessible, equitable, and Nebraska—emerge at the top quartile of the deliver high-quality care, all while controlling overall performance rankings. These states levels of spending and family health insurance generally rank high on multiple indicators premiums. Over the last decade, both states along each of the five dimensions assessed adopted policies to expand children’s access (Figure ES-2). Many have among the nation’s to care and improve their quality of care. lowest uninsured rates for children. In particular, Iowa and Vermont expanded Conversely, the 13 states at the bottom SCHIP and mandated that all child health quartile of the overall performance plans and local and regional children’s health ranking—Illinois, New Mexico, New Jersey, systems publicly report data on the quality of Alaska, Oregon, Arkansas, Nevada, Texas, care. This analysis indicates that such policies Arizona, Louisiana, Mississippi, Florida, make a difference. and Oklahoma—lag well behind their peers Figure ES-2. State Ranking on Child Health System Performance WA NH ME MT ND VT OR MN ID SD WI NY MA WY MI RI CT IA PA NV NE NJ IN OH UT IL DE CO WV MD CA KS MO VA KY DC NC TN AZ OK NM AR SC AL GA MS TX LA AK FL HI Quartile Top quartile (Best: Iowa) Second quartile Third quartile Bottom quartile Source: The Commonwealth Fund’s calculations based on state’s rankings on access, quality, cost, healthy lives, and equity dimensions. Executive Summary ix Figure ES-3 Summary of Variations in Child Health System Performance Overall Potential to Lead Top quartile State Access Quality Costs Equity Rank* Healthy Lives Second quartile 1 Iowa 2 2 12 19 17 Third quartile 2 Vermont 6 6 44 1 1 Bottom quartile 3 Maine 14 5 46 3 2 4 Massachusetts 1 1 47 2 20 5 Ohio 5 8 34 10 31 6 Hawaii 6 26 5 11 41 6 New Hampshire 24 14 40 7 4 8 Rhode Island 3 4 49 5 31 9 Kentucky 13 21 32 12 18 10 Kansas 12 17 16 30 23 10 Wisconsin 9 11 38 14 26 12 Michigan 3 15 28 17 36 13 Nebraska 31 7 22 23 18 14 Connecticut 23 3 49 6 21 15 Alabama 9 10 8 28 48 16 South Dakota 27 16 22 36 11 16 Wyoming 22 27 37 18 8 18 Pennsylvania 17 9 42 8 37 18 Washington 21 34 32 20 6 20 West Virginia 11 19 39 4 43 21 North Dakota 30 25 21 32 9 22 Indiana 17 12 28 30 33 23 Minnesota 19 21 36 38 7 24 Virginia 31 23 8 35 25 25 New York 16 28 45 8 27 26 Tennessee 15 18 26 24 43 27 Utah 44 40 2 39 3 28 Maryland 35 24 31 12 28 29 Missouri 25 33 17 27 29 30 Montana 46 38 12 22 15 31 North Carolina 39 13 11 25 46 32 District of Columbia 8 32 51 15 38 33 Idaho 33 48 7 45 13 34 California 40 41 12 40 15 34 Colorado 48 36 17 42 5 36 South Carolina 20 35 20 33 41 37 Delaware 38 19 40 20 34 38 Georgia 37 29 6 36 47 39 Illinois 36 31 25 26 38 39 New Mexico 44 49 12 41 10 41 New Jersey 42 29 43 16 29 42 Alaska 27 44 47 29 13 42 Oregon 26 39 24 47 24 44 Arkansas 27 42 1 46 48 45 Nevada 48 50 2 51 21 46 Texas 50 42 28 44 12 47 Arizona 46 46 2 49 35 48 Louisiana 40 45 17 33 51 49 Mississippi 43 47 10 48 50 50 Florida 51 37 34 43 38 51 Oklahoma 33 51 26 49 45 *Final rank for overall health system performance across five dimensions. Source: The Commonwealth Fund’s calculations based on state’s rankings on access, quality, cost, healthy lives, and equity dimensions. x U.S. Variations In Child Health System Performance: A State Scorecard on multiple indicators across dimensions the past year; being able to access needed (Figure ES-3). Uninsured rates for children specialist care and services; and having a in these states are well above national personal doctor/nurse who usually/always averages, and more than double those in the spends enough time and communicates quartile of states with the lowest rates. Rates clearly, provides telephone advice and urgent for receipt of recommended preventive care care when needed, and follows up after are generally low in these states, while rates specialist care. of infant mortality and risk of developmental delay are often high. • Across states, better access to care is closely associated with better quality of care. Seven • There is wide variation in children’s access states—Massachusetts, Iowa, Rhode Island, to care and health care quality across the Ohio, Vermont, Alabama, and Wisconsin— United States. The proportion of children are national leaders in giving children who are uninsured ranges from 5 percent access to care and ensuring high-quality care in Michigan to 20 percent in Texas. The (Figure ES-4). proportion of children who have regular medical and dental preventive care ranges • There are strong regional patterns in child from 75 percent in Massachusetts to 46 health system performance. New England percent in Idaho. The proportion of children and the North-Central states perform hospitalized for asthma ranges from 55 per well on indicators of health care access, 100,000 children in Vermont to 314 per quality, and equity, while many western and 100,000 in South Carolina (among the 33 southern states have lower health care costs. states reporting this indicator). New England, Upper Midwest, East North- Central, and West North-Central states • Children’s access to medical homes— perform well on indicators measuring the primary care providers who deliver potential for children to lead healthy lives. health care services that are easily Yet, within any region, there are exceptions. accessible, family-centered, continuous, Alabama is in the top quartile of states in comprehensive, coordinated, and culturally terms of both access and quality. Texas and competent—varies widely across states. New Mexico perform well on child health Sixty-one percent of children in New outcomes, while Kentucky and West Virginia Hampshire, and over half of all children in perform well on measures of health system all the New England states, have a medical equity. Learning more about such exceptions home, compared with only one-third in to regional patterns may provide insights into Mississippi. Research shows that medical effective policies to support children’s health. homes are an effective way to improve health For example, Alabama was an early implementer care quality and reduce disparities by race, of SCHIP and provides additional coverage insurance status, and income.3 In this report, through Alabama Blue Cross Blue Shield for having a medical home is defined as having children in families with income just above at least one preventive medical care visit in SCHIP’s eligibility threshold. Executive Summary xi Figure ES-4. State Ranking on Access and Quality Dimensions State Ranking on Quality R2 = 0.49* State Ranking on Access *p<.05 Source: The Commonwealth Fund’s calculations based on state’s rankings on access dimension and quality dimension. Benchmarks set by leading states show there are Likewise, nearly 11 million additional children opportunities to improve health system performance would have a medical home to help coordinate care, to benefit children. If all states achieved top levels and 1.6 million fewer children ages 1 to 5 would on each dimension of performance, 4.7 million be at moderate-to-high risk for developmental more children would be insured and nearly 12 delays later in life. million more children would receive at least one medical and dental preventive care visit per year This report reveals critical areas in which state (Figure ES-5). More than 750,000 more children and federal policies are needed to improve child ages 19 to 35 months would be up-to-date on all health system performance for all U.S. families. recommended doses of five key vaccines, and more States that invest in children’s health reap the than 412,000 fewer children with special health benefits of having children who are able to learn care needs who needed specialist care would have in school and become healthy, productive adults. problems getting referrals to specialty care services. Other states can learn from models of high xii U.S. Variations In Child Health System Performance: A State Scorecard performance to shape policies that ensure all The indicators of child health care quality presented children are given the opportunity to lead long, here are largely parent-reported; however, data on healthy lives and realize their potential. clinical quality are necessary to paint a clear picture of state child health quality. Thus, the collection Further, investment in children’s health care of clinical data for children’s health care quality measurement and data collection at the state level is integral to future state and federal child health could enrich understanding of variations in child policy reform and could modify the state rankings health system performance. For many dimensions, provided in this report. Work currently under only a limited set of indicators is available. In the way should lay a firmer foundation for public and case of costs, measures used in this report are for private action. the total population and not specific to children. Figure ES-5. National Cumulative Impact if All States Achieved Top-State Rates If all states improved their performance to the level of the Indicator best-performing state for this indicator, then: 4,691,326 more children would be covered by health insurance (public or private), and therefore would be more likely to receive health care Children uninsured when needed Children ages 19–35 months received all 756,942 more children (ages 19 to 35 months) would be up-to-date on all recommended doses of five key vaccines recommended doses of five key vaccines Children with both medical and dental 11,775,795 more children (ages 0–17) would have both a medical and dental preventive care visits preventive care visit each year 10,858,812 more children (ages 0–17) would have a medical home to help Children with a medical home ensure that care is coordinated and accessible when needed Children with special health care needs 412,895 fewer children with special health care needs (ages 0–17) who who needed specialist care with problems needed specialist care would have problems getting referrals to specialty getting referrals to specialty care services care services Children at risk for developmental delays 1,613,347 fewer children (ages 1–5) would be at risk for developmental delays Source: The Commonwealth Fund’s calculations based on summation of differences between highest-achieving state and all other states for each indicator. Executive Summary xiii Introduction The early years of a child’s life are pivotal to future The report includes 13 key indicators of health and development. Disparities in health and children’s health system performance along the skills emerge during children’s first few years and dimensions of access, quality, costs, and the worsen with age.4 For these reasons and others, it is “potential to lead healthy lives.” Six of these critical that the nation’s health care system ensures indicators were included in the previously that all children have the opportunity to lead long, released State Scorecard, while others were drawn healthy, and productive lives. Our current health from government sources. The analysis gauges system, however, underperforms in comparison the equity of states’ child health care systems by with other industrialized countries.5 Even within measuring health disparities by insurance status, the United States, health care access, as well as family income, and race/ethnicity for two of these quality, costs, and equity, vary widely.6 indicators (receipt of preventive medical and dental visits in past year and percent of children with a This report examines performance variations medical home). among states’ child health systems, building on the previously published State Scorecard on All 50 states, plus the District of Columbia, are Health System Performance, prepared for The ranked on each indicator and on the five dimensions Commonwealth Fund Commission on a High of performance, using the same methodology Performance Health System.7 It offers insights into employed in the State Scorecard. The rankings states’ experiences and benchmarks against which for each dimension are then summed to derive an policymakers and other stakeholders can gauge the overall ranking for child health system performance. success of their efforts to ensure young families Figure 1 shows the indicators included, their range have access to high-quality, efficient, and equitable of variation across states, and the highest-achieving care. With a goal of focusing on opportunities to state on each indicator. (See “Appendix: Study improve, the analysis assesses performance relative Methodology” for further details.) to what is achievable, based on benchmarks drawn from the range of state health system performance. Introduction 1 Figure 1. Indicators of State Child Health System Performance Range of State All States Best Access Year Performance Median State (Bottom–Top) Children uninsured 2005– 2006 9.1 20.1–4.9 MI Low-income children uninsured 2005– 2006 16.6 34.5–7.0 DC Quality Children ages 19–35 months received all 2005 81.6 66.7–93.5 MA recommended doses of five key vaccines Children with both medical and dental preventive 2003 59.2 45.7–74.9 MA care visits Children with emotional, behavioral, or developmental problems received mental 2003 61.9 43.4–77.2 WY health care Children with a medical home 2003 47.6 33.8–61.0 NH Children needing specialty care, those whose personal doctor or nurse follows up after they get 2003 57.9 49.8–68.0 WV specialty care services Children with special health care needs who needed specialist care with problems getting referrals to 2001 22.0 33.5–13.5 SD specialty care services Hospital admissions for pediatric asthma 2002 176.7 314.2–54.9 VT per 100,000 children Costs State total personal health spending 2004 $5,327 $8,295–3,972 UT Family premium for employer-based health insurance 2005 $10,637 $8,334–11,924 ND Potential to Lead Healthy Lives Young children at moderate/high risk for 2003 23.6 32.9–16.4 VT developmental delay Infant mortality: deaths per 1,000 live births 2002 7.1 11.0–4.3 ME Equity Income 2003 -11 point gap -33.7–6.4 gap VT Race/Ethnicity 2003 -14.2 point gap -29.3–13.2 gap VT Insurance coverage 2003 -19.2 point gap -36.2–3.9 gap MA Source: State Variations in Child Health System Performance, The Commonwealth Fund, May 2008. 2 U.S. Variations in Child Health System Performance: A State Scorecard Findings Leading states consistently outperform lagging Conversely, the 13 states at the bottom quartile states on multiple child health indicators and of the overall performance ranking—Illinois, New dimensions. Thirteen states—Iowa, Vermont, Mexico, New Jersey, Alaska, Oregon, Arkansas, Maine, Massachusetts, Ohio, Hawaii, New Nevada, Texas, Arizona, Louisiana, Mississippi, Hampshire, Rhode Island, Kentucky, Kansas, Florida, and Oklahoma—lag well behind their Wisconsin, Michigan, and Nebraska—emerge at peers on multiple indicators. Uninsured rates for the top quartile of the overall children’s health children in these states are well above national system performance rankings. These states generally averages, and more than double those in the rank high on multiple indicators in each of the five quartile of states with the lowest rates. In these dimensions of performance assessed. Many have states, rates for receipt of recommended preventive among the lowest uninsured rates for children in care are generally low, while infant mortality and the nation (Figures 2 and 3). risk of developmental delay are often high. Findings 3 Figure 2. Summary of Variations in Child Health System Performance Top quartile Overall Potential to Lead Second quartile State Access Quality Costs Equity Rank* Healthy Lives Third quartile 1 Iowa 2 2 12 19 17 Bottom quartile 2 Vermont 6 6 44 1 1 3 Maine 14 5 46 3 2 4 Massachusetts 1 1 47 2 20 5 Ohio 5 8 34 10 31 6 Hawaii 6 26 5 11 41 6 New Hampshire 24 14 40 7 4 8 Rhode Island 3 4 49 5 31 9 Kentucky 13 21 32 12 18 10 Kansas 12 17 16 30 23 10 Wisconsin 9 11 38 14 26 12 Michigan 3 15 28 17 36 13 Nebraska 31 7 22 23 18 14 Connecticut 23 3 49 6 21 15 Alabama 9 10 8 28 48 16 South Dakota 27 16 22 36 11 16 Wyoming 22 27 37 18 8 18 Pennsylvania 17 9 42 8 37 18 Washington 21 34 32 20 6 20 West Virginia 11 19 39 4 43 21 North Dakota 30 25 21 32 9 22 Indiana 17 12 28 30 33 23 Minnesota 19 21 36 38 7 24 Virginia 31 23 8 35 25 25 New York 16 28 45 8 27 26 Tennessee 15 18 26 24 43 27 Utah 44 40 2 39 3 28 Maryland 35 24 31 12 28 29 Missouri 25 33 17 27 29 30 Montana 46 38 12 22 15 31 North Carolina 39 13 11 25 46 32 District of Columbia 8 32 51 15 38 33 Idaho 33 48 7 45 13 34 California 40 41 12 40 15 34 Colorado 48 36 17 42 5 36 South Carolina 20 35 20 33 41 37 Delaware 38 19 40 20 34 38 Georgia 37 29 6 36 47 39 Illinois 36 31 25 26 38 39 New Mexico 44 49 12 41 10 41 New Jersey 42 29 43 16 29 42 Alaska 27 44 47 29 13 42 Oregon 26 39 24 47 24 44 Arkansas 27 42 1 46 48 45 Nevada 48 50 2 51 21 46 Texas 50 42 28 44 12 47 Arizona 46 46 2 49 35 48 Louisiana 40 45 17 33 51 49 Mississippi 43 47 10 48 50 50 Florida 51 37 34 43 38 51 Oklahoma 33 51 26 49 45 *Final rank for overall health system performance across five dimensions. Source: The Commonwealth Fund’s calculations based on state’s rankings on access, quality, cost, healthy lives, and equity dimensions. 