Large variations exist in children's health care among states

Using data from sources such as the US Census and the National Center for Health Statistics, the report calculated how much better the nation could do if all states came up to the level of the highest ranked states. About 4.7 million more children would have health insurance, over 750,000 children aged 19 to 35 months would be up to date on the five key vaccines, and 11.8 million more children would have had both medical and dental visits in the last year.

In terms of children who received the most important vaccines, the national average was 80.7%. However the top five states (Massachusetts, Nebraska, South Dakota, Connecticut, and Virginia) averaged 88.3%, and the bottom five states (Utah, District of Columbia, Oregon, Arkansas, and Nevada) averaged 71%.

Edward Schor, MD, Commonwealth Fund vice president and a pediatrician, talked to reporters in a conference call. "Unlike adult health care in this country-which is largely driven by federal policy-child health care is in general a state function. Children rely heavily on Medicaid and SCHIP [State Child Health Insurance Program] in their states ... the states really are responsible for what is available to the children."

The report notes some regional standouts. For example, most Southern states have high levels of uninsured children, but Alabama is seventh in providing coverage for children. Only 6% of children are uninsured. And for coverage of children at or below 200% of poverty, Alabama ranked 13th, with 12.5% uninsured.

Karen Davis, PhD, Commonwealth Fund president, said, "certainly with regard to Alabama it was a matter of leadership. The state was the first one to take advantage of [SCHIP], enacted in 1997. It was also very effective at forging a public-private partnership, specifically with BlueCross BlueShield of Alabama, whereby the Blues agreed to provide insurance coverage to children in families with incomes just above the cut-off for eligibility for SCHIP program."

Schor added, "As you go up that income scale, the actual cost of insuring children for health care probably goes down ... it's a fairly inexpensive process."

The report cited some statistics to indicate how information lags. For example, the 2003 National Survey on Children Health stated that the top five states had almost 60% of children with a medical home, but the bottom five states had only 36%.

Schor said, "There is a relative paucity of data on children's health and health care services in the US. There is only one set of surveys that actually gives us uniform data across the states. We could use more data, particularly at a local level."

"We certainly hope and expect that the SCHIP legislation will be authorized when it next comes before Congress and the president," said Schor. "And that adequate funding will be there ... that the legislation will include language that speaks to the quality of care that is provided, to reporting on data about the care that children are receiving and to help establish standards of what the benefits should be for SCHIP, particularly for preventive care for developmental services for young children."

KATHRYN FOXHALL is a contributing editor to Contemporary Pediatrics.