In This Issue

The State Child Health Insurance Program (SCHIP), which was enacted in August 1997 as part of Title XXI of the Social Security Act, gave states a new source of revenue for children’s health coverage. Although the scope of this program is unprecedented, it also represents the latest in a series of federal and private initiatives related to child health. Careful scrutiny of all these programs and a thorough analysis of the lessons they provide are essential in order to establish the groundwork for future programs.

The first three articles in this issue report on programs that were designed to improve children’s health care. Paul W. Newacheck and his colleagues lead with a presentation of results from the Child Health Initiative, a project funded by the Robert Wood Johnson Foundation. The Initiative was designed to promote strategies for integrating children’s health services into a coherent system that would replace the current piecemeal approach. Certain objectives were considered to be critical: simplifying eligibility rules; removing constraints on funded services; and easing restrictions on provider participation. The authors conclude that the demonstration projects failed to achieve these objectives, largely because of three factors: a lack of consensus and clarity; an inability to obtain high-level support for the program; and an inadequate time frame for carrying out such a degree of systematic reform. They offer insightful, practical observations and recommendations, useful to anyone conducting research or wishing to institute changes in publicly financed health care delivery systems.

One of the more successful federal child health care initiatives is the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, a benefit that has been in place since 1967 for Medicaid-eligible children. It was designed to ensure that these children receive comprehensive health coverage, particularly for preventive services. In 1989 the program was strengthened with the enactment of a federal mandate under the Omnibus Budget Reconciliation Act (OBRA). Alice Sardell and Kay Johnson examine the political dynamics affecting the EPSDT program between 1989 and 1997. Also reporting on the EPSDT program are Norma I. Gavin and her colleagues, who discuss how the OBRA’89 legislation has affected children’s health services in four states, concluding that these states became more intent on improving the effectiveness of EPSDT after the passage of OBRA’89. The intensified state efforts had the added effects of encouraging provider participation and increasing the number of children’s visits for preventive services.

In the last issue of the Quarterly, I noted that state Medicaid programs are rapidly converting from traditional fee-for-service coverage to managed care. This shift has dramatically transformed the role of Medicaid programs, which now must negotiate, implement, and monitor contracts and actively oversee the costs and quality of care provided by various managed care organizations. Maryland has been a leader in this transformation; since 1990, the state has instituted three different systems of managed care for Medicaid enrollees. In that same issue (MQ 76:1), Thomas R. Oliver’s history of Medicaid managed care in Maryland illustrated the complex demands that have been placed on Medicaid programs. Here, Mary E. Stuart and Michael Weinrich analyze data from the Maryland Medicaid database to assess the successes and limitations of managed care initiatives in that state. One important conclusion is that traditional managed care approaches may not be appropriate for persons with the most complex health care needs. Instead, specialized programs should be created for certain subgroups of patients. The authors recommend more comprehensive public policies as a way to improve quality and reduce costs.

In an earlier article (MQ 74:2), David Mechanic described changes in the organization and financing of health care that have adversely affected the patient-physician relationship and have contributed to the erosion of patient trust. Because one powerful determinant of trust is effective communication, Mechanic here expands on his earlier theme by discussing the innovations and interventions that could improve communication and lead to the creation of a “health care partnership.”

Paul D. Cleary

Author(s): Paul D. Cleary

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Volume 76, Issue 2 (pages 155–156)
Published in 1998