committee members agreed that a variety of strategies could be used to expand children's health insurance coverage, with funds for those strategies coming from several possible sources: federal and state budgets, employers, families, health plans, insurers, and communities. After discussion, they agreed that the ultimate goal of health insurance is to provide access to coordinated, efficient, and effective care and services when needed for all American children, including those who have preventable illnesses and injuries as well as those with chronic conditions and other special health care needs.

The timing of this study presented unusual challenges. During the months when the committee was meeting, children's health insurance took on national prominence as both political parties and the Clinton Administration presented a variety of proposals that were widely discussed by Congress, state policymakers, national professional organizations, the media, and the general public. Among the proposals were Medicaid expansions, block grants, vouchers, refundable tax credits for families, a tax credit for all children, family Medical Savings Accounts, and a new Children's Health Trust Fund.

It was unclear what, if any, national legislative approach would be taken until Congress passed the Balanced Budget Act of 1997 in August, with its provisions for the State Children's Health Insurance Program (SCHIP). The structure of the SCHIP legislation reflected the diversity of opinions about insurance strategies. Under SCHIP, states may choose to expand Medicaid, to design or expand state-sponsored or private programs, or to use a combination of strategies to improve insurance coverage for uninsured, low-income children.

The committee began the study with a decision to take an evidence-based approach to its examination of the relationship between health insurance and access to care. With the rapid rate of ongoing change in the health care insurance and delivery picture for children, the committee later decided to supplement the review of scientific and empirical evidence with an analysis of health care trends that are likely to affect the implementation of new children's insurance programs. Key sources of information included the following:

  • analyses of the Current Population Survey conducted by the Employee Benefits Research Institute especially for this study;
  • health services research findings published in peer-reviewed journals;
  • publicly available descriptions of federal and state programs, and research findings and public statements by federal and state agencies;
  • published materials and public statements submitted to the committee by national organizations;
  • policy analyses, reports, newsletters, and news analyses by private organizations;
  • published reports of philanthropic organizations, including the Annie E. Casey Foundation, the Kaiser Commission on the Future of Medicaid, the David and Lucile Packard Foundation, and the Robert Wood Johnson Foundation; and
  • reports published by the Institute of Medicine and the National Research Council.

The committee's goal for this report was to draw a general set of conclusions about ways to help improve children's access to care that would apply to a variety of public and private insurance programs. The committee hopes this report will help to improve the evidence base for children's health and children's health insurance efforts and for efforts to improve the quality of children's health care. The committee's specific concerns about the need for data to evaluate the SCHIP program and its recommendations for designing a system of accountability for SCHIP are presented in a companion report entitled Systems of Accountability: Implementing Children's Health Insurance Programs (IOM, 1998).

Trends In Health Insurance Coverage For Children

The majority of American children have private insurance through their parents' employers. Over the past decade, the rates of employer-based coverage for children have been declining. With increasing



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