4 U.S. Variations in Child Health System Performance: A State Scorecard Figure 3. State Ranking on Child Health System Performance WA NH ME MT ND VT OR MN ID SD WI NY MA WY MI RI CT IA PA NV NE NJ IN OH UT IL DE CO WV MD CA KS MO VA KY DC NC OK TN AZ NM AR SC AL GA MS TX LA AK FL HI Quartile Top quartile (Best: Iowa) Second quartile Third quartile Bottom quartile Source: The Commonwealth Fund’s calculations based on state’s rankings on access, quality, cost, healthy lives, and equity dimensions. Findings 5 Iowa: National Leader in Child Health Iowa, since primary care providers are the first point of contact for all child health problems, physical and System Performance mental, the state has decided that allowing them to provide some care, presumably short-term care for Iowa ranks first overall on children’s health system uncomplicated mental health problems, is a workable performance and second on the measures of health strategy that likely increases access. care access and quality. The state also ranks among the top states in the annual KIDS COUNT Data Book.8 State leaders also have focused on childhood outcomes by promoting the federal Early and Periodic Screening, Iowa has a longstanding commitment to children. In Diagnosis, and Treatment (EPSDT) program. In 1993, the past decade, the state paid particular attention to an EPSDT Interagency Collaborative was formed with the needs of its youngest residents, from birth to age a fourfold purpose: to increase the number of Iowa 5. After piloting a variety of early childhood preventive children enrolled in EPSDT; to increase the percentage programs in the early 1990s to identify and serve of children who receive well-child screenings; to ensure at-risk children and families, the Iowa Legislature effective linkages to diagnostic and treatment services; established a statewide initiative to fund designated and to promote the overall quality of services delivered “local empowerment areas” across the state to create through EPSDT. As a result of these efforts, statewide local partnerships among clinicians, parents, child care rates of well-child screenings rose from 9 percent in representatives, and educators focused on preventive 1991 to 95 percent in 2005.9 services. In 2000, Iowa Governor Vilsack formed the Governor’s Children’s Cabinet, which comprised the directors of the five state departments responsible for Iowa’s State Children’s Health Insurance Program children’s services, to serve as the leadership body to targets two groups: all children, regardless of age, in implement the state’s vision. families with income levels up to 133 percent of the federal poverty level are covered through an expansion Additionally, Iowa‘s Medicaid program has a separate of Medicaid; meanwhile, all children in families with managed care program for mental health services open income from 133 percent to 200 percent of the poverty to all recipients who have a mental health diagnosis, level are covered through private insurance, in a except the elderly. Children with emotional or mental program known as hawk-i. Iowa contracts with private health issues are permitted to have 12 visits a year to health plans to provide covered services to children their primary care physician before services must be enrolled in the hawk-i program, with little or no cost- provided by an approved managed behavioral health sharing for families. Iowa’s innovative policies and care provider. In general, primary care providers are not public–private partnerships to improve children’s eligible to be paid for providing mental health care when health care can serve as evidence-based models for an insurer has carved out a separate mental health/ other states to move toward a higher-performing child behavioral health managed care contract. However, in health system.10 Access: Medicaid and The number of uninsured children has declined in most states following enactment of the State SCHIP Are Critical Children’s Health Insurance Program (SCHIP) in Insurance coverage for children varies widely 1997. Since then, the number of states with more across the states. The proportion of children who than 16 percent of children uninsured has declined are uninsured ranges from 5 percent in Michigan from 12 to five.11 Despite its success, the program to 20 percent in Texas (Figure 4). Meanwhile, the hit a political stalemate over reauthorization in proportion of children in families with incomes at 2007, with President Bush and the Democratic or below twice the federal poverty level who are majority in Congress divided over issues related uninsured ranges from 7 percent in the District to the SCHIP income eligibility level and amount of Columbia to 35 percent in Colorado—a of federal funding. Resolution of the controversy fivefold variation. 6 U.S. Variations in Child Health System Performance: A State Scorecard was postponed with an extension of the program percent of the federal poverty level, and to children to March 2009.12 ages 6 to 18 living in families with incomes at or below 100 percent of poverty. SCHIP gives states Reaching agreement over the future direction flexibility in determining eligibility levels above of SCHIP may be essential to continued progress Medicaid’s mandated income coverage levels, and in covering uninsured children. The U.S. Census many states have adopted more generous eligibility Bureau reported in August 2007 that 8.7 million criteria. Thus, children’s risk of being uninsured children were uninsured in 2006, up from 8.0 depends in some part on where they live, due to million in 2005—an increase of 9 percent in just the wide variation across states in coverage of low- one year.13 income children. Medicaid and SCHIP play crucial roles in In this analysis, states’ ranking on access to care providing health insurance for children in low- is based on the uninsured rates among all children, income families, for whom private plans are often as well as uninsured rates among children in unavailable or unaffordable. States are required to families with incomes at or below twice the federal extend Medicaid eligibility to children under 6 years poverty level. New England and states in the East old living in families with incomes at or below 133 North-Central and West North-Central regions Figure 4. Percent of Uninsured Children Declined Since Enactment of SCHIP in 1997, but Gaps Remain 1999–2000 2005–2006 NH ME WA VT NH ME ND WA VT MT MN MT ND OR MN NY MA WI OR NY MA ID SD RI WI MI ID SD WY MI RI PA CT IA NJ WY CT PA NJ NE OH IA IN DE NE OH NV IN DE IL WV VA MD NV UT IL MD CO DC UT WV VA CA KS MO KY CO DC CA KS MO KY NC TN NC OK TN AR SC AZ NM OK AR SC MS AL GA AZ NM MS AL GA TX LA TX LA FL FL AK AK HI Quartile HI 16% or more 10%–15.9% 7%–9.9% Less than 7% Source: The Commonwealth Fund’s two-year averages 1999–2000, updated with 2007 CPS correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys. Findings 7 of the U.S. are among the best performers on the More than just insurance status affects children’s dimension of access to care (Figure 5). But there are access to health care. Variables such as waiting notable exceptions. For example, Alabama is in the times for appointments when sick or in need of top quartile of states—undoubtedly reflecting that care, average copayments for preventive care, and the state was among the first to implement SCHIP residence in medically underserved communities and supplement it with additional coverage, also have an impact on families’ access to health care. provided by Alabama Blue Cross Blue Shield, for Better state-level data on these dimensions of care children in families just above the SCHIP income would provide a richer picture of children’s actual eligibility threshold. access to care. Access Figure 5. State Ranking on Access Dimension WA NH ME MT ND VT OR MN ID SD WI NY MA WY MI RI CT IA PA NJ NV NE OH UT IL IN DE CO WV MD CA KS MO VA KY DC NC AZ OK TN NM AR SC GA MS AL TX LA AK FL HI Quartile Top quartile (Best: Massachusetts) Second quartile Third quartile Bottom quartile Access dimension includes: percent of children uninsured and percent of low-income (below 200% of the federal poverty level) children uninsured. Source: U.S. Census Bureau, Current Population Survey, 2007, 2006 and 2005 Annual Social and Economic Supplements. 8 U.S. Variations in Child Health System Performance: A State Scorecard Vermont’s Progressive Approach to insurance may buy into a private insurance plan called Catamount Health; individuals or families with incomes Serving Children below 300 percent of poverty may also receive premium Ranked second overall on children’s health and first in assistance to buy this coverage. The Act also increased terms of equity and child health outcomes, Vermont has Medicaid reimbursement rates for preventive care, long placed a high priority on children. In 1989, the state dental care, and some other developmental services. enacted the Dr. Dynasaur program, which expanded health insurance coverage to children up to age 17 in Vermont is also home to the Vermont Child Health families earning less than 225 percent of the federal Improvement Project (VCHIP), a regional partnership poverty level, as well as pregnant women in families of professional society chapters; the Department earning less than 200 percent of poverty. The program of Public Health; the state’s Medicaid agency; the operates through the private health insurance market and University of Vermont’s Department of Pediatrics has a strong emphasis on prenatal and preventive care. faculty; the Banking, Insurance, Securities and Health Care Administration; and three Vermont managed care In 2006, Vermont expanded SCHIP income eligibility organizations. These public and private partners use levels for children in families with incomes up to 300 measurement-based efforts and a systems approach percent of the federal poverty level. The Vermont to improve the quality of children’s health care. VCHIP Health Care Affordability Act of 2006 introduced shares lessons learned and other findings with public reforms through the state’s Medicaid program, health agencies and policymakers to inform decision- reducing premiums for children in public programs making, enhance services, and target resources. by half. Individuals and families with incomes above Disease management programs are also being 300 percent of poverty who are not eligible for public introduced into public insurance plans. Quality: Wide State and West rank lowest on this dimension, while Variation, with Shortfalls states in the Upper Midwest, East North- Central and West North-Central, and Northeast Across Nation regions rank highest. The five highest-ranking Families expect that their health care providers will states on quality, in order of their ranking, were recommend and provide effective services, that Massachusetts, Iowa, Connecticut, Rhode Island, their care will be well coordinated, and that those and Maine. delivering services will be responsive to their needs. This report includes seven indicators of health care Still, even in the best states, performance falls quality, including four that assess the extent to far short of recommended standards. The share of which children receive the “right care” (preventive children receiving at least one dental and medical care and care delivered according to medical preventive care visit in the past year ranges from 75 guidelines) and three that assess care coordination percent in Massachusetts to less than half (46%) in (access to a medical home, referrals to specialty Idaho. Childhood immunization rates range from care services, and follow-up after specialized care). 94 percent of all children ages 19 to 35 months in As with the other dimensions presented, there Massachusetts to less than 75 percent of children in are wide variations among states in terms of the the bottom five states. The provision of children’s quality of children’s health care (Figure 6). There are mental health care services also varies widely also distinct geographic patterns in states’ overall across states. Only 43 percent of children with rankings on child health care quality. With some emotional, behavioral, or developmental problems notable exceptions, states in the South, Southwest, received some mental health care in Texas, while Findings 9 77 percent of all children in Wyoming who needed culturally sensitive services.14 Children who have such services received care. a regular practitioner are more likely to adhere The American Academy of Pediatrics (AAP) to prescribed medications, receive preventive recommends that all children and adolescents have care, and have care that is well coordinated a primary care professional (or a multidisciplinary and family-centered; they are also less likely team for children with severe chronic illnesses) to visit the emergency department and be whose practice serves as a medical home that hospitalized. In addition, their practitioner is provides accessible, family-centered, continuous, more likely to recognize health problems and comprehensive, coordinated, compassionate, and track information.15 Quality Figure 6. State Ranking on Quality Dimension WA NH ME MT ND VT OR MN ID SD WI NY MA WY MI RI CT IA PA NV NE NJ IN OH UT IL DE CO WV MD CA KS MO VA KY DC NC OK TN AZ NM AR SC AL GA MS TX LA FL AK HI Quartile Top quartile (Best: Massachusetts) Second quartile Third quartile Bottom quartile Quality dimension includes: percent of children 19–35 months who received all recommended doses of five key vaccines; children with both a medical and dental preventive visit in past year; children with emotional, behavioral, or developmental problems received mental health care; children with a medical home; children whose personal doctor or nurse follows-up after they get specialty care services; hospital admissions for pediatric asthma per 100K children; and children with special health care needs with problems getting referrals to specialty care services. Note: Medical home is defined as having at least one preventive medical care visit in the past year; being able to access needed specialist care and services; and having a personal doctor/nurse who usually/always spends enough time and communicates clearly, provides telephone advice and urgent care when needed, and follows up after specialist care. Source: 2003 National Survey of Children's Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. 