The Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 has the potential to transform children’s health care in the United States. This report analyzes selected provisions of the legislation that involve outreach and enrollment, as well as child health quality and measurement. Using input from interviews with a range of stakeholders and a panel of experts, the report provides a set of recommendations for the federal government officials charged with implementing CHIPRA.

The authors found that children who experience short spells of uninsurance are less likely to have a usual source of care and are more likely to experience delays in needed care than those with continuous private or public insurance. The consequences are even worse for children who experience more substantial periods of uninsurance, because they are also less likely to receive preventive care or visit the doctor during the year and are more likely to experience delays in receiving needed medical care and prescriptions than those with continuous coverage.

This issue brief describes three legislative proposals and additional quality provisions related specifically to primary care to consider for incorporation into federal law. These provisions include: 1) establishing a core set of primary child health service outcomes for tracking within Medicaid and SCHIP; 2) creating a structure within CMS that focuses on strengthening primary, preventive, and developmental child health services; 3) supporting additional research on child health quality and outcomes in primary care; and 4) providing incentives to states to promote evidence-based practices in children’s primary health care.

In October 2007, the KCMU and NASHP convened a meeting of policy officials and oral health experts to discuss children’s access to dental care in Medicaid and the SCHIP and exchange information and perspectives on the strategies have worked best to improve it. This report summarizes the recommendations on a wide assortment of effective actions that states can take related to each of several key dimensions of children’s access to oral health care in Medicaid and SCHIP. In addition, the report includes discussion of larger, systemic barriers to access and care that must ultimately be tackled, and advice on how Medicaid and SCHIP might contribute.

The number and proportion of Americans reporting going without or delaying needed medical care increased sharply between 2003 and 2007. One in five Americans—59 million people—reported not getting or delaying needed medical care in 2007, up from one in seven—36 million people—in 2003. In addition, unmet medical needs increased for low-income children, reversing earlier trends and widening the access gap with higher-income children. People reporting access problems increasingly cited cost as an obstacle to needed care, along with rising rates of health plan and health system barriers.

The paper argues for an expanded definition of access measuring whether providers accept a particular form of insurance, ease of contacting providers for appointments, length of time it takes to get an appointment, and proximity of providers to patients. Interviews with Medicaid providers in Florida show that approximately 87% were accepting new patients, but only 68% were accepting new Medicaid patients. The survey also showed that beneficiaries may encounter difficulty in reaching physicians and making appointments: 22% of all calls were not answered on the first attempt and over two-thirds of providers had no weekend or evening hours.

Child health problems that are caused or exacerbated by unhealthy behaviors remain a leading cause of medical spending for children. The authors examined receipt of clinician advice by low-income children, comparing children who had public insurance with those who had private insurance, as well as with children who were uninsured for part or all of the year. Results show that enrolling more uninsured children in Medicaid and SCHIP could improve the chances that families receive advice about health behaviors and injury prevention.

Pay-for-performance (P4P) initiatives are being pursued by state Medicaid programs. In 2006, 28 states had adopted some type of initiative, half of which have been in existence for five years or more. However, policymakers have been given little information on the effectiveness of these initiatives in shifting physician practice. Program evaluations indicate that P4P, when combined with other quality initiatives, is associated with quality improvement; however, the role of P4P in contributing to those improvements often is unclear. This report, and the accompanying Policy Brief, reviews the available evidence on the issue and answers important questions.

As a mainstay of health coverage in the United States and one of the nation’s major health purchasers, Medicaid has an important role to play in moving health care quality efforts forward and improving quality for the populations it serves, especially children. This issue brief provides recommendations at the state and federal levels to improve quality in Medicaid.

Health information technology (HIT) is a key tool that both public and commercial insurers are employing to improve patient care and increase efficiency in the health care system. HIT can help measure quality, facilitate coordination of care, and help to bridge fragmented delivery systems and gaps in coverage. HIT can also help meet the needs of medically fragile populations, minimize unnecessary procedures, and reduce administrative costs. This issue brief highlights some ideas on ways in which states can use information technology to improve efficiency and quality of care in the Medicaid program.

The Commonwealth Fund 2006 Health Care Quality Survey found that when adults have health insurance coverage and a medical home, racial and ethnic disparities in access and quality are reduced or even eliminated. Replication of this model, particularly among safety net providers, could potentially improve the quality of care delivered to all patients while reducing disparities in care experienced by vulnerable populations.

The impact of individual behavior on the cost of health care is attracting a great deal of attention from policymakers, as a number of Medicaid programs are offering rewards for healthy behavior. States that provide incentives for behavior generally aim to either increase the number of beneficiaries who obtain regular health screenings or to decrease the incidence of smoking and obesity. This report comments that although these are valid goals for state Medicaid programs, there is little hard evidence that incentive programs will actually achieve these goals, particularly in terms of reducing smoking and obesity.

Providing better health care for children involves monitoring quality and making quality improvements, enrolling eligible children in Medicaid and SCHIP, and ensuring that health care systems are responsive to the unique health needs of kids. To discuss issues of quality and access, the Commonwealth Fund and the Alliance for Health Reform sponsored this briefing. A transcript of the briefing is provided, for additional resources, see the Alliance for Health Reform.

Over the past few years, pay-for-performance programs have emerged as a promising strategy to improve the quality and cost-effectiveness of care for Medicaid and SCHIP beneficiaries. In 2006, the Center for Health Care Strategies conducted a 50-state survey to identify innovative practices in the reimbursement of high-quality health care in the public sector. This guide offers lessons learned from Medicaid, Medicare, and commercial programs.

This chartbook summarizes current knowledge about health insurance coverage, the health needs of low-income children in the United States, and the roles that Medicaid and SCHIP play in improving children’s access to health care and their health status.

Conducted in the spring of 2006, this survey was designed to identify the ways in which state Medicaid and SCHIP programs are currently measuring the quality of care provided to children and families, including those with special needs. The results reveal that the majority of programs across the country are engaged in performance measurement and quality improvement activities of one kind or another, focusing heavily on pediatric preventive and primary care.

Having a usual source of care has been linked to many positive outcomes, such as increased use of preventive care, decreased use of emergency room care, and better continuity of care. This report synthesizes qualitative and quantitative evidence on the extent to which SCHIP enrollees report having a usual source of care.