For cost-conscious purchasers and public policymakers, accountability rests on a foundation of good information. There are technical problems, gaps, and inconsistencies in analyzing health insurance and health status information from Medicaid, national surveys, and other sources. These include differences in capacity to report current information; differences in definitions and data collection methods; lack of statistical breakdowns for children, or breakdowns at different ages; lag time in collecting and reporting information; and many other technical challenges. These technical problems make it difficult to measure performance, to protect children as health care consumers, and to improve the quality of care.

In the area of clinical information, relatively few performance measures have been developed for children, and their scope and quality need to be improved. Additional research is needed to develop new measures of child health status and outcomes that can be used to assess performance of health plans in meeting children's health needs, especially for children with special health care needs.

With the design and implementation of new SCHIP programs, many new opportunities will be available to study the impact of changing mechanisms for financing and providing insurance. For example, changes in sources of care (types of providers and settings) after enrollment in SCHIP would be a useful measure of the program's impact. Comparisons of utilization rates for preventive care, basic services, and visits to specialists would be extremely useful to compare the program's impact for different subgroups, such as racial and ethnic minorities, or children with disabilities.

Commercial managed care plans measure access to care in terms of utilization and penetration rates, such as the number of visits per 1,000 enrollees; length of time to follow-up appointments; provider to enrollee ratios; and other information that is readily available from most managed care information systems. For the new SCHIP programs and Medicaid managed care, additional access measures may need to be developed to reflect the array of child-specific services such as subsidized child care or transportation assistance, or expanded services such as telephone advice nurses, translators, or health education.

Monitoring and evaluation strategies require commitments of time and resources on the part of government, private foundations, health plans, providers, and others to provide timely and useful information for a variety of audiences and purposes. The committee believes that future data and information systems can be designed and implemented in ways that are efficient and easy to use and in ways that provide timely feedback for midcourse corrections as well as for longer-term applications. Incentives should be developed to encourage the use of data sources that have rapid turnaround times, are inexpensive, and that can be used to evaluate short-term trends and make program adjustments.

Organization Of This Report

The first three chapters of this report address the contextual issues that describe the relationship between insurance status and access to care. Chapter 1, Introduction and Overview, has described the rationale for the study, the committee's approach to the study, and its conclusions. Chapter 2, Health Insurance and Children in America, reviews evidence related to the patterns of health insurance coverage for children. including trends in employer-based coverage and Medicaid enrollment. Chapter 3, Health Insurance and Access to Care, reviews the evidence about the effects of health insurance status on the care that children receive and describes different ways of defining the scope of health care services that should be accessible to children.

The second section of the report describes a variety of means for financing health care for children. Chapter 4, Safety Net Providers, describes the current safety net providers and the ways in which they are meeting the demands for expansion of health insurance coverage for children during a period of rapid change in the health care delivery system. Chapter 5, Medicaid, describes the Medicaid program in its current form as a major source of public financing for health care and how its role is changing because of market forces, welfare reform, children's health insurance legislation, and other factors. Chapter 6, State and Private Insurance Initiatives, describes a variety of programs that have been implemented to provide



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