10 U.S. Variations in Child Health System Performance: A State Scorecard A majority of children and adolescents do after specialty care services, with West Virginia not receive care that meets all of the elements of a topping the charts with 68 percent. In Oregon, medical home as defined by pediatric experts. Rates parents of only about half of children said their of children with a medical home are regionally child’s personal doctor or nurse followed up after clustered, ranging from over half of all children in specialty care services. New England states to only a third in Mississippi. Barriers include lack of adequate reimbursement Care coordination is especially important for care coordination services, lack of available to children with special health care needs and community services, and lack of collaboration their families, who often need help in accessing among different state programs, private health and integrating services from a complex web of plans, and providers serving children.16 For the providers and programs.17 According to parents, purposes of this report, having a medical home is the proportion of children with special health care defined as having at least one preventive medical needs who experienced problems getting referrals care visit in the past year; being able to access to specialty care services ranged from a high needed specialist care and services; and having a of 34 percent in New Mexico to 14 percent in personal doctor/nurse who usually/always spends South Dakota. enough time and communicates clearly, provides telephone advice and urgent care when needed, In some cases, hospital admissions can be and follows up after specialty care. averted through effective management of chronic conditions like asthma, and through timely, One component of a medical home is follow- preventive well-child care.18 Access to primary care up care after children receive care from a specialist. outside of usual office hours also can help children Across the United States, parents of only 58 percent avoid costly hospitalizations or emergency care. of children report that their child’s personal doctor Among the 33 states that collect all-payer hospital or nurse provided follow-up services after specialty data, rates of hospital admissions for childhood care. Even among the top five states, parents of asthma range from a low of 55 per 100,000 only 65 percent of children, on average, reported children in Vermont to 314 per 100,000 in South that their personal doctor or nurse followed up Carolina—nearly six times higher (Figure 7). Massachusetts Health Quality of physicians, hospitals, health plans, purchasers, consumers, and government agencies working together Partners: Success Through to promote improvement in the quality of health care Collaboration services. The coalition convened a large number of Massachusetts health care organizations—including State policies and regional collaborations can make a the Massachusetts Department of Public Health, the significant difference in the quality of children’s health Massachusetts Medical Society, the Massachusetts care. For example, Massachusetts achieved the highest Hospital Association, physician specialty societies, performance in the area of health care quality in part and several major health plans—to endorse a set of because of the state’s many local quality improvement preventive care recommendations and immunization entities, such as Massachusetts Health Quality guidelines for children, and then disseminated them to Partners (MHQP). MHQP is a broad-based coalition over 7,000 clinicians in the state. Findings 11 Quality Figure 7. State Rates of Hospital Admissions for Pediatric Asthma per 100,000 Children, 2002 Rate for children 0–17 years 350 300 250 200 150 100 50 0 Je ee nn lo y l a nt ia ut ew ky ar rk a od Te ia Isl s Te iss d N e ri th irg a hi na as al on us a Ha tts C an ii M ra s ar do d Il o eo is W Ca inia irg a N reg t ra n a Io h M a isc ine ne in ev a W Ar da O on e xa ol sa K a nn ou Pe F rse G lino eb o a hi sy rid in t V lin or V rgi M n N sot ch rni an sk w C Yo in ns Ke van in So N uc e w M C ngt a ew ss as izo Ut a W a O ol rm es ro sa ifo M o yl o Ve h Rh N Source: 2002 Healthcare Cost and Utilization Project State Inpatient Databases (AHRQ, HCUP-SID 2002). Across states, better access to care and higher comprehensive health plans, which most states rates of insurance are closely associated with better do.19 A recent Commonwealth Fund report found quality. States with the lowest rates of uninsured that only a handful states are now using EQROs children tend to score highest on measures of to assess children’s preventive and developmental preventive care and coordination of care, as well services, but more states could do so if a key stake- as other child health quality indicators (Figure 8). holder elects to champion the issue and if state staff Preventive care for children occurs at well-child and EQROs have the relevant knowledge base.20 care visits—which necessitates health coverage and the ability to pay for a primary care visit. Three of the five leading states in the access Access and quality preventive care for children are dimension—Massachusetts, Iowa, and Rhode intrinsically linked. Island—also rank among the top five states in terms of quality. Moreover, states with low quality States with large Medicaid enrollments and high rankings tend to have high rates of uninsured rates of poverty can leverage federal regulations that children. This cross-state pattern points to the encourage state Medicaid agencies to use “external importance of affordable access as a first step for quality review organizations” (EQROs) to help ensuring that families obtain essential care and implement strategies for assessing the quality of receive care that is well coordinated and patient- services provided to Medicaid beneficiaries enrolled centered. In states where more children are insured, in managed care plans. States are required to use children are more likely to have a medical home an EQRO if their Medicaid program contracts with and receive recommended preventive care. 12 U.S. Variations in Child Health System Performance: A State Scorecard Figure 8. State Ranking on Access and Quality Dimensions State Ranking on Quality R2 = 0.49* State Ranking on Access *p<.05 Source: The Commonwealth Fund’s calculations based on state’s rankings on access dimension and quality dimension. Costs: A Major Concern in the Northeast are among the most costly (Figure in All States 9). The five top-performing states are Arkansas, While the rising costs of care are of concern to Arizona, Nevada, Utah, and Hawaii. Each of these families across the nation, there is wide variation states has relatively low rates of total personal in both per-capita health care costs and insurance health care spending per capita and low average premiums. Health systems should ensure that family premiums for employer-sponsored health families have access to high-quality care while insurance. Notably, of these five, only Hawaii is a minimizing the costs of care. The indicators in this top-ranked state overall; the other four fall in the area target two important measures of costs: total bottom half of states. personal health care spending per capita, and the average family premium for employer-based health Per-capita health care spending can shed light coverage. Neither of these indicators is specific to on differences in the organization and delivery children. A comprehensive evaluation of health of health services, as well as on the demographic system efficiency would compare broader measures and economic factors contributing to health of inappropriate care, waste, and administrative care spending patterns. State spending on health overhead—but such measures for child health care care ranges from a high of $8,295 per capita in are not available at the state level. Washington, D.C., to a low of $3,972 in Utah (Figure 10). Improving care and developing more Overall, the Southwest and Southeast rank efficient care systems have the potential to generate best on these measures—that is, these regions major savings. have the lowest costs or premiums—while states Findings 13 Costs Figure 9. State Ranking on Costs Dimension WA NH MT VT ME ND OR MN ID SD WI NY MA WY MI RI CT IA PA NV NE NJ OH UT IL IN DE CO WV MD CA KS MO VA KY DC NC OK TN AZ NM AR SC AL GA MS TX LA AK FL Quartile HI Top quartile (Best: Arkansas) Second quartile Third quartile Bottom quartile Costs dimension includes: total personal health spending per capita and average family premium for employer-sponsored health insurance. Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group and Kaiser Family Foundation State Health Facts. Employer-based health insurance is becoming covered under private insurance and public less and less affordable for the American family. programs.22 Yet, states differ in the extent to which Health insurance premiums have increased rapidly they regulate health insurance markets. North over the recent past, growing a cumulative 78 Dakota, which has the lowest average premium percent between 2001 and 2007 and far outpacing for family employer-sponsored insurance, requires cumulative wage growth of 19 percent over the insurers in the small group market to cover same period.21 The mean family premiums for everyone, regardless of health status. Rhode Island, employer-sponsored insurance vary widely among which has the most costly premiums, strongly the states, ranging from $8,334 in North Dakota regulates the private health insurance market to $11,924 a year in Rhode Island (Figure 11). and includes a variety of benefit mandates for women and young children.23 So some variation For the most part, variation in insurance in health insurance premiums may reflect states’ premiums reflects differences in the cost of health commitment to sharing risks more broadly or care and health insurance, rather than benefits investing in preventive care for children. 14 U.S. Variations in Child Health System Performance: A State Scorecard Costs Figure 10. State Variation: Personal Health Care Spending per Capita, 2004 Total personal health care spending in dollars $8,295 $8,400 $7,200 $6,091 $6,000 $5,327 $4,800 $4,312 $3,972 DC $3,600 $2,400 UT $1,200 $0 Best state Top 5 Median Bottom 5 Last state average average Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. Costs Figure 11. State Variation: Average Family Premium for Employer-Based Health Insurance, 2005 Total dollars per enrolled employee $11,924 $12,000 $11,650 $10,637 $9,139 $8,334 $8,000 RI $4,000 ND $0 Best state Top 5 Median Bottom 5 Last state average average Source: Kaiser Family Foundationt State Health Facts. Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. 2005 Medical Expenditure Panel Survey (MEPS)–Insurance Component. Tables II.D.1, II.D.2, II.D.3 available at: Medical Expenditure Panel Survey (MEPS), accessed August 8, 2007. Findings 15 Among the five states with the lowest family federal and state governments alike, and research premiums and per capita personal health spending, using Medicare data has demonstrated an inverse only Hawaii is a top-ranked state overall. However, relationship between spending and quality among across all states, states with higher spending rank older adults.24 Yet, the results presented here higher on the child quality dimension (Figure suggest this may not be the case for children. 12). By contrast, higher spending is not correlated More research is needed to explore the relationship with higher quality for the overall population. between health care spending and the quality of Rising health care costs are a concern for both children’s health care. Figure 12. State Ranking on Costs and Quality Dimensions R2 = 0.22* State Ranking on Quality State Ranking on Costs *p<.05 Source: The Commonwealth Fund’s calculations based on state’s rankings on cost dimension and quality dimension. 16 U.S. Variations in Child Health System Performance: A State Scorecard Equity: Quality Differs home and receipt of at least one preventive medical and dental visit in the past year. by Race/Ethnicity and by Income and There are disparities by income and insurance Insurance Status status in most states. The gaps are widest in Through programs such as Medicaid and SCHIP, states that perform poorly overall on quality and all states devote considerable resources to the access indicators (Nevada, Oklahoma, Arizona, provision of care for children in low-income and Mississippi). There are also strong regional families. Such children are at increased risk for differences: New England and the Mid-Atlantic poor health due to lack of access to timely medical region significantly surpass the South and care and greater risk of accidents and illness.25 Southwest on all equity indicators. Still, some poorer states, such as Kentucky and West Virginia, In recognition that good-quality care can rank in the top quartile of the equity ranking help disadvantaged children become contributing (Figures 13 and 14). This suggests that states members of society, Medicaid’s EPSDT program facing similar demographics and challenges, such provides comprehensive preventive services to as Mississippi and Arkansas, can effectively address covered children. EPSDT is the only major disparities and deliver equitable care. insurance benefit package designed explicitly to meet the needs of children.26 Along with SCHIP, Access to, and quality of, child health care the standardized benefits of the EPSDT program varies by income and insurance: lower-income represent policy strategies that have successfully families and uninsured children face more access reduced state variation in access to children’s health problems and thus receive lower-quality care across care, and thus the availability of quality preventive most states. On average, 65 percent of uninsured care for vulnerable families across the nation. and 51 percent of poor children (below 100 Other effective policy strategies to ameliorate percent of the federal poverty level) did not receive health disparities among low-income and minority recommended preventive services. By comparison, families include increasing eligibility levels for 37 percent of privately insured children and public coverage and eliminating enrollment 30 percent of children in families with income and retention barriers. In addition, states could exceeding four times the poverty level failed to mandate minimum benefits for all child health receive such care. The pattern extends to the insurance, require child health plans to report second indicator included here, percent of children on the quality of care, and make quality reports with a medical home. On average, 77 percent of available to families, providers, and purchasers. uninsured children and 70 percent of poor children (those in families with income below 100 percent This analysis gauges the equity of states’ child of poverty) do not have a regular medical home to health care systems by measuring differences coordinate their care, compared with 47 percent between low-income, uninsured, and minority of privately insured and 42 percent of children populations and national averages. It uses two in families with higher incomes (more than 400 indicators: percent of children with a medical percent of poverty). Findings 17 Equity Figure 13. State Ranking on Equity Dimension WA NH MT VT ME ND OR MN ID SD WI NY MA WY MI RI CT IA PA NV NE NJ IN OH UT IL DE CO WV MD CA KS MO VA KY DC NC OK TN AZ NM AR SC AL GA MS TX LA AK FL Quartile HI Top quartile (Best: Vermont) Second quartile Third quartile Bottom quartile Equity dimension is: the percentage point difference or “gaps” for each vulnerable subgroup (i.e., minority, low-income, uninsured) compared with the U.S. average for the full population for each of two indicators: percent of children with medical home and percent of children with at least one preventive and dental visit in past year. Source: National Survey of Children's Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. In addition, performance on these indicators medical homes were 14 percentage points higher varies by minority group across all states. Minority among black children and 23 percentage points children often have lower incomes and are more higher among Hispanic children than white children. likely to be uninsured than whites; thus, the disparities observed among minorities also reflect Across the United States, minority children differences related to income and insurance status. are also at great risk of missing recommended Hispanics tend to have the highest uninsured rates preventive care. On average, 51 percent of and are the least likely to report a regular source Hispanic children did not receive a preventive of care among U.S. race/ethnic population groups. medical or dental care visit in the past year. The Both black and Hispanic children are at high risk of gaps were generally widest in states with the highest lacking a medical home: rates of children lacking uninsured rates. 