Iowa tops new scorecard on children's health care

Iowa received the overall top ranking in a new report on the health care system in all 50 states and the District of Columbia. The Commonwealth Fund is a private foundation supporting research on health care issues and policies to achieve “better access, improved quality, and greater efficiency, particularly for society’s most vulnerable.” Researchers who compiled the 2011 state scorecard uncovered huge disparities in terms of access to care, health care quality, and health outcomes:

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

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

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

Iowa was the top-performing state in just one category: percentage of young children receiving all recommended doses of the six key vaccines. However, Iowa’s relatively high scores (among the top 5 states on nine indicators and in the top quartile for 14 indicators) made our state number one overall and in the “prevention and treatment” subgroup, number two in “potential to lead healthy lives” subgroup, and number six in the “access and affordability” subgroup. More detail on Iowa’s rankings can be found on this chart. To compare Iowa to other states, use this interactive map or download the full report here.

The new report’s executive summary highlights the benefits of the federal Children’s Health Insurance Program (generally known as SCHIP):

The Scorecard’s findings on children’s health insurance attest to the pivotal role of federal and state partnerships. Until the start of this decade, the number of uninsured children had been rising rapidly as the levels of employer-sponsored family coverage eroded for low- and middle-income families. This trend was reversed across the nation as a result of state-initiated Medicaid expansions and enactment and renewal of the Children’s Health Insurance Program (CHIP). Currently, Medicaid, CHIP, and other public programs fund health care for more than one-third of all children nationally. Children’s coverage has expanded in 35 states since the start of the last decade and held steady even in the middle of a severe recession. At the same time, coverage for parents-lacking similar protection-deteriorated in 41 states.

SCHIP used to be a favorite punching bag for Representative Steve King, who voted against funding what he called “Socialized Clinton style Hillarycare for Illegals and their Parents.” Fortunately, the majority in Congress recognized this program’s potential.

After the jump I’ve posted a sidebar from the general summary of the Commonwealth Fund’s report, called “Iowa’s Comprehensive Public Policies Make a Difference for Children’s Health.” I also included some methodological notes and listed the 20 indicators measured by researchers.

From The Commonwealth Fund 2011 state scorecard on child health system performance:


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

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

Iowa has also been making strides in providing high-quality mental health care for children. Its 1st Five Healthy Mental Development Initiative focuses on a child’s first five years. The state-led initiative helps private providers to develop a sound structure for assessing young children’s social and developmental skills. Under the 1st Five system, a primary care provider screens children and their caregivers when they come in for a visit; if a concern is identified, the provider notifies the 1st Five Child Health Center. The center’s care coordinator then contacts the family to link them to appropriate services in the community or help coordinate referrals.

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

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

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

Note on methodology:

The State Scorecard on Child Health System Performance, 2011, includes 20 key indicators grouped into four performance dimensions: access and affordability; prevention and treatment; potential to lead healthy lives; and equity. The analysis ranks all 50 states and the District of Columbia on each indicator and then averages the indicator ranks to determine the dimension rank. All four dimension scores are averaged to determine the overall rank. Equity measures the gaps in performance between vulnerable groups and the national average. This analysis uses the most recent data available at the time of publication-typically from 2007 to 2009. Sabrina How, Ashley-Kay Fryer, Douglas McCarthy, Cathy Schoen, and Edward Schor authored the report.

The 20 measured “indicators of state child health system performance”:

Under “Access and Affordability”:

1 Children ages 0-18 insured

2 Parents ages 19-64 insured

3 Currently insured children whose health insurance coverage is adequate to meet needs

4 Average total premium for employer-based family coverage as percent of median income for family household

Under “Prevention and Treatment”

5 Children with a medical home

6 Children ages 19 to 35 months received all recommended doses of six key vaccines

7 Children with a preventive medical care visit in the past year

8 Children ages 1-17 with a preventive dental care visit in the past year

9 Children ages 2-17 needing mental health treatment/counseling who received mental health care in the past year

10 Young children (10 months to 5 years) received standardized developmental screening during visit

11 Hospital admissions for pediatric asthma per 100,000 children ages 2-17

12 Children with special health care needs who had no problems receiving referrals when needed

13 Children with special health care needs whose families received all needed family support services

Under “Potential to lead healthy lives”

14 Infant mortality, deaths per 1,000 lives births

15 Child mortality, deaths per 100,000 children ages 1-14

16 Young children (ages 4 months to 5 years) at moderate/high risk for developmental or behavioral delays

17 Children ages 10-17 who are overweight or obese

18 Children ages 1-17 with oral health problems

19 High school students who currently smoked cigarettes

20 High school students not meeting recommended physical activity level

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