and providers, geographic distribution of uninsured children, and the potential sources of financing, among others.

This flexibility also raises some technical and practical issues. The most fundamental question is this: With so much variation possible, how will we know whether SCHIP is effective?


This report describes the responsibilities of Congress, the U.S. Department of Health and Human Services (DHHS), and the states in implementing and evaluating SCHIP. The report presents a framework and recommendations for designing systems of accountability for the program as states take a variety of steps to reduce the number of uninsured children. The committee defines systems of accountability as those processes and procedures that provide information for analysis and decision-making and that provide a basis for designing, implementing, evaluating, and improving programs.

The committee strongly supports the flexibility and innovation that are built into the SCHIP legislation, provided there are ways to measure the program's impact on a national basis and to ensure that the funds spent actually improve insurance coverage and health outcomes for children. From the beginning, it will be important to learn where states are heading with their spending and services. Later on, it will be important to be able to identify which program components are effective so that “best practices” can be continued and replicated in other locations and less effective practices can be avoided. Thus, the committee's accountability framework includes steps that can be taken immediately, as well as steps that are needed to build infrastructure, capacities, and systems for a coordinated, longer-term approach.


What Is Accountability?

In general terms, accountability is the process by which an individual or organization accepts responsibility for an activity and provides information regarding its progress in meeting requirements and expectations. Accountability involves the development and dissemination of information regarding the process, quality, and outcomes of work; the use of fiscal resources; the problems encountered or anticipated; and other activities undertaken to fulfill contractual, fiscal, statutory, professional, or public responsibilities. For a children's health insurance program, accountability refers to responsible spending to expand children's access to affordable, high-quality health care.

Systems of accountability should specify the mechanisms and formats for collecting and transmitting the expected information. These formats may be oral, written, electronic, or in some other standardized technology. The systems also should specify the ways in which feedback on the information will be exchanged, and what kinds of responses might be expected as a result.

Accountability is an interactive process. In other words, accountability should be defined specifically in the context of relationships. Figure 1 portrays the specific relationships through which the committee believes accountability for SCHIP must be established.

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