18 U.S. Variations in Child Health System Performance: A State Scorecard Figure 14. Equity Dimension: Disparities by Income, Insurance Status, and Race/Ethnicity Top quartile Overall Rank on Insurance Race/Ethnicity State Income Equity Second quartile Dimension* Coverage Equity Equity Third quartile 1 Vermont 1 2 1 2 Massachusetts 4 1 5 Bottom quartile 3 Maine 4 8 3 4 West Virginia 3 12 1 5 Rhode Island 6 4 7 6 Connecticut 8 7 4 7 New Hampshire 2 4 14 8 New York 18 6 5 8 Pennsylvania 9 3 17 10 Ohio 15 9 11 11 Hawaii 12 17 9 12 Kentucky 10 14 15 12 Maryland 21 9 9 14 Wisconsin 15 9 17 15 District of Columbia 11 26 8 16 New Jersey 28 14 11 17 Michigan 24 18 23 18 Wyoming 18 32 16 19 Iowa 26 12 29 20 Delaware 25 22 21 20 Washington 27 30 11 22 Montana 31 23 17 23 Nebraska 7 43 24 24 Tennessee 13 33 33 25 North Carolina 17 29 34 26 Illinois 34 23 27 27 Missouri 42 18 25 28 Alabama 13 35 39 29 Alaska 43 14 32 30 Indiana 20 27 43 30 Kansas 35 21 34 32 North Dakota 33 20 38 33 Louisiana 37 39 17 33 South Carolina 21 25 47 35 Virginia 30 35 31 36 Georgia 21 35 49 36 South Dakota 38 30 37 38 Minnesota 40 27 39 39 Utah 28 45 34 40 California 44 42 22 41 New Mexico 32 40 39 42 Colorado 50 34 28 43 Florida 49 38 26 44 Texas 40 51 29 45 Idaho 38 40 51 46 Arkansas 36 47 48 47 Oregon 47 44 45 48 Mississippi 44 48 45 49 Arizona 47 50 42 49 Oklahoma 44 45 50 51 Nevada 51 49 43 *Equity rank on insurance, income, and race is the average difference between the US average for the indicators (medical home and preventive care) and each state’s uninsured group, most vulnerable non-white group, or most vulnerable low-income (0–99% FPL or 100%–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. Source: National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. Findings 19 Some states rank low on measures of equitable states with relatively homogeneous populations, care for racial/ethnic minorities, as a result of large such as Maine, Vermont, and Wyoming, often had shortfalls for certain minority groups that comprise few subgroups for ranking. However, the absence relatively small shares of their total populations. of race/ethnicity data for some states appears to For example, Minnesota’s scores were often low for have little impact on equity rankings. Overall, a group that included Asian Americans and Native the rankings for racial and ethnic disparities Americans. For these states, improvement efforts closely follow rankings observed in the income focused on these groups could substantially reduce and insurance analyses. States in which low- health disparities. income and uninsured groups fared better tend to have the smallest gaps for minority subgroups. This analysis of racial and ethnic disparities As a result, the equity rankings remain similar, focuses on subgroups for which there were regardless of whether racial and ethnic disparities sufficient data for comparisons. As a result, small are considered. 20 U.S. Variations in Child Health System Performance: A State Scorecard Potential to Lead The analysis found a wide range in states’ ability to promote healthy lives for their children, with Healthy Lives: Distinct distinct regional patterns. Southeastern states Regional Patterns consistently underperform on this dimension, Ensuring that children and families have access to while states in the West and Northeast do well services that can promote early childhood health (Figure 15). Improving health outcomes is a and development is likely to pay off over a lifetime. challenge for health care and public health systems This report uses two indicators to assess how well as states grapple with underlying population states support their children’s potential to lead risks, such as rising rates of obesity or high levels healthy lives: rates of infant mortality and risk of poverty, that put children and families’ health for developmental delay among young children. in jeopardy. Healthy Lives Figure 15. State Ranking on Potential to Lead Healthy Lives WA NH ME MT ND VT OR MN ID SD WI NY MA WY MI RI CT IA PA NV NE NJ OH UT IL IN DE CO WV MD CA KS MO VA KY DC NC TN AZ OK NM AR SC AL GA MS TX LA AK FL Quartile HI Top quartile (Best: Vermont) Second quartile Third quartile Bottom quartile Healthy Lives dimension includes: percent of young children at moderate/high risk for developmental delay and infant mortality (deaths per 1,000 live births). Source: National Vital Statistics System - Linked Birth and Infant Death Data (NCHS, NVSS n.d.). Reported in the 2005 National Healthcare Quality Report (AHRQ 2005) and National Survey of Children's Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. Findings 21 There is a twofold range across states in for a developmental delay, compared with 16 infant mortality rates (Figure 16). Rates in the percent of young children in Vermont. If not states with the lowest mortality rates (Maine, diagnosed and addressed, developmental delays Vermont, Massachusetts, New Hampshire, Iowa, can lead to serious problems for families, schools, and Minnesota) are 50 percent below those in and communities. states with the highest rates (Washington, D.C., Mississippi, Louisiana, Tennessee, and South Child health system performance is only Carolina). If the latter states could achieve the one of many forces that shape health status and same infant mortality rates as the top-performing longevity. Family history, immigration status, states, many lives could be saved. and environment including risks for obesity and asthma may also affect state-level population The analysis also found a twofold difference health indicators. Public health policies, including in rates of children ages 1 to 5 who are at risk mandated screening for developmental delays with for developmental delay. Thirty-three percent of a standardized assessment tool, can help promote Louisiana children are at moderate-to-high risk long, healthy lives. Healthy Lives Figure 16. Infant Mortality by State, 2002 Deaths per 1,000 live births U.S. Average = 7.1 deaths per 1,000 25 20 15 DC 11.0 9.9 10 7.1 4.3 4.8 DC 5 ME 0 Best state Top 5 Median Bottom 5 Last average average state Quartile (range) Top quartile (4.3–5.8) Best: Maine Second quartile (6.0–7.0) Third quartile (7.1–7.9) Bottom quartile (8.1–11.0) Source: National Vital Statistics System - Linked Birth and Infant Death Data (NCHS, NVSS n.d.). Reported in the 2005 National Healthcare Quality Report (AHRQ 2005). 22 U.S. Variations in Child Health System Performance: A State Scorecard Cumulative Impact of a Higher-Performing Child Health Care System All states have substantial room to improve their features of a child health care system and population child health care system. On some indicators, even factors such as socioeconomic demographics the best-performing states are performing at levels contribute to performance variations will inform well below what should be achievable. Fifteen efforts to improve. states—Iowa, Vermont, Maine, Massachusetts, New Hampshire, Ohio, Hawaii, Rhode Island, The range of performance is often wide across Kentucky, Kansas, Wisconsin, Michigan, Alabama, states, with a twofold to threefold or greater Connecticut, and Nebraska—emerge at the top spread from top to bottom. The variability extends quartile of the overall performance rankings. These to many of the 13 indicators across the five states generally rank high on multiple indicators dimensions of health system performance: access, along each of the five dimensions assessed. quality, costs, equity, and the potential to live healthy lives. Improving performance across the Conversely, the 12 states at the bottom quartile nation to levels achieved by the leading states could of the overall performance ranking—Illinois, New increase the potential for children to lead healthy Jersey, Alaska, Oregon, Arkansas, Nevada, Texas, lives, improve the quality of life for families, and Arizona, Louisiana, Mississippi, Florida, and enhance the value gained from our substantial Oklahoma—lag well behind their peers on multiple investment in health care (Figure 17). indicators across dimensions. Understanding how Figure 17. National Cumulative Impact if All States Achieved Top-State Rates If all states improved their performance to the level of the Indicator best-performing state for this indicator, then: 4,691,326 more children would be covered by health insurance (public or private), and therefore would be more likely to receive health care Children uninsured when needed Children ages 19–35 months received all 756,942 more children (ages 19 to 35 months) would be up-to-date on all recommended doses of five key vaccines recommended doses of five key vaccines Children with both medical and dental 11,775,795 more children (ages 0–17) would have both a medical and dental preventive care visits preventive care visit each year 10,858,812 more children (ages 0–17) would have a medical home to help Children with a medical home ensure that care is coordinated and accessible when needed Children with special health care needs 412,895 fewer children with special health care needs (ages 0–17) who who needed specialist care with problems needed specialist care would have problems getting referrals to specialty getting referrals to specialty care services care services Children at risk for developmental delays 1,613,347 fewer children (ages 1–5) would be at risk for developmental delays Source: The Commonwealth Fund’s calculations based on summation of differences between highest-achieving state and all other states for each indicator. Cumulative Impact of a Higher-Performing Child Health Care System 23 The United States would cover about 4.7 care needs who needed specialist care would have million additional children through public or problems getting referrals to specialty care services. private health insurance if all states’ coverage About 11 million more children would have a rates mirrored those in Massachusetts—cutting medical home to help coordinate care. the national rate of uninsurance among children in half. If all states reached the level of heath If all states reached the low levels of risk for care quality achieved in Massachusetts, nearly 12 developmental problems achieved by Vermont, million additional children would receive at least nearly 1.6 million fewer children ages 1 to 5 would one medical and dental preventive care visit each be at moderate-to-high risk for developmental year, thus reducing preventable health problems delay later in life. While some savings would be like developmental disability and poorly controlled offset by the costs of health care interventions and asthma. Similarly, some 750,000 more children insurance coverage expansions, there would be a ages 19 to 35 months would be up-to-date on all net gain in value from having a higher-performing recommended doses of five key vaccines, and more health system. than 412,000 fewer children with special health 24 U.S. Variations in Child Health System Performance: A State Scorecard A Call to Action: Federal and State Collaboration Benchmarks set by leading states, as well as • Medical homes—primary care providers exemplary models within the United States, show that deliver health care services that are that there are crucial opportunities to ensure that accessible, family-centered, continuous, all American families have high-quality, affordable comprehensive, coordinated, and culturally health care. This analysis demonstrates the impor- competent—are an efficient way of tance of collecting data on children across all states improving health care quality and reducing through use of standard measures and methods. disparities. States can strengthen their health system by ensuring that every child has a Variations in state child health system performance medical home. point to six important findings: • Across states, better access to care is closely • High performance is possible. States that associated with better quality of care. Seven excel typically have policies and programs states—Massachusetts, Iowa, Rhode Island, in place that are dedicated to improving Ohio, Vermont, Alabama, and Wisconsin— children’s health. Medicaid and SCHIP are are national leaders in giving children access critical to achieving high rates of insurance to care and ensuring high-quality care. coverage for low-income children. • While there are strong regional patterns in • Leading states consistently outperform child health system performance, examples lagging states on multiple child health of excellence exist within every region. indicators and dimensions. States achieve Even in regions with the most challenging synergy across dimensions of health system conditions—high poverty rates, a large performance. For example, high rates of proportion of minority children, prevalent insurance coverage contribute to improved childhood obesity, or difficult environmental quality and equity. health conditions—there are examples of high performance, such as Alabama • There is wide variation in child health care and Kentucky. States can learn from best access and quality across the United States. practices around the nation and within their Rates of uninsured children vary fourfold own region. across the states, and hospitalization rates for pediatric asthma vary sixfold. A Call to Action: Federal and State Collaboration 25 Further, investment in children’s health care system. Adequate funding of SCHIP can help measurement and data collection at the state level all states expand insurance coverage for children. could enrich understanding of variations in child National policies can foster more efficient insurance health system performance. For many dimensions, arrangements by reducing complexity for families only a limited set of indicators is available. In the and providers, making premiums, deductibles, case of costs, measures used in this report are for and out-of-pocket costs more affordable relative to the total population and not specific to children. family income, and ensuring coverage of essential The indicators of child health care quality presented health care services in the private market. National here are largely parent-reported; however, clinical policies also can ensure that states have the resources quality data are necessary to paint a clear picture and leverage they need to provide developmental of state child health quality. Thus, the collection screening to all their families. Quality standards, of clinical data for children’s health care quality such as the qualifications for a medical home for is integral to future state and federal child health children, can set a performance target across all policy reform and could modify the state rankings states and narrow variation. based here on a limited set of indicators. Work currently under way should lay a firmer foundation Investing in children’s health yields long-term for public and private action. payoffs. Healthy children are more able to learn in school and more likely to become healthy, National leadership and collaboration across productive adults. And society as a whole benefits— public and private sectors are essential for coherent, from reduced dependency and disability, a healthier strategic reforms to improve the child health future workforce, and a stronger economy. 26 U.S. Variations in Child Health System Performance: A State Scorecard Appendix: Study Methodology This report applies the methodology used in the 3. Costs includes annual per capita personal State Scorecard on Health System Performance, health spending and annual private health prepared for The Commonwealth Fund insurance premiums. Data are taken from Commission on a High Performance Health the Centers for Medicare and Medicaid Ser- System, to measure child health care systems in all vices National Health Statistics Group and the 50 states and the District of Columbia. The 13 key Kaiser Family Foundation’s State Health Facts, indicators used are organized into five dimensions available at http://www.statehealthfacts.org/. that capture critical aspects of child health system performance: access, quality, costs, equity, and the 4. Equity includes differences in performance potential to lead healthy lives. associated with family income level, type of insurance, or race or ethnicity. The two 1. Access includes rates of insurance coverage outcome measures used were percent of for all children and for children at or below children with a medical home and percent of 200 percent of the federal poverty level. Data children with at least one preventive medical are two-year averages from the U.S. Census and dental visit in the past year. Data are Bureau Current Population Surveys, from taken from the State Scorecard. 2007 and 2006. 