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News from the National Academies
Date: June 11, 1998
Contacts: Dan Quinn, Media Relations Officer
Dumi Ndlovu, Media Relations Assistant
(202) 334-2138; e-mail <news@nas.edu>

EMBARGOED: NOT FOR PUBLIC RELEASE BEFORE NOON EDT THURSDAY, JUNE 11

States Must Be Held Accountable for
New Health Plans for Children

WASHINGTON -- Passage of a law last year that expands health insurance for children by $24 billion offers an unprecedented opportunity to improve children's health, but Congress and the federal government must take immediate steps to ensure that states are held accountable for meeting the goals of the new programs, according to two new reports from a committee of the Institute of Medicine. Congress must devote adequate funding to track the effectiveness of the state programs, and federal and state officials must develop new tools to monitor the programs' impact on access to care, use of medical services, and health outcomes and status.

America's Children: Health Insurance and Access to Care examines the relationship between children's health and access to care; a companion report, Systems of Accountability: Implementing Children's Health Insurance Programs, makes recommendations for state and federal officials who are implementing the new and expanded insurance plans.

"This historic new commitment to children's health holds the promise of improving the lives of millions of children," said committee chair Molly Joel Coye, director, West Coast office, The Lewin Group, San Francisco. "As the federal government, the states, and the private sector work to implement the new programs, it is critical that we learn what works and what doesn't. If we do not have reliable, consistent ways of collecting information, we will never know -- and we will miss a critical opportunity to improve accountability in health care. The time for action is now, while these new plans are being established."

The five-year insurance expansion was passed as part of the Balanced Budget Act of 1997. It allocates $20.3 billion for states to use in expanding private insurance for children and another $3.6 billion to improve coverage under Medicaid. While the states have been given great latitude under the act, they must apply for federal funds through the U.S. Department of Health and Human Services (HHS), which approves and funds each state's plan.

While the committee supported the versatility under the act, it is concerned about how to evaluate the results. Performance measures should be established by HHS to provide comparable information for all approaches used to implement the programs, and a new national survey is needed to track these measures, the committee said. Moreover, the agency should develop systems to improve the availability of information on the national and state levels about how many children are covered by insurance, their use of health care services, and the status of their health. Presently, these data are not available for most states.

11 Million Uninsured

More than 11 million children, or one in seven, are estimated to be uninsured in the United States. Most are in families with working parents who have jobs that do not provide insurance and who cannot afford to buy it on their own. Nationally, one out of six African-American children and one out of four Hispanic children is uninsured, compared with one in 10 white children.

The problem has been exacerbated in the last decade by changes in the benefits that employers provide for their workers. The percentage of children who are covered by employer-based insurance has declined in the past decade; this decline has been partially offset by an increase in the number of children enrolled in Medicaid, which now reaches a quarter of all children in the United States.

The committee's examination of the relationship between insurance coverage and health revealed that uninsured children are more likely to be sick as newborns, less likely to be immunized as preschoolers, and less likely to receive medical treatment for injuries or for illnesses such as acute or recurrent ear infections, asthma, and tooth decay. Untreated illnesses and injuries can have lifelong consequences. Untreated ear infections, for example, can lead to hearing loss or deafness. Language or other developmental delays resulting from untreated neurological problems can inhibit normal development and social interactions.

Uninsured and underinsured children presently receive a patchwork of care from "safety-net" providers at hospitals, clinics, public health departments, community and school-based health centers, and individual practitioners. In the wake of shrinking government support and pressures brought by the market's transition to managed care, these safety-net providers face increasing financial challenges. Safety-net providers are taking a variety of steps to adapt to the competitive health care marketplace, but this is a period of major transition and uncertainty.

Guarding Against Underenrollment

Expanding access to insurance alone is not likely to eliminate all of the barriers that keep some children from getting appropriate health care services, the committee said. Even insured children must rely on their parents to identify problems and seek treatment. Parents whose families are insured may delay getting care because of out-of-pocket expenses, the difficulty of scheduling appointments, cultural differences with providers, or a lack of easily accessible care. For this reason, states may also need to provide assistance with child care and transportation, culturally appropriate services, and better use of information technology to improve access and utilization of service.

Presently, more than 3 million children who are eligible for Medicaid are not enrolled. Such underenrollment also will be a problem with the new state plans, unless states improve outreach to eligible families, simplify procedures for determining eligibility, or provide new programs to insure children. All state efforts should be designed to achieve the highest possible enrollment, the committee said. States should coordinate their initiatives with other state and private programs to maximize children's opportunities to receive access to care. States also must provide adequate reimbursement rates to maintain and improve provider participation, and quality standards must be enforced for all providers.

A committee roster follows. The study was funded by the Robert Wood Johnson Foundation. The Institute of Medicine is a private, non-profit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences.

Read the full text of America's Children: Health Insurance and Access to Care for free on the Web, as well as more than 1,800 other publications from the National Academies. Printed copies are available for purchase from the National Academy Press Web siteor at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).


INSTITUTE OF MEDICINE
Division of Health Care Services
and
Board on Children, Youth, and Families
of the IOM and National Research Council

Committee on Children, Health Insurance, and Access to Care
        Molly Joel Coye, M.D., M.P.H. * (chair)
        Director, West Coast Office
        The Lewin Group
        San Francisco

        Irene Aguilar, M.D.
        Primary Care Physician
        Westside Family Health Center
        Denver

        Brian K. Atchinson, J.D.
        Second Vice President
        Government Relations
        UNUM
        Portland, Maine

        Stephen Borowitz, M.D.
        Associate Professor of Pediatrics
        Health Sciences Center
        University of Virginia
        Charlottesville

        Richard Bucciarelli, M.D.
        Professor, Institute for Child Health Policy, and
        Associate Chair, Department of Pediatrics
        University of Florida College of Medicine
        Gainesville

        Peter Budetti, M.D., J.D.
        Professor of Health Services Management,
        Preventive Medicine, and Law, and
        Director, Institute for Health Services Research
        and Policy Studies
        Northwestern University
        Chicago

        Thomas W. Chapman, M.P.H.
        Senior Vice President for Network Development, and
        Professor of Health Services Management and Policy
        George Washington University Medical Center
        Washington, D.C.

        Margaret C. Heagarty, M.D. *
        Director of Pediatrics
        Harlem Hospital Center, and
        Professor of Pediatrics
        College of Physicians and Surgeons
        Columbia University
        New York City

        Robert B. Helms, Ph.D.
        Resident Scholar, and
        Director of Health Policy Studies
        American Enterprise Institute
        Washington, D.C.

        Velvet Miller, Ph.D., M.P.A.
        Deputy Commissioner
        New Jersey Department of Human Services
        Trenton

        Arnold Milstein, M.D., M.P.H.
        Managing Director
        William M. Mercer Inc., and
        Medical Director
        Pacific Business Group on Health
        San Francisco

        Paul Newacheck, Dr.P.H.
        Professor of Health Policy and Pediatrics
        Institute for Health Policy Studies, and
        Department of Pediatrics
        University of California
        San Francisco

        David S. Weiner, M.P.H.
        President and Chief Executive Officer
        Children's Hospital
        Boston

        Steven Woolf, M.D., M.P.H.
        Clinical Professor
        Department of Family Practice
        Medical College of Virginia, and
        Fairfax Family Practice Center
        Fairfax

        INSTITUTE OF MEDICINE STAFF

        Margaret Edmunds, Ph.D.
        Study Director

        _________________________________________
        (*) Member, Institute of Medicine