September 23, 1998
The Honorable Donna E. Shalala
Secretary of Health and Human Services
200 Independence Avenue SW
Washington, D.C. 20201
Dear Secretary Shalala:
The State Childrens Health Insurance Program (SCHIP), authorized by the Balanced Budget Act of 1997, provides an unprecedented opportunity to expand health insurance coverage to many of the nations ten million uninsured children. To date, almost all States have indicated they plan to participate in this optional program. Consequently, SCHIP may bring about profound changes in the manner in which previously uninsured children from low income families obtain and receive health care.
As enacted, Congress gave States substantial discretion in designing and implementing their SCHIP plans. States choosing to participate can cover all or part of the target population of low income uninsured children. States may provide coverage through expansions of their existing Medicaid programs, a separate childrens health insurance plan, or a combination of both. Although States must meet certain minimum standards, they have substantial discretion in establishing the scope of benefits to be offered in their plans. Within certain limits, States that choose to offer a separate childrens health insurance plan can impose premiums, deductibles, co- insurance, or other co-payments on enrollees.
The wide latitude granted to States was intended to permit them to tailor the new program to meet unique local needs. The resulting mix of State level programs now being designed and implemented provides an unusual opportunity for assessing the effectiveness of divergent approaches to insuring and delivering health care to children.
Monitoring and evaluating SCHIP require data that systematically address concerns about access, quality, and outcomes of care. Timely and reliable data are needed to support the administration and operation of the new program at the federal and State levels, to measure the performance of States, and to gauge effective mechanisms for serving uninsured children. To achieve this objective, baseline and post implementation information are needed on enrollment levels, access to appropriate care, utilization of services, satisfaction with care, expenditures, and health outcomes. Information retrieval should be coordinated so that data collected at the State level on each of these domains can be aggregated to permit comparisons that will enable health planners to distinguish the more successful models for delivery of care from those that are less successful in meeting the objectives of SCHIP.
Assembling the data needed for monitoring and evaluation presents a formidable challenge. Fortunately the United States possesses a system for collecting and disseminating health information that is the envy of most developed countries. Existing population surveys, such asthe National Health Interview Survey (NHIS) and the Medical Expenditure Panel Survey (MEPS), can provide much relevant information at the national level on many of the important evaluative domains. However, none of our major current national surveys or other population- based data collection efforts can provide the information needed to evaluate the performance of SCHIP programs at the State level. The production of useful monitoring and evaluation data at the State and sub-State levels will require augmentation of existing surveys or creation of new data collection mechanisms.
As a cost effective approach to providing needed data at the State level, the National Committee on Vital and Health Statistics (NCVHS) strongly endorses an appropriate adaptation and use of the State and Local Area Integrated Telephone Survey (SLAITS) developed by the National Center for Health Statistics (NCHS). This population-based, multipurpose survey, which was originally designed for immunization surveillance and has now been pilot tested for other purposes, could readily be extended to collection of critical performance data on the new SCHIP initiative. The use of an existing survey, rather than the development of a costly new data collection mechanism with a single focus, is entirely consistent with the Departments survey integration plan. A prototype questionnaire suitable for collecting data on SCHIP has already been designed by NCHS and could be fielded across the States with little additional lead time. These data in conjunction with standard legislatively-mandated performance data could facilitate a comprehensive national and State-specific evaluation of SCHIP. However, there are currently no sources of funding identified for this purpose. The cost of a 50 State survey meeting minimum reliability and precision standards is tiny in comparison to the nearly $40 billion set aside at the federal level for SCHIP matching funds over the next ten years.
Implementing this survey would provide the Department with a comprehensive data collection mechanism for assuring accountability under the new program, while providing States with information needed for program planning and administration. Specific issues concerning implementation of this survey need to be addressed to maximize its utility for both the nation and individual States, such as involving the States in questionnaire design and sampling decisions in order to produce accurate State and sub-State estimates. The NCVHS is ready to assist in this process.
Don E. Detmer, M..D.
John Eisenberg, M.D.
Margaret Hamburg, M.D.