5. Potential to Lead Healthy Lives includes 2. Quality includes indicators that measure indicators that measure the degree to which three related components: receipt of the a state supports children’s potential to live “right care,” coordinated care, and patient- long and healthy lives. The two indicators centered care. Four of the seven quality include infant mortality rates and rates of indicators are taken from the State Scorecard young children at risk for developmental and the remaining three are from the National delays. The mortality data are from the State Survey of Children’s Health, 2003, and the Scorecard and developmental delay risk data National Survey of Children with Special are from the National Survey of Children’s Health Care Needs, 2001. Data for both Health, 2003. surveys were assembled and analyzed by the Child and Adolescent Health Measurement Initiative and are available at http://www. childhealthdata.org/content/Default.aspx. Appendix: Study Methodology 27 Indicators Overall Rankings For each indicator, the Appendix tables rank the The final state rankings for each dimension are best-performing state to the worst-performing. averaged and then sorted to determine final overall Indicator tables include actual data and ranks. rankings. See Appendix Table 1.1 for the overall Indicators were selected to be consistent with state rankings. This approach gives each dimension measures of health system performance as laid equal weight and, within dimensions, weights all out by The Commonwealth Fund Commission indicators equally. We use average rankings for on a High Performance Health System. However, this report because we believe that this approach state-level indicators to measure health care safety, is easily understandable. This method has been duplicative services, receipt of inappropriate established to assess quality of care at the state care, insurance administration overhead, and level across multiple indicators (e.g., National information system capacity are lacking for Scorecard, State Scorecard, Jencks et al., Journal of children’s care. Further, many quality metrics the American Medical Association, 2003).27 for child health care are still in development and are not available at the state level. Thus, these quality indicators are merely a subset to be Equity Scores expanded over time. Equity scores examine the percentage-point difference, or “gaps,” for each vulnerable subgroup (e.g., minority, low-income, uninsured) compared Dimensions with the U.S. average for the full population for States are ranked on each indicator and then on two indicators: percent of children with a medical the average of their ranking across indicators home and percent of children with at least one within each dimension. States are then sorted by preventive medical and dental visit in the past year. this average rank to determine the final state rank States are ranked by the gap on each indicator and for each dimension. The tables below display the then the average of the rankings on each indicator state rankings for each dimension. determines a state’s ranking across all indicators Table 1.1 State Ranking on Health System separately for race/ethnicity equity, income equity, Performance by Dimension and insurance equity. The average of state rankings across the equity groups is sorted to determine the Table 2.1 Access: Adequate Health Coverage for overall equity ranking. Children Table 3.1 Quality: Getting Right Care, Coordinated Care, and Family-Centered Care Table 4.1 Family Costs of Health Care Table 5.1 Equitable Care: Disparities by Income, Insurance Status, and Race/Ethnicity Table 6.1 Potential to Lead Healthy Lives 28 U.S. Variations in Child Health System Performance: A State Scorecard Table 1.1 State Ranking on Health System Performance by Dimension Potential to Overall Access Quality Cost Equity Lead Healthy Rank Order Lives Overall Average Overall Average State Rank Rank Rank Rank Rank State Rank* Rank Rank* Rank 15 Alabama 20.6 9 10 8 28 48 1 Iowa 10.4 42 Alaska 32.0 27 44 47 29 13 2 Vermont 11.6 47 Arizona 35.6 46 46 2 49 35 3 Maine 14 44 Arkansas 32.8 27 42 1 46 48 4 Massachusetts 14.2 34 California 29.6 40 41 12 40 15 5 Ohio 17.6 34 Colorado 29.6 48 36 17 42 5 6 Hawaii 17.8 14 Connecticut 20.4 23 3 49 6 21 6 New Hampshire 17.8 37 Delaware 30.2 38 19 40 20 34 8 Rhode Island 18.4 32 District of Columbia 28.8 8 32 51 15 38 9 Kentucky 19.2 50 Florida 40.6 51 37 34 43 38 10 Kansas 19.6 38 Georgia 31.0 37 29 6 36 47 10 Wisconsin 19.6 6 Hawaii 17.8 6 26 5 11 41 12 Michigan 19.8 33 Idaho 29.2 33 48 7 45 13 13 Nebraska 20.2 39 Illinois 31.2 36 31 25 26 38 14 Connecticut 20.4 22 Indiana 24.0 17 12 28 30 33 15 Alabama 20.6 1 Iowa 10.4 2 2 12 19 17 16 South Dakota 22.4 10 Kansas 19.6 12 17 16 30 23 16 Wyoming 22.4 9 Kentucky 19.2 13 21 32 12 18 18 Pennsylvania 22.6 48 Louisiana 37.2 40 45 17 33 51 18 Washington 22.6 3 Maine 14.0 14 5 46 3 2 20 West Virginia 23.2 28 Maryland 26.0 35 24 31 12 28 21 North Dakota 23.4 4 Massachusetts 14.2 1 1 47 2 20 22 Indiana 24 12 Michigan 19.8 3 15 28 17 36 23 Minnesota 24.2 23 Minnesota 24.2 19 21 36 38 7 24 Virginia 24.4 49 Mississippi 39.6 43 47 10 48 50 25 New York 24.8 29 Missouri 26.2 25 33 17 27 29 26 Tennessee 25.2 30 Montana 26.6 46 38 12 22 15 27 Utah 25.6 13 Nebraska 20.2 31 7 22 23 18 28 Maryland 26 45 Nevada 34.4 48 50 2 51 21 29 Missouri 26.2 6 New Hampshire 17.8 24 14 40 7 4 30 Montana 26.6 41 New Jersey 31.8 42 29 43 16 29 31 North Carolina 26.8 39 New Mexico 31.2 44 49 12 41 10 31 District of Columbia 28.8 25 New York 24.8 16 28 45 8 27 33 Idaho 29.2 31 North Carolina 26.8 39 13 11 25 46 34 California 29.6 21 North Dakota 23.4 30 25 21 32 9 34 Colorado 29.6 5 Ohio 17.6 5 8 34 10 31 36 South Carolina 29.8 51 Oklahoma 40.8 33 51 26 49 45 37 Delaware 30.2 42 Oregon 32.0 26 39 24 47 24 38 Georgia 31 18 Pennsylvania 22.6 17 9 42 8 37 39 Illinois 31.2 8 Rhode Island 18.4 3 4 49 5 31 39 New Mexico 31.2 36 South Carolina 29.8 20 35 20 33 41 41 New Jersey 31.8 16 South Dakota 22.4 27 16 22 36 11 42 Alaska 32 26 Tennessee 25.2 15 18 26 24 43 43 Oregon 32 46 Texas 35.2 50 42 28 44 12 44 Arkansas 32.8 27 Utah 25.6 44 40 2 39 3 45 Nevada 34.4 2 Vermont 11.6 6 6 44 1 1 46 Texas 35.2 24 Virginia 24.4 31 23 8 35 25 47 Arizona 35.6 18 Washington 22.6 21 34 32 20 6 48 Louisiana 37.2 20 West Virginia 23.2 11 19 39 4 43 49 Mississippi 39.6 10 Wisconsin 19.6 9 11 38 14 26 50 Florida 40.6 16 Wyoming 22.4 22 27 37 18 8 51 Oklahoma 40.8 * Final rank for overall health system performance across five dimensions. Source: The Commonwealth Fund’s calculations based on state’s rankings on access, quality, cost, healthy lives, and equity dimensions. Appendix: Study Methodology 29 Table 2.1 Access: Adequate Health Coverage for Children State Variation 2005-2006 Alphabetical Order Rank Order Top 5 States Average 4.1 Rank State Average Rank Rank State Average Rank All States Average 25.9 9 Alabama 10 1 Massachusetts 1.5 All States Median 27.0 27 Alaska 27.5 2 Iowa 2.5 Bottom 5 States Average 47.7 46 Arizona 46 3 Michigan 5 27 Arkansas 27.5 3 Rhode Island 5 40 California 39 5 Ohio 6.5 48 Colorado 47.5 6 Hawaii 7.5 23 Connecticut 23.5 6 Vermont 7.5 38 Delaware 34.5 8 District of Columbia 8.5 8 District of Columbia 8.5 9 Alabama 10 51 Florida 49.5 9 Wisconsin 10 37 Georgia 33.5 11 West Virginia 13.5 6 Hawaii 7.5 12 Kansas 14.5 33 Idaho 31.5 13 Kentucky 15 36 Illinois 33 14 Maine 16 17 Indiana 18 15 Tennessee 16.5 2 Iowa 2.5 16 New York 17.5 12 Kansas 14.5 17 Indiana 18 13 Kentucky 15 17 Pennsylvania 18 40 Louisiana 39 19 Minnesota 19.5 14 Maine 16 20 South Carolina 20 35 Maryland 32 21 Washington 21 1 Massachusetts 1.5 22 Wyoming 23 3 Michigan 5 23 Connecticut 23.5 19 Minnesota 19.5 24 New Hampshire 24 43 Mississippi 44 25 Missouri 25 25 Missouri 25 26 Oregon 27 46 Montana 46 27 Alaska 27.5 31 Nebraska 30.5 27 Arkansas 27.5 48 Nevada 47.5 27 South Dakota 27.5 24 New Hampshire 24 30 North Dakota 28 42 New Jersey 41.5 31 Nebraska 30.5 44 New Mexico 45.5 31 Virginia 30.5 16 New York 17.5 33 Idaho 31.5 39 North Carolina 36 33 Oklahoma 31.5 30 North Dakota 28 35 Maryland 32 5 Ohio 6.5 36 Illinois 33 33 Oklahoma 31.5 37 Georgia 33.5 26 Oregon 27 38 Delaware 34.5 17 Pennsylvania 18 39 North Carolina 36 3 Rhode Island 5 40 California 39 20 South Carolina 20 40 Louisiana 39 27 South Dakota 27.5 42 New Jersey 41.5 15 Tennessee 16.5 43 Mississippi 44 50 Texas 48 44 New Mexico 45.5 44 Utah 45.5 44 Utah 45.5 6 Vermont 7.5 46 Arizona 46 31 Virginia 30.5 46 Montana 46 21 Washington 21 48 Colorado 47.5 11 West Virginia 13.5 48 Nevada 47.5 9 Wisconsin 10 50 Texas 48 22 Wyoming 23 51 Florida 49.5 * Average Rank is the average of the state’s rank across all indicators in the dimension. Access domain includes: percent of children uninsured and percent of low-income (below 200% of the federal poverty level) children uninsured. Source: U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2006 through 2007. 30 U.S. Variations in Child Health System Performance: A State Scorecard Table 2.2 Percent of Children at or Below 200% Poverty Who Are Uninsured, Two Year Average, Ages 0–17 Alphabetical Order Rank Order State Variation 2005-2006 Rank State 2005-2006 Rank State 2005-2006 Top 5 States Average 7.7 13 Alabama 12.5 1 District of Columbia 7.0 All States Average 17.5 28 Alaska 17.4 1 Massachusetts 7.0 All States Median 16.6 44 Arizona 26.0 3 Iowa 7.4 Bottom 5 States Average 32.2 23 Arkansas 15.8 4 Ohio 8.2 36 California 20.1 5 Rhode Island 8.9 51 Colorado 34.5 5 Vermont 8.9 36 Connecticut 20.1 7 South Carolina 9.6 33 Delaware 18.8 8 Kentucky 10.2 1 District of Columbia 7.0 9 Michigan 10.3 50 Florida 33.5 10 West Virginia 10.4 30 Georgia 18.1 11 Hawaii 12.4 11 Hawaii 12.4 11 Indiana 12.4 24 Idaho 16.3 13 Alabama 12.5 35 Illinois 19.9 14 New York 12.7 11 Indiana 12.4 15 Tennessee 12.9 3 Iowa 7.4 15 Wisconsin 12.9 18 Kansas 13.7 17 Wyoming 13.6 8 Kentucky 10.2 18 Kansas 13.7 39 Louisiana 20.5 19 Maine 13.9 19 Maine 13.9 20 Oregon 14.4 38 Maryland 20.3 21 Pennsylvania 14.5 1 Massachusetts 7.0 22 Washington 14.9 9 Michigan 10.3 23 Arkansas 15.8 25 Minnesota 16.4 24 Idaho 16.3 42 Mississippi 22.6 25 Minnesota 16.4 27 Missouri 16.7 26 North Dakota 16.6 47 Montana 30.8 27 Missouri 16.7 43 Nebraska 24.1 28 Alaska 17.4 48 Nevada 31.1 29 Oklahoma 17.5 40 New Hampshire 20.6 30 Georgia 18.1 46 New Jersey 30.6 31 North Carolina 18.6 41 New Mexico 21.9 31 South Dakota 18.6 14 New York 12.7 33 Delaware 18.8 31 North Carolina 18.6 34 Virginia 18.9 26 North Dakota 16.6 35 Illinois 19.9 4 Ohio 8.2 36 California 20.1 29 Oklahoma 17.5 36 Connecticut 20.1 20 Oregon 14.4 38 Maryland 20.3 21 Pennsylvania 14.5 39 Louisiana 20.5 5 Rhode Island 8.9 40 New Hampshire 20.6 7 South Carolina 9.6 41 New Mexico 21.9 31 South Dakota 18.6 42 Mississippi 22.6 15 Tennessee 12.9 43 Nebraska 24.1 45 Texas 28.0 44 Arizona 26.0 48 Utah 31.1 45 Texas 28.0 5 Vermont 8.9 46 New Jersey 30.6 34 Virginia 18.9 47 Montana 30.8 22 Washington 14.9 48 Nevada 31.1 10 West Virginia 10.4 48 Utah 31.1 15 Wisconsin 12.9 50 Florida 33.5 17 Wyoming 13.6 51 Colorado 34.5 United States 19.0 Source: U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2006 through 2007. Appendix: Study Methodology 31 Table 2.3 Percent of Children Who Are Uninsured, Two Year Average, Ages 0–17 State Variation 2005-2006 Alphabetical Order Rank Order Top 5 States Average 5.6% Rank State 2005-2006 Rank State 2005-2006 All States Average 9.8% 7 Alabama 6.0% 1 Michigan 4.9% All States Median 9.1% 27 Alaska 9.3% 2 Iowa 5.6% Bottom 5 States Average 18.2% 48 Arizona 16.7% 2 Massachusetts 5.6% 32 Arkansas 10.0% 4 Hawaii 5.8% 42 California 13.1% 5 Rhode Island 5.9% 44 Colorado 14.1% 5 Wisconsin 5.9% 11 Connecticut 6.8% 7 Alabama 6.0% 36 Delaware 11.8% 8 New Hampshire 6.4% 16 District of Columbia 7.5% 9 Ohio 6.6% 49 Florida 18.5% 10 Vermont 6.7% 37 Georgia 11.9% 11 Connecticut 6.8% 4 Hawaii 5.8% 11 Kansas 6.8% 39 Idaho 12.2% 13 Maine 7.0% 31 Illinois 9.8% 14 Minnesota 7.1% 25 Indiana 8.8% 15 Pennsylvania 7.3% 2 Iowa 5.6% 16 District of Columbia 7.5% 11 Kansas 6.8% 17 West Virginia 7.6% 22 Kentucky 8.2% 18 Nebraska 7.7% 39 Louisiana 12.2% 18 Tennessee 7.7% 13 Maine 7.0% 20 Washington 7.8% 26 Maryland 9.1% 21 New York 8.0% 2 Massachusetts 5.6% 22 Kentucky 8.2% 1 Michigan 4.9% 23 Missouri 8.3% 14 Minnesota 7.1% 24 South Dakota 8.6% 46 Mississippi 15.1% 25 Indiana 8.8% 23 Missouri 8.3% 26 Maryland 9.1% 45 Montana 14.3% 27 Alaska 9.3% 18 Nebraska 7.7% 27 Virginia 9.3% 47 Nevada 16.6% 29 Wyoming 9.5% 8 New Hampshire 6.4% 30 North Dakota 9.6% 37 New Jersey 11.9% 31 Illinois 9.8% 50 New Mexico 18.9% 32 Arkansas 10.0% 21 New York 8.0% 33 South Carolina 10.5% 41 North Carolina 12.8% 34 Oklahoma 11.7% 30 North Dakota 9.6% 34 Oregon 11.7% 9 Ohio 6.6% 36 Delaware 11.8% 34 Oklahoma 11.7% 37 Georgia 11.9% 34 Oregon 11.7% 37 New Jersey 11.9% 15 Pennsylvania 7.3% 39 Idaho 12.2% 5 Rhode Island 5.9% 39 Louisiana 12.2% 33 South Carolina 10.5% 41 North Carolina 12.8% 24 South Dakota 8.6% 42 California 13.1% 18 Tennessee 7.7% 43 Utah 13.7% 51 Texas 20.1% 44 Colorado 14.1% 43 Utah 13.7% 45 Montana 14.3% 10 Vermont 6.7% 46 Mississippi 15.1% 27 Virginia 9.3% 47 Nevada 16.6% 20 Washington 7.8% 48 Arizona 16.7% 17 West Virginia 7.6% 49 Florida 18.5% 5 Wisconsin 5.9% 50 New Mexico 18.9% 29 Wyoming 9.5% 51 Texas 20.1% United States 11.3 Data: U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2006 through 2007. 32 U.S. Variations in Child Health System Performance: A State Scorecard Appendix: Study Methodology 33 34 Table 3.1 Quality: Getting Right Care, Coordinated Care, and Family-Centered Care Alphabetical Order Rank Order Average Average Rank State Rank State Rank A Rank B Rank C Rank D Rank E Rank F Rank G Rank* Rank* 10 Alabama 15.2 1 Massachusetts 1 1 8 3 26 2 12 7.6 44 Alaska 37.2 2 Iowa 9 15 8 13 3 3 5 8.0 46 Arizona 38.1 3 Connecticut 4 4 3 4 29 17 * 10.2 42 Arkansas 37.0 4 Rhode Island 20 2 11 2 16 8 25 12.0 41 California 36.7 5 Maine 17 9 8 6 9 33 6 12.6 36 Colorado 32.0 6 Vermont 27 5 6 5 24 26 1 13.4 3 Connecticut 10.2 7 Nebraska 2 27 4 20 31 13 3 14.3 19 Delaware 20.3 8 Ohio 12 17 29 12 5 12 18 15.0 32 District of Columbia 27.5 10 Alabama 17 26 12 20 7 9 * 15.2 37 Florida 33.6 9 Pennsylvania 19 8 2 10 27 10 30 15.1 29 Georgia 26.4 11 Wisconsin 25 16 13 15 22 14 7 16.0 26 Hawaii 23.3 12 Indiana 39 17 14 16 12 4 * 17.0 48 Idaho 39.3 13 North Carolina 6 25 20 27 8 19 22 18.1 31 Illinois 26.6 14 New Hampshire 22 3 21 1 36 28 * 18.5 12 Indiana 17.0 15 Michigan 23 19 19 23 20 10 * 19.0 2 Iowa 8.0 17 Kansas 13 21 28 18 23 22 15 20.0 17 Kansas 20.0 16 South Dakota 3 45 5 45 20 1 * 19.8 21 Kentucky 20.6 19 Delaware 11 14 40 14 19 24 * 20.3 45 Louisiana 37.8 18 Tennessee 21 27 26 19 6 15 27 20.1 5 Maine 12.6 19 West Virginia 46 12 22 8 1 30 23 20.3 U.S. Variations in Child Health System Performance: A State Scorecard 24 Maryland 22.0 21 Kentucky 29 23 25 17 4 15 31 20.6 1 Massachusetts 7.6 21 Minnesota 6 35 18 32 12 33 8 20.6 15 Michigan 19.0 24 Maryland 24 11 34 7 18 43 17 22.0 21 Minnesota 20.6 23 Virginia 5 20 27 26 33 21 21 21.9 47 Mississippi 38.7 25 North Dakota 8 46 14 37 10 18 * 22.2 33 Missouri 28.3 26 Hawaii 28 12 14 29 29 37 14 23.3 38 Montana 33.8 27 Wyoming 34 31 1 41 42 5 * 25.7 7 Nebraska 14.3 28 New York 26 6 37 9 35 38 32 26.1 50 Nevada 41.7 29 Georgia 10 29 30 35 33 28 20 26.4 14 New Hampshire 18.5 29 New Jersey 38 7 35 11 46 20 28 26.4 29 New Jersey 26.4 31 Illinois 15 22 23 24 39 44 19 26.6 49 New Mexico 41.5 32 District of Columbia 48 10 14 30 15 48 * 27.5 28 New York 26.1 33 Missouri 31 33 31 25 45 7 26 28.3 13 North Carolina 18.1 35 South Carolina 35 32 32 31 2 39 33 29.1 25 North Dakota 22.2 34 Washington 42 23 41 22 41 22 11 28.9 8 Ohio 15.0 36 Colorado 16 30 38 28 47 49 16 32.0 51 Oklahoma 42.3 37 Florida 31 38 43 36 11 47 29 33.6 39 Oregon 34.0 38 Montana 30 48 7 39 44 35 * 33.8 9 Pennsylvania 15.1 39 Oregon 49 40 24 34 50 39 2 34.0 4 Rhode Island 12.0 40 Utah 47 42 33 33 49 31 4 34.1 35 South Carolina 29.1 41 California 41 39 44 48 28 45 12 36.7 16 South Dakota 19.8 44 Alaska 45 36 46 47 17 32 * 37.2 18 Tennessee 20.1 42 Arkansas 50 46 49 40 31 6 * 37.0 42 Texas 37.0 42 Texas 36 37 51 42 42 27 24 37.0 40 Utah 34.1 45 Louisiana 43 43 50 43 12 36 * 37.8 6 Vermont 13.4 46 Arizona 33 41 42 49 50 42 10 38.1 23 Virginia 21.9 47 Mississippi 14 49 47 51 25 46 * 38.7 34 Washington 28.9 48 Idaho 39 51 38 46 37 25 * 39.3 19 West Virginia 20.3 49 New Mexico 36 34 36 44 48 51 * 41.5 11 Wisconsin 16.0 50 Nevada 51 50 45 50 37 50 9 41.7 27 Wyoming 25.7 51 Oklahoma 44 44 48 38 39 41 * 42.3 * Average Rank is the average of the state’s rank across all indicators in the dimension. Quality domain includes: percent of children 19–35 months who received all recommended doses of five key vaccines; children with both a medical and dental preventive visit in past year; children with emotional, behavioral, or developmental problems received mental health care; children with a medical home; children whose personal doctor or nurse follows-up after they get specialty care services; hospital admissions for pediatric asthma per 100K children; and children with special health care needs with problems getting referrals to specialty care services. Note: Medical home is defined as having at least one preventive medical care visit in the past year; being able to access needed specialist care and services; and having a personal doctor/nurse who usually/always spends enough time and communicates clearly, provides telephone advice and urgent care when needed, and follows up after specialist care. Source: National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. State Variation Average Rank Top 5 States Average 10.1 All States Average 25.2 All States Median 23.3 Bottom 5 States Average 40.7 Appendix: Study Methodology 35 36 Table 3.2 Percent of Children Ages 19–35 Months Table 3.3 Percent of Children Ages 0–17 Receiving All Recommended Doses of Five Key with Both a Medical and Dental Preventive Vaccines Care Visit in the Past Year Alphabetical Order Rank Order Alphabetical Order Rank Order Rank State 2005 Rank State 2005 Rank State 2003 Rank State 2003 17 Alabama 83.3 1 Massachusetts 93.5 26 Alabama 59.2 1 Massachusetts 74.9 45 Alaska 75.4 2 Nebraska 89.1 36 Alaska 54.5 2 Rhode Island 73.9 33 Arizona 79.2 3 South Dakota 86.9 41 Arizona 51.9 3 New Hampshire 71.8 50 Arkansas 67.8 4 Connecticut 86.1 46 Arkansas 49.0 4 Connecticut 71.6 41 California 77.9 5 Virginia 85.8 39 California 53.2 5 Vermont 70.7 16 Colorado 83.4 6 Minnesota 85.2 30 Colorado 57.7 6 New York 68.6 4 Connecticut 86.1 6 North Carolina 85.2 4 Connecticut 71.6 7 New Jersey 68.3 11 Delaware 84.2 8 North Dakota 85.0 14 Delaware 63.2 8 Pennsylvania 66.6 48 District of Columbia 73.5 9 Iowa 84.9 10 District of Columbia 65.7 9 Maine 66.4 31 Florida 79.3 10 Georgia 84.7 38 Florida 54.2 10 District of Columbia 65.7 10 Georgia 84.7 11 Delaware 84.2 29 Georgia 57.9 11 Maryland 65.5 28 Hawaii 80.1 12 Ohio 84.1 12 Hawaii 63.7 12 Hawaii 63.7 39 Idaho 78.1 13 Kansas 83.8 51 Idaho 45.7 12 West Virginia 63.7 15 Illinois 83.5 14 Mississippi 83.6 22 Illinois 60.6 14 Delaware 63.2 39 Indiana 78.1 15 Illinois 83.5 17 Indiana 61.2 15 Iowa 61.6 9 Iowa 84.9 16 Colorado 83.4 15 Iowa 61.6 16 Wisconsin 61.3 13 Kansas 83.8 17 Alabama 83.3 21 Kansas 60.7 17 Indiana 61.2 29 Kentucky 79.7 17 Maine 83.3 23 Kentucky 60.5 17 Ohio 61.2 43 Louisiana 76.0 19 Pennsylvania 83.2 43 Louisiana 51.3 19 Michigan 61.0 17 Maine 83.3 20 Rhode Island 83.1 9 Maine 66.4 20 Virginia 60.8 24 Maryland 82.3 21 Tennessee 82.9 11 Maryland 65.5 21 Kansas 60.7 U.S. Variations in Child Health System Performance: A State Scorecard 1 Massachusetts 93.5 22 New Hampshire 82.8 1 Massachusetts 74.9 22 Illinois 60.6 23 Michigan 82.7 23 Michigan 82.7 19 Michigan 61.0 23 Kentucky 60.5 6 Minnesota 85.2 24 Maryland 82.3 35 Minnesota 55.0 23 Washington 60.5 14 Mississippi 83.6 25 Wisconsin 82.2 49 Mississippi 47.2 25 North Carolina 59.3 31 Missouri 79.3 26 New York 81.6 33 Missouri 56.1 26 Alabama 59.2 30 Montana 79.6 27 Vermont 81.5 48 Montana 48.9 27 Nebraska 58.5 2 Nebraska 89.1 28 Hawaii 80.1 27 Nebraska 58.5 27 Tennessee 58.5 51 Nevada 66.7 29 Kentucky 79.7 50 Nevada 46.8 29 Georgia 57.9 22 New Hampshire 82.8 30 Montana 79.6 3 New Hampshire 71.8 30 Colorado 57.7 38 New Jersey 78.2 31 Florida 79.3 7 New Jersey 68.3 31 Wyoming 56.9 36 New Mexico 78.4 31 Missouri 79.3 34 New Mexico 55.3 32 South Carolina 56.8 26 New York 81.6 33 Arizona 79.2 6 New York 68.6 33 Missouri 56.1 6 North Carolina 85.2 34 Wyoming 78.6 25 North Carolina 59.3 34 New Mexico 55.3 8 North Dakota 85.0 35 South Carolina 78.5 46 North Dakota 49.0 35 Minnesota 55.0 12 Ohio 84.1 36 New Mexico 78.4 17 Ohio 61.2 36 Alaska 54.5 44 Oklahoma 75.7 36 Texas 78.4 44 Oklahoma 49.2 37 Texas 54.4 49 Oregon 72.9 38 New Jersey 78.2 40 Oregon 52.2 38 Florida 54.2 19 Pennsylvania 83.2 39 Idaho 78.1 8 Pennsylvania 66.6 39 California 53.2 20 Rhode Island 83.1 39 Indiana 78.1 2 Rhode Island 73.9 40 Oregon 52.2 35 South Carolina 78.5 41 California 77.9 32 South Carolina 56.8 41 Arizona 51.9 3 South Dakota 86.9 42 Washington 77.8 45 South Dakota 49.1 42 Utah 51.8 21 Tennessee 82.9 43 Louisiana 76.0 27 Tennessee 58.5 43 Louisiana 51.3 36 Texas 78.4 44 Oklahoma 75.7 37 Texas 54.4 44 Oklahoma 49.2 47 Utah 74.1 45 Alaska 75.4 42 Utah 51.8 45 South Dakota 49.1 27 Vermont 81.5 46 West Virginia 74.9 5 Vermont 70.7 46 Arkansas 49.0 5 Virginia 85.8 47 Utah 74.1 20 Virginia 60.8 46 North Dakota 49.0 42 Washington 77.8 48 District of Columbia 73.5 23 Washington 60.5 48 Montana 48.9 46 West Virginia 74.9 49 Oregon 72.9 12 West Virginia 63.7 49 Mississippi 47.2 25 Wisconsin 82.2 50 Arkansas 67.8 16 Wisconsin 61.3 50 Nevada 46.8 34 Wyoming 78.6 51 Nevada 66.7 31 Wyoming 56.9 51 Idaho 45.7 United States 80.8 United States 58.8 Note: Children ages 19–35 months who have received: 4+ doses of diphtheria- Data: National Survey of Children’s Health. Data assembled by the Child and tetanus-acellular pertussis (DTaP), 3+ doses of polio, 1+ dose of measles-mumps- Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from rubella (MMR), 3+ doses of Haemophilus influenzae B (Hib), and 3+ doses of www.childhealthdata.org, 2008. hepatitis B antigens. Data: National Immunization Survey (NCHS, NIS 2005). State Variation 2005 State Variation 2003 Top 5 States Average 88.3 Top 5 States Average 72.6 All States Average 80.7 All States Average 58.9 All States Median 81.6 All States Median 59.2 Bottom 5 States Average 71.0 Bottom 5 States Average 47.5 Appendix: Study Methodology 37 38 Table 3.4 Percent of Children Ages 1–17 Table 3.5 Percent of Children Ages 0–17 with Emotional, Behavioral, or Developmental with a Medical Home Problems Receiving Some Mental Health Care in the Past Year Alphabetical Order Rank Order Alphabetical Order Rank Order Rank State 2003 Rank State 2003 Rank State 2003 Rank State 2003 12 Alabama 67.0 1 Wyoming 77.2 20 Alabama 49.0 1 New Hampshire 61.0 46 Alaska 52.2 2 Pennsylvania 75.8 47 Alaska 37.7 2 Rhode Island 60.4 42 Arizona 55.0 3 Connecticut 74.1 49 Arizona 36.2 3 Massachusetts 60.3 49 Arkansas 47.7 4 Nebraska 72.8 40 Arkansas 40.8 4 Connecticut 59.1 44 California 54.0 5 South Dakota 71.0 48 California 37.5 5 Vermont 57.8 38 Colorado 56.9 6 Vermont 70.0 28 Colorado 45.8 6 Maine 56.6 3 Connecticut 74.1 7 Montana 68.4 4 Connecticut 59.1 7 Maryland 55.0 40 Delaware 56.7 8 Iowa 67.6 14 Delaware 51.7 8 West Virginia 54.3 14 District of Columbia 66.1 8 Maine 67.6 30 District of Columbia 45.2 9 New York 54.2 43 Florida 54.7 8 Massachusetts 67.6 36 Florida 43.0 10 Pennsylvania 54.0 30 Georgia 60.8 11 Rhode Island 67.5 35 Georgia 43.1 11 New Jersey 52.7 14 Hawaii 66.1 12 Alabama 67.0 29 Hawaii 45.3 12 Ohio 52.3 38 Idaho 56.9 13 Wisconsin 66.8 46 Idaho 37.9 13 Iowa 52.1 23 Illinois 63.0 14 District of Columbia 66.1 24 Illinois 48.2 14 Delaware 51.7 14 Indiana 66.1 14 Hawaii 66.1 16 Indiana 51.0 15 Wisconsin 51.2 8 Iowa 67.6 14 Indiana 66.1 13 Iowa 52.1 16 Indiana 51.0 28 Kansas 61.3 14 North Dakota 66.1 18 Kansas 49.8 17 Kentucky 50.5 25 Kentucky 62.5 18 Minnesota 64.6 17 Kentucky 50.5 18 Kansas 49.8 50 Louisiana 44.2 19 Michigan 63.8 43 Louisiana 39.2 19 Tennessee 49.7 8 Maine 67.6 20 North Carolina 63.6 6 Maine 56.6 20 Alabama 49.0 U.S. Variations in Child Health System Performance: A State Scorecard 34 Maryland 58.9 21 New Hampshire 63.5 7 Maryland 55.0 20 Nebraska 49.0 8 Massachusetts 67.6 22 West Virginia 63.3 3 Massachusetts 60.3 22 Washington 48.5 19 Michigan 63.8 23 Illinois 63.0 23 Michigan 48.4 23 Michigan 48.4 18 Minnesota 64.6 24 Oregon 62.7 32 Minnesota 44.1 24 Illinois 48.2 47 Mississippi 50.1 25 Kentucky 62.5 51 Mississippi 33.8 25 Missouri 47.7 31 Missouri 60.2 26 Tennessee 61.9 25 Missouri 47.7 26 Virginia 47.6 7 Montana 68.4 27 Virginia 61.8 39 Montana 40.9 27 North Carolina 46.5 4 Nebraska 72.8 28 Kansas 61.3 20 Nebraska 49.0 28 Colorado 45.8 45 Nevada 53.2 29 Ohio 61.2 50 Nevada 34.5 29 Hawaii 45.3 21 New Hampshire 63.5 30 Georgia 60.8 1 New Hampshire 61.0 30 District of Columbia 45.2 35 New Jersey 58.7 31 Missouri 60.2 11 New Jersey 52.7 31 South Carolina 44.5 36 New Mexico 58.3 32 South Carolina 59.8 44 New Mexico 39.0 32 Minnesota 44.1 37 New York 57.1 33 Utah 59.2 9 New York 54.2 33 Utah 43.7 20 North Carolina 63.6 34 Maryland 58.9 27 North Carolina 46.5 34 Oregon 43.4 14 North Dakota 66.1 35 New Jersey 58.7 37 North Dakota 41.7 35 Georgia 43.1 29 Ohio 61.2 36 New Mexico 58.3 12 Ohio 52.3 36 Florida 43.0 48 Oklahoma 48.2 37 New York 57.1 38 Oklahoma 41.5 37 North Dakota 41.7 24 Oregon 62.7 38 Colorado 56.9 34 Oregon 43.4 38 Oklahoma 41.5 2 Pennsylvania 75.8 38 Idaho 56.9 10 Pennsylvania 54.0 39 Montana 40.9 11 Rhode Island 67.5 40 Delaware 56.7 2 Rhode Island 60.4 40 Arkansas 40.8 32 South Carolina 59.8 41 Washington 56.4 31 South Carolina 44.5 41 Wyoming 40.5 5 South Dakota 71.0 42 Arizona 55.0 45 South Dakota 38.8 42 Texas 39.9 26 Tennessee 61.9 43 Florida 54.7 19 Tennessee 49.7 43 Louisiana 39.2 51 Texas 43.4 44 California 54.0 42 Texas 39.9 44 New Mexico 39.0 33 Utah 59.2 45 Nevada 53.2 33 Utah 43.7 45 South Dakota 38.8 6 Vermont 70.0 46 Alaska 52.2 5 Vermont 57.8 46 Idaho 37.9 27 Virginia 61.8 47 Mississippi 50.1 26 Virginia 47.6 47 Alaska 37.7 41 Washington 56.4 48 Oklahoma 48.2 22 Washington 48.5 48 California 37.5 22 West Virginia 63.3 49 Arkansas 47.7 8 West Virginia 54.3 49 Arizona 36.2 13 Wisconsin 66.8 50 Louisiana 44.2 15 Wisconsin 51.2 50 Nevada 34.5 1 Wyoming 77.2 51 Texas 43.4 41 Wyoming 40.5 51 Mississippi 33.8 United States 58.7 United States 46.1 Data: National Survey of Children’s Health. Data assembled by the Child and Note: Medical home is defined as having at least one preventive medical care Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from visit in the past year; being able to access needed specialist care and services; www.childhealthdata.org, 2008. and having a personal doctor/nurse who usually/always spends enough time and communicates clearly, provides telephone advice and urgent care when needed, and follows up after specialist care. Data: National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. State Variation 2003 State Variation 2003 Top 5 States Average 74.2 Top 5 States Average 59.7 All States Average 61.4 All States Average 47.0 All States Median 61.9 All States Median 47.6 Bottom 5 States Average 46.7 Bottom 5 States Average 35.9 Appendix: Study Methodology 39 40 Table 3.6 Percent of Children Ages 0–17 Whose Table 3.7 Percent of Children Ages 0–17 with Personal Doctor or Nurse Follows up After They Special Health Care Needs Who Have Problems Get Specialty Care Services Getting Referrals to Specialty Care Services, 2001 Alphabetical Order Rank Order Alphabetical Order Rank Order Rank State 2003 Rank State 2003 Rank State 2001 Rank State 2001 7 Alabama 62.7 1 West Virginia 68.0 9 Alabama 17.0 1 South Dakota 13.5 17 Alaska 60.4 2 South Carolina 65.0 32 Alaska 23.3 2 Massachusetts 13.7 50 Arizona 49.8 3 Iowa 64.8 42 Arizona 25.6 3 Iowa 14.0 31 Arkansas 56.9 4 Kentucky 64.0 6 Arkansas 16.0 4 Indiana 15.0 28 California 57.7 5 Ohio 63.5 45 California 27.3 5 Wyoming 15.1 47 Colorado 52.2 6 Tennessee 62.9 49 Colorado 28.4 6 Arkansas 16.0 29 Connecticut 57.5 7 Alabama 62.7 17 Connecticut 18.8 7 Missouri 16.4 19 Delaware 60.0 8 North Carolina 62.2 24 Delaware 21.2 8 Rhode Island 16.8 15 District of Columbia 61.2 9 Maine 61.8 48 District of Columbia 27.9 9 Alabama 17.0 11 Florida 61.5 10 North Dakota 61.6 47 Florida 27.7 10 Michigan 17.3 33 Georgia 56.4 11 Florida 61.5 28 Georgia 23.0 10 Pennsylvania 17.3 29 Hawaii 57.5 12 Indiana 61.3 37 Hawaii 23.9 12 Ohio 17.5 37 Idaho 55.0 12 Louisiana 61.3 25 Idaho 21.6 13 Nebraska 18.1 39 Illinois 54.6 12 Minnesota 61.3 44 Illinois 26.7 14 Wisconsin 18.4 12 Indiana 61.3 15 District of Columbia 61.2 4 Indiana 15.0 15 Kentucky 18.7 3 Iowa 64.8 16 Rhode Island 60.9 3 Iowa 14.0 15 Tennessee 18.7 23 Kansas 59.3 17 Alaska 60.4 22 Kansas 20.5 17 Connecticut 18.8 4 Kentucky 64.0 18 Maryland 60.2 15 Kentucky 18.7 18 North Dakota 19.1 12 Louisiana 61.3 19 Delaware 60.0 36 Louisiana 23.7 19 North Carolina 19.2 9 Maine 61.8 20 Michigan 59.6 33 Maine 23.5 20 New Jersey 19.7 18 Maryland 60.2 20 South Dakota 59.6 43 Maryland 26.6 21 Virginia 20.1 U.S. Variations in Child Health System Performance: A State Scorecard 26 Massachusetts 57.9 22 Wisconsin 59.5 2 Massachusetts 13.7 22 Kansas 20.5 20 Michigan 59.6 23 Kansas 59.3 10 Michigan 17.3 22 Washington 20.5 12 Minnesota 61.3 24 Vermont 58.6 33 Minnesota 23.5 24 Delaware 21.2 25 Mississippi 58.2 25 Mississippi 58.2 46 Mississippi 27.5 25 Idaho 21.6 45 Missouri 53.1 26 Massachusetts 57.9 7 Missouri 16.4 26 Vermont 22.0 44 Montana 53.7 27 Pennsylvania 57.8 35 Montana 23.6 27 Texas 22.5 31 Nebraska 56.8 28 California 57.7 13 Nebraska 18.1 28 Georgia 23.0 37 Nevada 55.0 29 Connecticut 57.5 50 Nevada 29.5 28 New Hampshire 23.0 36 New Hampshire 56.1 29 Hawaii 57.5 28 New Hampshire 23.0 30 West Virginia 23.1 46 New Jersey 52.6 31 Arkansas 56.9 20 New Jersey 19.7 31 Utah 23.2 48 New Mexico 52.1 31 Nebraska 56.8 51 New Mexico 33.5 32 Alaska 23.3 35 New York 56.2 33 Georgia 56.4 38 New York 24.0 33 Maine 23.5 8 North Carolina 62.2 33 Virginia 56.4 19 North Carolina 19.2 33 Minnesota 23.5 10 North Dakota 61.6 35 New York 56.2 18 North Dakota 19.1 35 Montana 23.6 5 Ohio 63.5 36 New Hampshire 56.1 12 Ohio 17.5 36 Louisiana 23.7 39 Oklahoma 54.9 37 Idaho 55.0 41 Oklahoma 24.3 37 Hawaii 23.9 50 Oregon 49.8 37 Nevada 55.0 39 Oregon 24.1 38 New York 24.0 27 Pennsylvania 57.8 39 Oklahoma 54.9 10 Pennsylvania 17.3 39 Oregon 24.1 16 Rhode Island 60.9 39 Illinois 54.6 8 Rhode Island 16.8 39 South Carolina 24.1 2 South Carolina 65.0 41 Washington 54.4 39 South Carolina 24.1 41 Oklahoma 24.3 20 South Dakota 59.6 42 Texas 54.0 1 South Dakota 13.5 42 Arizona 25.6 6 Tennessee 62.9 42 Wyoming 54.0 15 Tennessee 18.7 43 Maryland 26.6 42 Texas 54.0 44 Montana 53.7 27 Texas 22.5 44 Illinois 26.7 49 Utah 51.8 45 Missouri 53.1 31 Utah 23.2 45 California 27.3 24 Vermont 58.6 46 New Jersey 52.6 26 Vermont 22.0 46 Mississippi 27.5 33 Virginia 56.4 47 Colorado 52.2 21 Virginia 20.1 47 Florida 27.7 41 Washington 54.4 48 New Mexico 52.1 22 Washington 20.5 48 District of Columbia 27.9 1 West Virginia 68.0 49 Utah 51.8 30 West Virginia 23.1 49 Colorado 28.4 22 Wisconsin 59.5 50 Arizona 49.8 14 Wisconsin 18.4 50 Nevada 29.5 42 Wyoming 54.0 50 Oregon 49.8 5 Wyoming 15.1 51 New Mexico 33.5 United States 57.8 United States 21.9 Note: Children ages 0–17 who have a PDN and needed specialist care or Note: Children with Special Health Care Needs Ages 0 -17 who needed care specialized health services/equipment during the past 12 months from a specialty doctor during the past 12 months Data: 2001 National Survey Data: National Survey of Children’s Health. Data assembled by the Child and of Children with Special Health Care Needs. Prepared by Child and Adolescent Adolescent Health Measurement Initiative (CAHMI 2005). Health Measurement Initiative (CAHMI) Data Resource Center for Child and Adolescent Health, www.childhealthdata.org. Retrieved from www.childhealthdata.org, 2008. State Variation 2003 State Variation 2001 Top 5 States Average 65.1 Top 5 States Average 14.3 All States Average 58.1 All States Average 21.6 All States Median 57.9 All States Median 22.0 Bottom 5 States Average 51.1 Bottom 5 States Average 29.4 Appendix: Study Methodology 41 42 Table 3.8 Hospital Admissions for Pediatric Table 4.1 Family Costs of Health Care Asthma per 100,000 Children Ages 0–17 Alphabetical Order Rank Order Alphabetical Order Rank Order Average Average Rank State Rank State Rank State 2002 Rank State 2002 Rank* Rank* * Alabama * 1 Vermont 54.9 8 Alabama 13 1 Arkansas 6.5 * Alaska * 2 Oregon 75.2 47 Alaska 47 2 Arizona 8 10 Arizona 141.9 3 Nebraska 91.0 2 Arizona 8 2 Nevada 8 * Arkansas * 4 Utah 91.8 1 Arkansas 6.5 2 Utah 8 12 California 154.4 5 Iowa 93.8 12 California 15 5 Hawaii 9 16 Colorado 174.9 6 Maine 111.5 17 Colorado 19.5 6 Georgia 9.5 * Connecticut * 7 Wisconsin 118.0 49 Connecticut 47.5 7 Idaho 11 * Delaware * 8 Minnesota 125.3 40 Delaware 39.5 8 Alabama 13 * District of Columbia * 9 Nevada 141.7 51 District of Columbia 49.5 8 Virginia 13 29 Florida 238.5 10 Arizona 141.9 34 Florida 32 10 Mississippi 13.5 20 Georgia 184.2 11 Washington 149.2 6 Georgia 9.5 11 North Carolina 14 14 Hawaii 160.7 12 California 154.4 5 Hawaii 9 12 California 15 * Idaho * 12 Massachusetts 154.4 7 Idaho 11 12 Iowa 15 19 Illinois 179.5 14 Hawaii 160.7 25 Illinois 23.5 12 Montana 15 * Indiana * 15 Kansas 162.8 28 Indiana 26.5 12 New Mexico 15 5 Iowa 93.8 16 Colorado 174.9 12 Iowa 15 16 Kansas 17.5 15 Kansas 162.8 17 Maryland 176.7 16 Kansas 17.5 17 Colorado 19.5 31 Kentucky 273.3 18 Ohio 177.3 32 Kentucky 28.5 17 Louisiana 19.5 * Louisiana * 19 Illinois 179.5 17 Louisiana 19.5 17 Missouri 19.5 6 Maine 111.5 20 Georgia 184.2 46 Maine 45 20 South Carolina 20 17 Maryland 176.7 21 Virginia 187.2 31 Maryland 27.5 21 North Dakota 20.5 U.S. Variations in Child Health System Performance: A State Scorecard 12 Massachusetts 154.4 22 North Carolina 196.1 47 Massachusetts 47 22 Nebraska 21.5 * Michigan * 23 West Virginia 197.8 28 Michigan 26.5 22 South Dakota 21.5 8 Minnesota 125.3 24 Texas 210.4 36 Minnesota 33.5 24 Oregon 22 * Mississippi * 25 Rhode Island 212.4 10 Mississippi 13.5 25 Illinois 23.5 26 Missouri 220.7 26 Missouri 220.7 17 Missouri 19.5 26 Oklahoma 24.5 * Montana * 27 Tennessee 221.6 12 Montana 15 26 Tennessee 24.5 3 Nebraska 91.0 28 New Jersey 225.6 22 Nebraska 21.5 28 Indiana 26.5 9 Nevada 141.7 29 Florida 238.5 2 Nevada 8 28 Michigan 26.5 * New Hampshire * 30 Pennsylvania 244.3 40 New Hampshire 39.5 28 Texas 26.5 28 New Jersey 225.6 31 Kentucky 273.3 43 New Jersey 40.5 31 Maryland 27.5 * New Mexico * 32 New York 303.9 12 New Mexico 15 32 Kentucky 28.5 32 New York 303.9 33 South Carolina 314.2 45 New York 44 32 Washington 28.5 22 North Carolina 196.1 * Alabama * 11 North Carolina 14 34 Florida 32 * North Dakota * * Alaska * 21 North Dakota 20.5 34 Ohio 32 18 Ohio 177.3 * Arkansas * 34 Ohio 32 36 Minnesota 33.5 * Oklahoma * * Connecticut * 26 Oklahoma 24.5 37 Wyoming 34 2 Oregon 75.2 * Delaware * 24 Oregon 22 38 Wisconsin 35.5 30 Pennsylvania 244.3 * District of Columbia * 42 Pennsylvania 40 39 West Virginia 37.5 25 Rhode Island 212.4 * Idaho * 49 Rhode Island 47.5 40 Delaware 39.5 33 South Carolina 314.2 * Indiana * 20 South Carolina 20 40 New Hampshire 39.5 * South Dakota * * Louisiana * 22 South Dakota 21.5 42 Pennsylvania 40 27 Tennessee 221.6 * Michigan * 26 Tennessee 24.5 43 New Jersey 40.5 24 Texas 210.4 * Mississippi * 28 Texas 26.5 44 Vermont 43 4 Utah 91.8 * Montana * 2 Utah 8 45 New York 44 1 Vermont 54.9 * New Hampshire * 44 Vermont 43 46 Maine 45 21 Virginia 187.2 * New Mexico * 8 Virginia 13 47 Alaska 47 11 Washington 149.2 * North Dakota * 32 Washington 28.5 47 Massachusetts 47 23 West Virginia 197.8 * Oklahoma * 39 West Virginia 37.5 49 Connecticut 47.5 7 Wisconsin 118.0 * South Dakota * 38 Wisconsin 35.5 49 Rhode Island 47.5 * Wyoming * * Wyoming * 37 Wyoming 34 51 District of Columbia 49.5 United States 187.6 * Average Rank is the average of the state’s rank across all indicators in the dimension. * Indicates data value is missing. Costs dimension includes: total personal health spending per capita and average Note: Excludes obstetric and neonatal admissions and transfers from other family premium for employer-sponsored health insurance. institutions. Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Data: Healthcare Cost and Utilization Project (HCUP) State Inpatient Health Statistics Group and KFF State Health Facts. Databases; not all States participate in HCUP. Estimates for the total U.S. are from the Nationwide Inpatient Sample (AHRQ, HCUP-SID 2002). Reported in the 2005 National Healthcare Quality Report (AHRQ 2005). State Variation 2002 State Variation Average Rank Top 5 States Average 81.3 Top 5 States Average 7.9 All States Average 174.7 All States Average 26.0 All States Median 176.7 All States Median 24.5 Bottom 5 States Average 274.8 Bottom 5 States Average 47.7 Appendix: Study Methodology 43 Table 4.2 Personal Health Care Spending per Capita, 2004 State Variation 2005 Alphabetical Order Rank Order Top 5 States Average 4311.7 Rank State 2004 Rank State 2004 All States Average 5399.3 21 Alabama 5,135 1 Utah 3,972 All States Median 5327.2 47 Alaska 6,450 2 Arizona 4,103 Bottom 5 States Average 6091.1 2 Arizona 4,103 3 Idaho 4,444 11 Arkansas 4,863 4 New Mexico 4,471 8 California 4,638 5 Nevada 4,569 9 Colorado 4,717 6 Georgia 4,600 46 Connecticut 6,344 7 Texas 4,601 45 Delaware 6,306 8 California 4,638 51 District of Columbia 8,295 9 Colorado 4,717 33 Florida 5,483 10 Virginia 4,822 6 Georgia 4,600 11 Arkansas 4,863 14 Hawaii 4,941 12 Oregon 4,880 3 Idaho 4,444 13 Oklahoma 4,917 24 Illinois 5,293 14 Hawaii 4,941 25 Indiana 5,295 15 Louisiana 5,040 27 Iowa 5,380 16 Michigan 5,058 28 Kansas 5,382 17 Mississippi 5,059 32 Kentucky 5,473 18 Montana 5,080 15 Louisiana 5,040 19 Washington 5,092 49 Maine 6,540 20 South Carolina 5,114 34 Maryland 5,590 21 Alabama 5,135 50 Massachusetts 6,683 22 North Carolina 5,191 16 Michigan 5,058 23 Wyoming 5,265 38 Minnesota 5,795 24 Illinois 5,293 17 Mississippi 5,059 25 Indiana 5,295 30 Missouri 5,444 26 South Dakota 5,327 18 Montana 5,080 27 Iowa 5,380 35 Nebraska 5,599 28 Kansas 5,382 5 Nevada 4,569 29 New Hampshire 5,432 29 New Hampshire 5,432 30 Missouri 5,444 39 New Jersey 5,807 31 Tennessee 5,464 4 New Mexico 4,471 32 Kentucky 5,473 48 New York 6,535 33 Florida 5,483 22 North Carolina 5,191 34 Maryland 5,590 40 North Dakota 5,808 35 Nebraska 5,599 37 Ohio 5,725 36 Wisconsin 5,670 13 Oklahoma 4,917 37 Ohio 5,725 12 Oregon 4,880 38 Minnesota 5,795 41 Pennsylvania 5,933 39 New Jersey 5,807 44 Rhode Island 6,193 40 North Dakota 5,808 20 South Carolina 5,114 41 Pennsylvania 5,933 26 South Dakota 5,327 42 West Virginia 5,954 31 Tennessee 5,464 43 Vermont 6,069 7 Texas 4,601 44 Rhode Island 6,193 1 Utah 3,972 45 Delaware 6,306 43 Vermont 6,069 46 Connecticut 6,344 10 Virginia 4,822 47 Alaska 6,450 19 Washington 5,092 48 New York 6,535 42 West Virginia 5,954 49 Maine 6,540 36 Wisconsin 5,670 50 Massachusetts 6,683 23 Wyoming 5,265 51 District of Columbia 8,295 United States $5,283 Note: For Medicare, enrollees are the number of persons enrolled in the hospital and/or supplementary medical insurance programs. Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. 44 U.S. Variations in Child Health System Performance: A State Scorecard Table 4.3 Average Family Premium per Enrolled Employee for Employer-Based Health Insurance, FY 2005 Alphabetical Order Rank Order State Variation 2005 Rank State 2005 Rank State 2005 Top 5 States Average 9139.0 5 Alabama $9,420 1 North Dakota $8,334 All States Average 10612.4 47 Alaska $11,542 2 Arkansas $9,190 All States Median 10637.0 14 Arizona $10,268 3 Iowa $9,359 Bottom 5 States Average 11650.0 2 Arkansas $9,190 4 Hawaii $9,392 22 California $10,551 5 Alabama $9,420 30 Colorado $10,850 6 North Carolina $9,657 49 Connecticut $11,717 7 Kansas $9,734 34 Delaware $10,964 8 Nebraska $9,805 48 District of Columbia $11,623 9 Missouri $9,948 31 Florida $10,852 10 Mississippi $9,987 13 Georgia $10,262 11 Nevada $10,011 4 Hawaii $9,392 12 Montana $10,058 19 Idaho $10,398 13 Georgia $10,262 23 Illinois $10,574 14 Arizona $10,268 28 Indiana $10,678 15 Utah $10,282 3 Iowa $9,359 16 Virginia $10,292 7 Kansas $9,734 17 South Dakota $10,312 25 Kentucky $10,617 18 Tennessee $10,361 24 Louisiana $10,602 19 Idaho $10,398 41 Maine $11,289 20 South Carolina $10,436 21 Maryland $10,528 21 Maryland $10,528 44 Massachusetts $11,435 22 California $10,551 37 Michigan $11,005 23 Illinois $10,574 29 Minnesota $10,846 24 Louisiana $10,602 10 Mississippi $9,987 25 Kentucky $10,617 9 Missouri $9,948 26 New Mexico $10,637 12 Montana $10,058 27 Ohio $10,662 8 Nebraska $9,805 28 Indiana $10,678 11 Nevada $10,011 29 Minnesota $10,846 50 New Hampshire $11,835 30 Colorado $10,850 42 New Jersey $11,403 31 Florida $10,852 26 New Mexico $10,637 32 Oregon $10,898 40 New York $11,280 33 West Virginia $10,900 6 North Carolina $9,657 34 Delaware $10,964 1 North Dakota $8,334 35 Wisconsin $10,983 27 Ohio $10,662 36 Oklahoma $10,985 36 Oklahoma $10,985 37 Michigan $11,005 32 Oregon $10,898 38 Washington $11,018 39 Pennsylvania $11,108 39 Pennsylvania $11,108 51 Rhode Island $11,924 40 New York $11,280 20 South Carolina $10,436 41 Maine $11,289 17 South Dakota $10,312 42 New Jersey $11,403 18 Tennessee $10,361 43 Vermont $11,420 46 Texas $11,533 44 Massachusetts $11,435 15 Utah $10,282 45 Wyoming $11,467 43 Vermont $11,420 46 Texas $11,533 16 Virginia $10,292 47 Alaska $11,542 38 Washington $11,018 48 District of Columbia $11,623 33 West Virginia $10,900 49 Connecticut $11,717 35 Wisconsin $10,983 50 New Hampshire $11,835 45 Wyoming $11,467 51 Rhode Island $11,924 United States $10,728 Source: KFF State Health Facts. Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. 2005 Medical Expenditure Panel Survey (MEPS) -Insurance Component. Tables II.D.1, II.D.2, II.D.3 available at: Medical Expenditure Panel survey (MEPS), accessed August 8, 2007. Appendix: Study Methodology 45 46 Table 5.1 Equitable Care: Disparities by Income, Insurance Status, and Race/Ethnicity Alphabetical Order Rank Order Insurance Race/Ethnicity Average Average Rank State Income Equity Rank State Coverage Equity Equity Rank* Rank* 28 Alabama 13 35 39 29.0 1 Vermont 1.3 29 Alaska 43 14 32 29.7 2 Massachusetts 3.3 49 Arizona 47 50 42 46.3 3 Maine 5.0 46 Arkansas 36 47 48 43.7 4 West Virginia 5.3 40 California 44 42 22 36.0 5 Rhode Island 5.7 42 Colorado 50 34 28 37.3 6 Connecticut 6.3 6 Connecticut 8 7 4 6.3 7 New Hampshire 6.7 20 Delaware 25 22 21 22.7 8 New York 9.7 15 District of 11 26 8 15.0 8 Pennsylvania 9.7 Columbia 43 Florida 49 38 26 37.7 10 Ohio 11.7 36 Georgia 21 35 49 35.0 11 Hawaii 12.7 11 Hawaii 12 17 9 12.7 12 Kentucky 13.0 45 Idaho 38 40 51 43.0 12 Maryland 13.0 26 Illinois 34 23 27 28.0 14 Wisconsin 13.7 30 Indiana 20 27 43 30.0 15 District of 15.0 Columbia 19 Iowa 26 12 29 22.3 16 New Jersey 17.7 30 Kansas 35 21 34 30.0 17 Michigan 21.7 12 Kentucky 10 14 15 13.0 18 Wyoming 22.0 33 Louisiana 37 39 17 31.0 19 Iowa 22.3 3 Maine 4 8 3 5.0 20 Delaware 22.7 12 Maryland 21 9 9 13.0 20 Washington 22.7 U.S. Variations in Child Health System Performance: A State Scorecard 2 Massachusetts 4 1 5 3.3 22 Montana 23.7 17 Michigan 24 18 23 21.7 23 Nebraska 24.7 38 Minnesota 40 27 39 35.3 24 Tennessee 26.3 48 Mississippi 44 48 45 45.7 25 North Carolina 26.7 27 Missouri 42 18 25 28.3 26 Illinois 28.0 22 Montana 31 23 17 23.7 27 Missouri 28.3 23 Nebraska 7 43 24 24.7 28 Alabama 29.0 51 Nevada 51 49 43 47.7 29 Alaska 29.7 7 New Hampshire 2 4 14 6.7 30 Indiana 30.0 16 New Jersey 28 14 11 17.7 30 Kansas 30.0 41 New Mexico 32 40 39 37.0 32 North Dakota 30.3 8 New York 18 6 5 9.7 33 Louisiana 31.0 25 North Carolina 17 29 34 26.7 33 South Carolina 31.0 32 North Dakota 33 20 38 30.3 35 Virginia 32.0 10 Ohio 15 9 11 11.7 36 Georgia 35.0 49 Oklahoma 44 45 50 46.3 36 South Dakota 35.0 47 Oregon 47 44 45 45.3 38 Minnesota 35.3 8 Pennsylvania 9 3 17 9.7 39 Utah 35.7 5 Rhode Island 6 4 7 5.7 40 California 36.0 33 South Carolina 21 25 47 31.0 41 New Mexico 37.0 36 South Dakota 38 30 37 35.0 42 Colorado 37.3 24 Tennessee 13 33 33 26.3 43 Florida 37.7 44 Texas 40 51 29 40.0 44 Texas 40.0 39 Utah 28 45 34 35.7 45 Idaho 43.0 1 Vermont 1 2 1 1.3 46 Arkansas 43.7 35 Virginia 30 35 31 32.0 47 Oregon 45.3 20 Washington 27 30 11 22.7 48 Mississippi 45.7 4 West Virginia 3 12 1 5.3 49 Arizona 46.3 14 Wisconsin 15 9 17 13.7 49 Oklahoma 46.3 18 Wyoming 18 32 16 22.0 51 Nevada 47.7 * Average Rank is the average of the state’s rank across all indicators in the equity type. Equity domain is: the percentage point difference or “gaps” for each vulnerable subgroup (i.e., minority, low-income, uninsured) compared with the U.S. average for the full population for each of two indicators: percent of children with medical home and percent of children with at least one preventive and dental visit in past year. Source: National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. State Variation Average Rank Top 5 States Average 4.1 All States Average 25.7 All States Median 28.0 Bottom 5 States Average 46.3 Appendix: Study Methodology 47 Table 5.2 Equity: Insurance Percent of Children Ages 0–17 Without a Medical Home Percent of Children Ages 0–17 Without Both a Medical and Dental Preventive Care Visit in the Past Year Alphabetical Order Rank Order Rank on Medical Rank on Preventive Overall Rank State Overall Rank State Average Insurance Equity Home Equity Care Equity 35 Alabama 1 Massachusetts 5 1 3 14 Alaska 2 Vermont 3 4 3.5 50 Arizona 3 Pennsylvania 6 5 5.5 47 Arkansas 4 New Hampshire 2 10 6 42 California 4 Rhode Island 10 2 6 34 Colorado 6 New York 11 3 7 7 Connecticut 7 Connecticut 4 11 7.5 22 Delaware 8 Maine 1 16 8.5 26 District of Columbia 9 Maryland 12 8 10 38 Florida 9 Ohio 8 12 10 35 Georgia 9 Wisconsin 13 7 10 17 Hawaii 12 Iowa 6 19 12.5 40 Idaho 12 West Virginia 9 16 12.5 23 Illinois 14 Alaska 18 15 16.5 27 Indiana 14 Kentucky 15 18 16.5 12 Iowa 14 New Jersey 20 13 16.5 21 Kansas 17 Hawaii 28 6 17 14 Kentucky 18 Michigan 22 13 17.5 39 Louisiana 18 Missouri 14 21 17.5 8 Maine 20 North Dakota 17 23 20 9 Maryland 21 Kansas 24 20 22 1 Massachusetts 22 Delaware 25 22 23.5 18 Michigan 23 Illinois 26 26 26 27 Minnesota 23 Montana 19 33 26 48 Mississippi 25 South Carolina 23 30 26.5 18 Missouri 26 District of Columbia 46 9 27.5 23 Montana 27 Indiana 21 35 28 43 Nebraska 27 Minnesota 16 40 28 49 Nevada 29 North Carolina 33 25 29 4 New Hampshire 30 South Dakota 38 24 31 14 New Jersey 30 Washington 28 34 31 40 New Mexico 32 Wyoming 31 36 33.5 6 New York 33 Tennessee 40 28 34 29 North Carolina 34 Colorado 30 39 34.5 20 North Dakota 35 Alabama 27 43 35 9 Ohio 35 Georgia 41 29 35 45 Oklahoma 35 Virginia 43 27 35 44 Oregon 38 Florida 34 37 35.5 3 Pennsylvania 39 Louisiana 35 38 36.5 4 Rhode Island 40 Idaho 32 42 37 25 South Carolina 40 New Mexico 44 30 37 30 South Dakota 42 California 48 30 39 33 Tennessee 43 Nebraska 35 44 39.5 51 Texas 44 Oregon 39 46 42.5 45 Utah 45 Oklahoma 37 49 43 2 Vermont 45 Utah 45 41 43 35 Virginia 47 Arkansas 42 48 45 30 Washington 48 Mississippi 47 45 46 12 West Virginia 49 Nevada 50 47 48.5 9 Wisconsin 50 Arizona 49 51 50 32 Wyoming 51 Texas 51 50 50.5 A Gap is the difference between the US average for this each indicator and each state’s uninsured group. Note: Medical home is defined as having at least one preventive medical care visit in the past year; being able to access needed specialist care and services; and having a personal doctor/nurse who usually/always spends enough time and communicates clearly, provides telephone advice and urgent care when needed, and follows up after specialist care. Data: National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. 48 U.S. Variations in Child Health System Performance: A State Scorecard 5.3 Equity: Income Percent of Children Ages 0–17 Without a Medical Home Percent of Children Ages 0–17 Without Both a Medical and Dental Preventive Care Visit in the Past Year Alphabetical Order Rank Order Overall Rank State Overall Rank State Rank Rank Average Income Equity 13 Alabama 1 Vermont 2 1 1.5 43 Alaska 2 New Hampshire 1 4 2.5 47 Arizona 3 West Virginia 4 2 3 36 Arkansas 4 Maine 7 5 6 44 California 4 Massachusetts 9 3 6 50 Colorado 6 Rhode Island 3 11 7 8 Connecticut 7 Nebraska 8 9 8.5 25 Delaware 8 Connecticut 5 13 9 11 District of Columbia 9 Pennsylvania 13 6 9.5 49 Florida 10 Kentucky 11 12 11.5 21 Georgia 11 District of Columbia 17 7 12 12 Hawaii 12 Hawaii 17 10 13.5 38 Idaho 13 Alabama 16 14 15 34 Illinois 13 Tennessee 14 16 15 20 Indiana 15 Ohio 12 24 18 26 Iowa 15 Wisconsin 6 30 18 35 Kansas 17 North Carolina 33 8 20.5 10 Kentucky 18 New York 28 15 21.5 37 Louisiana 18 Wyoming 25 18 21.5 4 Maine 20 Indiana 25 21 23 21 Maryland 21 Georgia 20 27 23.5 4 Massachusetts 21 Maryland 24 23 23.5 24 Michigan 21 South Carolina 28 19 23.5 40 Minnesota 24 Michigan 22 26 24 44 Mississippi 25 Delaware 32 17 24.5 42 Missouri 26 Iowa 22 29 25.5 31 Montana 27 Washington 10 44 27 7 Nebraska 28 New Jersey 36 20 28 51 Nevada 28 Utah 14 42 28 2 New Hampshire 30 Virginia 25 32 28.5 28 New Jersey 31 Montana 21 38 29.5 32 New Mexico 32 New Mexico 40 22 31 18 New York 33 North Dakota 19 45 32 17 North Carolina 34 Illinois 37 28 32.5 33 North Dakota 35 Kansas 41 25 33 15 Ohio 36 Arkansas 34 40 37 44 Oklahoma 37 Louisiana 42 33 37.5 47 Oregon 38 Idaho 28 48 38 9 Pennsylvania 38 South Dakota 35 41 38 6 Rhode Island 40 Minnesota 46 31 38.5 21 South Carolina 40 Texas 43 34 38.5 38 South Dakota 42 Missouri 31 47 39 13 Tennessee 43 Alaska 45 35 40 40 Texas 44 California 49 35 42 28 Utah 44 Mississippi 47 37 42 1 Vermont 44 Oklahoma 38 46 42 30 Virginia 47 Arizona 48 39 43.5 27 Washington 47 Oregon 44 43 43.5 3 West Virginia 49 Florida 39 49 44 15 Wisconsin 50 Colorado 50 50 50 18 Wyoming 51 Nevada 51 51 51 A Gap is the difference between the US average for this indicator (53.9) and each state’s most vulnerable low-income (0-99% FPL or 100-199% 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: National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. Appendix: Study Methodology 49 Table 5.4 Equity: Race/Ethnicity Percent of Children Ages 0–17 Without a Medical Home Percent of Children Ages 0–17 Without Both a Medical and Dental Preventive Care Visit in the Past Year Alphabetical Order Rank Order Rank State Rank Med Home Rank Prev Care Average Rank* Rank State Rank Med Home Rank Prev Care Average Rank* 39 Alabama 45 30 37.5 1 Vermont 1 2 1.5 32 Alaska 41 21 31.0 1 West Virginia 2 1 1.5 42 Arizona 50 31 40.5 3 Maine 3 3 3.0 48 Arkansas 47 45 46.0 4 Connecticut 7 6 6.5 22 California 31 14 22.5 5 Massachusetts 10 4 7.0 28 Colorado 24 29 26.5 5 New York 9 5 7.0 4 Connecticut 7 6 6.5 7 Rhode Island 6 9 7.5 21 Delaware 25 18 21.5 8 District of Columbia 15 6 10.5 8 District of Columbia 15 6 10.5 9 Hawaii 16 8 12.0 26 Florida 22 28 25.0 9 Maryland 12 12 12.0 49 Georgia 49 47 48.0 11 New Jersey 14 11 12.5 9 Hawaii 16 8 12.0 11 Ohio 8 17 12.5 51 Idaho 51 49 50.0 11 Washington 11 14 12.5 27 Illinois 20 31 25.5 14 New Hampshire 4 23 13.5 43 Indiana 43 41 42.0 15 Kentucky 19 13 16.0 29 Iowa 18 39 28.5 16 Wyoming 25 10 17.5 34 Kansas 29 42 35.5 17 Louisiana 23 19 21.0 15 Kentucky 19 13 16.0 17 Montana 21 21 21.0 17 Louisiana 23 19 21.0 17 Pennsylvania 17 25 21.0 3 Maine 3 3 3.0 17 Wisconsin 5 37 21.0 9 Maryland 12 12 12.0 21 Delaware 25 18 21.5 5 Massachusetts 10 4 7.0 22 California 31 14 22.5 23 Michigan 30 16 23.0 23 Michigan 30 16 23.0 39 Minnesota 35 40 37.5 24 Nebraska 27 20 23.5 45 Mississippi 44 43 43.5 25 Missouri 12 36 24.0 25 Missouri 12 36 24.0 26 Florida 22 28 25.0 17 Montana 21 21 21.0 27 Illinois 20 31 25.5 24 Nebraska 27 20 23.5 28 Colorado 24 29 26.5 43 Nevada 40 44 42.0 29 Iowa 18 39 28.5 14 New Hampshire 4 23 13.5 29 Texas 34 23 28.5 11 New Jersey 14 11 12.5 31 Virginia 33 27 30.0 39 New Mexico 42 33 37.5 32 Alaska 41 21 31.0 5 New York 9 5 7.0 33 Tennessee 32 38 35.0 34 North Carolina 37 34 35.5 34 Kansas 29 42 35.5 38 North Dakota 28 46 37.0 34 North Carolina 37 34 35.5 11 Ohio 8 17 12.5 34 Utah 36 35 35.5 50 Oklahoma 46 51 48.5 37 South Dakota 47 26 36.5 45 Oregon 39 48 43.5 38 North Dakota 28 46 37.0 17 Pennsylvania 17 25 21.0 39 Alabama 45 30 37.5 7 Rhode Island 6 9 7.5 39 Minnesota 35 40 37.5 47 South Carolina 38 50 44.0 39 New Mexico 42 33 37.5 37 South Dakota 47 26 36.5 42 Arizona 50 31 40.5 33 Tennessee 32 38 35.0 43 Indiana 43 41 42.0 29 Texas 34 23 28.5 43 Nevada 40 44 42.0 34 Utah 36 35 35.5 45 Mississippi 44 43 43.5 1 Vermont 1 2 1.5 45 Oregon 39 48 43.5 31 Virginia 33 27 30.0 47 South Carolina 38 50 44.0 11 Washington 11 14 12.5 48 Arkansas 47 45 46.0 1 West Virginia 2 1 1.5 49 Georgia 49 47 48.0 17 Wisconsin 5 37 21.0 50 Oklahoma 46 51 48.5 16 Wyoming 25 10 17.5 51 Idaho 51 49 50.0 A Gap is the difference between the US average for this indicator 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. Healthy Lives domain includes: percent of young children at moderate/high risk for developmental delay and infant mortality (deaths per 1,000 live births). Source: National Vital Statistics System - Linked Birth and Infant Death Data (NCHS, NVSS n.d.). Reported in the 2005 National Healthcare Quality Report (AHRQ 2005) and National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. 50 U.S. Variations in Child Health System Performance: A State Scorecard Table 6.1 Potential to Lead Healthy Lives Alphabetical Order Rank Order State Variation 2002 Rank State Average Rank Rank State Average Rank Top 5 States Average 5.2 48 Alabama 45.5 1 Vermont 1.5 All States Average 25.7 13 Alaska 15.0 2 Maine 4.0 All States Median 25.0 35 Arizona 33.0 3 Utah 6.0 Bottom 5 States Average 46.6 48 Arkansas 45.5 4 New Hampshire 7.0 15 California 18.5 5 Colorado 7.5 5 Colorado 7.5 6 Washington 10.0 21 Connecticut 21.5 7 Minnesota 11.5 34 Delaware 32.5 8 Wyoming 12.5 38 District of Columbia 36.0 9 North Dakota 13.0 38 Florida 36.0 10 New Mexico 13.5 47 Georgia 43.0 11 South Dakota 14.0 41 Hawaii 36.5 12 Texas 14.5 13 Idaho 15.0 13 Alaska 15.0 38 Illinois 36.0 13 Idaho 15.0 33 Indiana 32.0 15 California 18.5 17 Iowa 19.0 15 Montana 18.5 23 Kansas 22.0 17 Iowa 19.0 18 Kentucky 19.5 18 Kentucky 19.5 51 Louisiana 50.0 18 Nebraska 19.5 2 Maine 4.0 20 Massachusetts 20.5 28 Maryland 27.0 21 Connecticut 21.5 20 Massachusetts 20.5 21 Nevada 21.5 36 Michigan 35.0 23 Kansas 22.0 7 Minnesota 11.5 24 Oregon 22.5 50 Mississippi 49.0 25 Virginia 23.5 29 Missouri 29.0 26 Wisconsin 25.0 15 Montana 18.5 27 New York 26.0 18 Nebraska 19.5 28 Maryland 27.0 21 Nevada 21.5 29 Missouri 29.0 4 New Hampshire 7.0 29 New Jersey 29.0 29 New Jersey 29.0 31 Ohio 31.0 10 New Mexico 13.5 31 Rhode Island 31.0 27 New York 26.0 33 Indiana 32.0 46 North Carolina 42.5 34 Delaware 32.5 9 North Dakota 13.0 35 Arizona 33.0 31 Ohio 31.0 36 Michigan 35.0 45 Oklahoma 40.5 37 Pennsylvania 35.5 24 Oregon 22.5 38 District of Columbia 36.0 37 Pennsylvania 35.5 38 Florida 36.0 31 Rhode Island 31.0 38 Illinois 36.0 41 South Carolina 36.5 41 Hawaii 36.5 11 South Dakota 14.0 41 South Carolina 36.5 43 Tennessee 39.0 43 Tennessee 39.0 12 Texas 14.5 43 West Virginia 39.0 3 Utah 6.0 45 Oklahoma 40.5 1 Vermont 1.5 46 North Carolina 42.5 25 Virginia 23.5 47 Georgia 43.0 6 Washington 10.0 48 Alabama 45.5 43 West Virginia 39.0 48 Arkansas 45.5 26 Wisconsin 25.0 50 Mississippi 49.0 8 Wyoming 12.5 51 Louisiana 50.0 United States 7.0 Healthy Lives domain includes: percent of young children at moderate/high risk for developmental delay and infant mortality (deaths per 1,000 live births). Source: National Vital Statistics System - Linked Birth and Infant Death Data (NCHS, NVSS n.d.). Reported in the 2005 National Healthcare Quality Report (AHRQ 2005) and National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Appendix: Study Methodology 51 52 Table 6.2 Infant Mortality, Deaths per 1,000 Live Births Table 6.3 Percent of Children Ages 1–5 Years at Moderate/High Risk for Developmental Delay Alphabetical Order Rank Order Alphabetical Order Rank Order Rank State 2002 Rank State 2002 Rank State 2003 Rank State 2003 46 Alabama 9.1 1 Maine 4.3 45 Alabama 27.2 1 Vermont 16.4 8 Alaska 5.6 2 Vermont 4.4 22 Alaska 23.4 2 Colorado 16.6 20 Arizona 6.4 3 Massachusetts 4.8 46 Arizona 27.6 3 Wyoming 19.1 41 Arkansas 8.4 4 New Hampshire 5.0 50 Arkansas 32.8 4 Utah 19.3 7 California 5.4 5 Iowa 5.3 30 California 23.9 5 Montana 19.4 13 Colorado 6.0 5 Minnesota 5.3 2 Colorado 16.6 6 South Dakota 20.4 21 Connecticut 6.5 7 California 5.4 22 Connecticut 23.4 7 Maine 20.7 43 Delaware 8.6 8 Alaska 5.6 22 Delaware 23.4 8 North Dakota 21.0 51 District of Columbia 11.0 8 Utah 5.6 21 District of Columbia 23.2 8 Washington 21.0 32 Florida 7.5 10 New Jersey 5.7 40 Florida 26.3 10 New Hampshire 21.1 45 Georgia` 9.0 10 Oregon 5.7 41 Georgia 26.5 11 Texas 21.3 29 Hawaii 7.4 12 Washington 5.8 44 Hawaii 27.1 12 Kentucky 22.1 15 Idaho 6.1 13 Colorado 6.0 15 Idaho 22.3 12 New Mexico 22.1 29 Illinois 7.4 13 New York 6.0 43 Illinois 26.6 14 Nebraska 22.2 36 Indiana 7.8 15 Idaho 6.1 28 Indiana 23.7 15 Idaho 22.3 5 Iowa 5.3 15 Nevada 6.1 33 Iowa 24.8 16 Missouri 22.4 27 Kansas 7.2 15 New Mexico 6.1 17 Kansas 22.5 17 Kansas 22.5 27 Kentucky 7.2 18 North Dakota 6.3 12 Kentucky 22.1 18 Minnesota 22.6 49 Louisiana 10.0 18 Texas 6.3 51 Louisiana 32.9 18 Virginia 22.6 1 Maine 4.3 20 Arizona 6.4 7 Maine 20.7 20 Maryland 23.0 34 Maryland 7.6 21 Connecticut 6.5 20 Maryland 23.0 21 District of Columbia 23.2 U.S. Variations in Child Health System Performance: A State Scorecard 3 Massachusetts 4.8 22 South Dakota 6.7 38 Massachusetts 25.7 22 Alaska 23.4 38 Michigan 8.1 22 Wyoming 6.7 32 Michigan 24.4 22 Connecticut 23.4 5 Minnesota 5.3 24 Wisconsin 6.8 18 Minnesota 22.6 22 Delaware 23.4 49 Mississippi 10.0 25 Nebraska 7.0 49 Mississippi 31.5 25 Ohio 23.5 42 Missouri 8.5 26 Rhode Island 7.1 16 Missouri 22.4 26 South Carolina 23.6 32 Montana 7.5 27 Kansas 7.2 5 Montana 19.4 26 Wisconsin 23.6 25 Nebraska 7.0 27 Kentucky 7.2 14 Nebraska 22.2 28 Indiana 23.7 15 Nevada 6.1 29 Hawaii 7.4 28 Nevada 23.7 28 Nevada 23.7 4 New Hampshire 5.0 29 Illinois 7.4 10 New Hampshire 21.1 30 California 23.9 10 New Jersey 5.7 29 Virginia 7.4 48 New Jersey 29.7 31 Tennessee 24.0 15 New Mexico 6.1 32 Florida 7.5 12 New Mexico 22.1 32 Michigan 24.4 13 New York 6.0 32 Montana 7.5 39 New York 26.2 33 Iowa 24.8 38 North Carolina 8.1 34 Maryland 7.6 47 North Carolina 28.0 34 West Virginia 25.0 18 North Dakota 6.3 34 Pennsylvania 7.6 8 North Dakota 21.0 35 Oregon 25.2 37 Ohio 7.9 36 Indiana 7.8 25 Ohio 23.5 36 Rhode Island 25.5 40 Oklahoma 8.2 37 Ohio 7.9 41 Oklahoma 26.5 37 Pennsylvania 25.6 10 Oregon 5.7 38 Michigan 8.1 35 Oregon 25.2 38 Massachusetts 25.7 34 Pennsylvania 7.6 38 North Carolina 8.1 37 Pennsylvania 25.6 39 New York 26.2 26 Rhode Island 7.1 40 Oklahoma 8.2 36 Rhode Island 25.5 40 Florida 26.3 47 South Carolina 9.3 41 Arkansas 8.4 26 South Carolina 23.6 41 Georgia 26.5 22 South Dakota 6.7 42 Missouri 8.5 6 South Dakota 20.4 41 Oklahoma 26.5 47 Tennessee 9.3 43 Delaware 8.6 31 Tennessee 24.0 43 Illinois 26.6 18 Texas 6.3 44 West Virginia 8.9 11 Texas 21.3 44 Hawaii 27.1 8 Utah 5.6 45 Georgia 9.0 4 Utah 19.3 45 Alabama 27.2 2 Vermont 4.4 46 Alabama 9.1 1 Vermont 16.4 46 Arizona 27.6 29 Virginia 7.4 47 South Carolina 9.3 18 Virginia 22.6 47 North Carolina 28.0 12 Washington 5.8 47 Tennessee 9.3 8 Washington 21.0 48 New Jersey 29.7 44 West Virginia 8.9 49 Louisiana 10.0 34 West Virginia 25.0 49 Mississippi 31.5 24 Wisconsin 6.8 49 Mississippi 10.0 26 Wisconsin 23.6 50 Arkansas 32.8 22 Wyoming 6.7 51 District of Columbia 11.0 3 Wyoming 19.1 51 Louisiana 32.9 United States 7.0 United States 24.5 Data: National Vital Statistics System - Linked Birth and Infant Death Data (NCHS, NVSS n.d.). Note: Children with 1 or more parent-reported concerns indicative of developmental risk. Reported in the 2005 National Healthcare Quality Report (AHRQ 2005). Data: National Survey of Children’s Health. Data assembled by the Child and Adolescent Health Measurement Initiative (CAHMI 2005). Retrieved from www.childhealthdata.org, 2008. State Variation 2002 State Variation 2003 Top 5 States Average 4.8 Top 5 States Average 18.2 All States Average 7.1 All States Average 24.0 All States Median 7.1 All States Median 23.6 Bottom 5 States Average 9.9 Bottom 5 States Average 31.0 Appendix: Study Methodology 53 Notes 1 J. M. Lambrew, The State Children’s Health Insurance 5 J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, Program: Past, Present, and Future (New York: and D. McCarthy, Aiming Higher: Results from a The Commonwealth Fund, Feb. 2007); Henry J. State Scorecard on Health System Performance (New Kaiser Family Foundation, Impacts of Medicaid and York: The Commonwealth Fund Commission on SCHIP on Low-Income Children’s Health, Fact Sheet a High Performance Health System, June 2007); (Washington, D.C.: Kaiser Family Foundation, May The Commonwealth Fund Commission on a High 2007), available at http://www.kff.org/medicaid/ Performance Health System, Why Not the Best? upload/7645.pdf. Results from a National Scorecard on U.S. Health 2 E. S. Fisher, D. E. Wennberg, T. A. Stukel et System Performance (New York: The Commonwealth al., “The Implications of Regional Variations in Fund, Sept. 2006). Medicare Spending. Part 1: The Content, Quality, 6 Fisher, Wennberg, Stukel et al., “Implications of and Accessibility of Care,” Annals of Internal Regional Variations,” 2003; Baicker and Chandra, Medicine, Feb. 18, 2003 138(4):273–87; K. Baicker “Medicare Spending,” 2004. and A. Chandra, “Medicare Spending, the Physician 7 Cantor, Schoen, Belloff et al., Aiming Higher, 2007. Workforce, and Beneficiaries’ Quality of Care,” 8 Annie E. Casey Foundation, KIDS COUNT, 2007; Health Affairs Web Exclusive (Apr. 7, 2004):w4- available at http://www.aecf.org/KnowledgeCenter/ 184–w4-197. KCDataResrchRpts.aspx (last accessed Apr. 2, 3 A. C. Beal, M. M. Doty, S. E. Hernandez, K. K. 2008). Shea, and K. Davis, Closing the Divide: How Medical 9 N. Kaye, J. May, and M. Abrams, State Policy Options Homes Promote Equity in Health Care: Results From to Improve Delivery of Child Development Services: The Commonwealth Fund 2006 Health Care Quality Strategies from the Eight ABCD States (Portland, Survey (New York: The Commonwealth Fund, June Maine, and New York: National Academy for State 2007). Health Policy and The Commonwealth Fund, Dec. 4 E. I. Knudsen, J. J. Heckman, J. Cameron et al., 2006). “Economic, Neurobiological, and Behavioral 10 P. C. Damiano and J. C. Willard, Hawk-i: Impact on Perspectives on Building America’s Future Access and Health Status, Fourth Evaluation Report to Workforce,” Proceedings of the National Academy of The hawk-i Clinical Advisory Committee (Iowa City, Sciences, July 5, 2006 103(27):10155–62. Iowa: Health Policy Research Program, University of Iowa, Apr. 2003). 11 The Urban Studies Institute at the University of Louisville, analysis of data from the U.S. Census Bureau, Current Population Survey (March supplement), 1990 through 2007 (including March 2001 bridge file). Updated Sept. 2007. 12 Lambrew, State Children’s Health Insurance Program, 2007. Notes 55 13 C. DeNavas-Walt, B. D. Proctor, and J. Smith, 21 Henry J. Kaiser Family Foundation/Health Research “Income, Poverty, and Health Insurance Coverage and Educational Trust, Employer Health Benefits in the United States: 2006” (Washington, D.C.: 2007 Annual Survey (Washington, D.C., and U.S. Census Bureau, 2007). Chicago: KFF and HRET, 2007), available at http:// 14 Medical Home Initiatives for Children with Special www.kff.org/insurance/7672/index.cfm. Needs Project Advisory Committee, American 22 J. Holahan, Variations Among States in Health Academy of Pediatrics, “The Medical Home,” Insurance Coverage and Medical Expenditures: How Pediatrics, July 2002 110(1 Pt 1):184–86. Much Is Too Much? (Washington, D.C.: Urban 15 D. A Christakis, L. Mell, T. D. Koepsell et al., Institute, June 2002), available at http://www.urban. “Association of Lower Continuity of Care with org/uploadedpdf/310520_DP0207.pdf. Greater Risk of Emergency Department Use and 23 Henry J. Kaiser Family Foundation, State Health Hospitalization in Children,” Pediatrics, Mar. Facts: Rhode Island and North Dakota (Washington, 2001 107(3):524–29; B. Starfield and L. Shi, “The D.C.: Kaiser Family Foundation, 2007), available Medical Home, Access to Care, and Insurance: A at www.statehealthfacts.org (last accessed Dec. 21, Review of Evidence,” Pediatrics, May 2004 113(5 2007). Suppl):1493–98. 24 Baicker and Chandra, “Medicare Spending,” 2004. 16 M. Regalado and N. Halfon, Primary Care Services: 25 A. Case, D. Lubotsky, and C. Paxson, Economic Promoting Optimal Child Development from Birth to Status and Health in Childhood: The Origins of the Three Years (New York: The Commonwealth Fund, Gradient (Princeton, N.J.: Princeton University Sept. 2002). Center for Health and Wellbeing, Feb. 2002), 17 M. Krauss, N. Wells, S. Gulley et al., “Navigating available at http://www.princeton.edu/~rpds/ Systems of Care: Results from a National Survey downloads/case_paxson_economic_status_paper. of Families of Children with Special Health Care pdf (last accessed Apr. 2, 2008); D. Wood, “Effect Needs,” in Children’s Services: Social Policy, Research, of Child and Family Poverty on Child Health in the and Practice (Mahwah, N.J.: Lawrence Erlbaum United States,” Pediatrics, Sept. 2003 112(3):707–11. Associates, Inc., 2001), 165–87. 26 E. L. Schor, M. K. Abrams, and K. K. Shea, 18 Cantor, Schoen, Belloff et al., Aiming Higher, 2007. “Medicaid: Health Promotion and Disease 19 Centers for Medicare & Medicaid Services, 2006 Prevention for School Readiness,” Health Affairs, National Summary of State Medicaid Managed Mar./Apr. 2007 26(2):420–29. Care Programs, (Washington, D.C.: CMS, July 27 S. F. Jencks, E. D. Huff, and T. Cuerdon, “Change 20, 2006), available at http://www.cms.hhs. in the Quality of Care Delivered to Medicare gov/MedicaidDataSourcesGenInfo/Downloads/ Beneficiaries, 1998–1999 to 2000–2001,” Journal nationalsummreport06.pdf. of the American Medical Association, Jan. 15, 2003 20 H. T. Ireys, T. Krissik, J. M. Verdier et al., Using 289(3):305–12. External Quality Review Organizations to Improve the Quality of Preventive and Developmental Services for Children (New York: The Commonwealth Fund, June 2005). 56 U.S. Variations in Child Health System Performance: A State Scorecard One East 75th Street New York, NY 10021-2692 Tel 212.606.3800 Fax 212.606.3500 www.commonwealthfund.org