Stephanie M. Hale Walker, MD, MPH


Assistant Professor in Pediatrics and Neonatology, Vanderbilt University School of Medicine, Nashville, TN

Dr. Hale is Assistant Professor of Pediatrics/Neonatologist, Monroe Children’s Hospital/Vanderbilt University, Nashville, TN. She previously joined the Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center as a Neonatologist and an Instructor in Pediatrics at Harvard Medical School. Her research interests focus on disparities as they relate to neonatal outcomes and mortality in the U.S., as well as quality improvement within the neonatal intensive care unit, with emphasis on those centers serving vulnerable populations. Dr. Hale’s goal is to be an advocate for the health care of all children and to develop successful programs and policies that will improve the health and survival of infants in underserved communities across the nation. Dr. Hale has been the recipient of a Presidential Scholarship at the Harvard School of Public Health in 2006-2007, and the Dr. Milton Rosenbluth Fellowship at Cornell University Medical School. Her community service endeavors have included teaching STD and AIDS programs in schools in Philadelphia and New York City, as well as mentoring at the Inwood House for Pregnant Teens and “Lifting as We Climb” program. Dr. Hale received her Bachelor’s of Science from Vanderbilt University in 1997 and her medical degree from Cornell University Medical College in 2001. She completed her residency in Pediatrics at Children’s Hospital of Philadelphia in 2004 and her fellowship in Neonatology at the Children’s Hospital of Los Angeles/University of Southern California Medical Center in 2006. She received an M.P.H. from the Harvard School of Public Health in 2007 as a CFHU Fellow.

Informing Policy Choices in Children’s Health Insurance Programs: Improving Quality of Children’s Health Care in the State Child Health Insurance Program Reauthorization


In 1997, the State Child Health Insurance Program (SCHIP) was created as part of the Federal Balanced Budget Act, in which legislation provided funding to states, with the goal of expanding health insurance to cover uninsured, low-income children who do not qualify for Medicaid. Today, public insurance programs such as Medicaid and SCHIP have proven to be essential healthcare safety nets, estimated to finance care for over 30 million children. This is equivalent to nearly one in three of America’s nearly 73 million children ages 0-17 and up to 40% of all children under age six in many states. The role of health insurance coverage in improving access to care is well documented.  Medicaid and SCHIP provide low income children with a level of access to care that is comparable to that of low income children with private insurance coverage. Although these programs have been essential in providing access to care for millions, it is important to understand that access to care is no guarantee for high quality of care. These programs have a responsibility to finance or provide care that meets quality standards. They can also play a powerful role in shaping the quality of care provided in the private marketplace.

With the ten year reauthorization deadline of September 30, 2007, fast approaching, Congress is actively discussing the new shape and scope of SCHIP. While the majority of the discussions are focused on the financing and scope of eligibility of the program, only a few have focused on providing high quality care. We aim to take advantage of this unique “policy window of opportunity” to educate policymakers about children’s healthcare quality. This portion of the project focused on evaluating the current state of health care for publicly insured children and successful strategies to improve quality. Although much work will focus on quality in SCHIP, it is important to note that the impact of such an intervention will go well beyond the care of children insured by SCHIP.


The findings and recommendations from the August 2006 national expert meeting hosted by National Initiative of Children’s Healthcare Quality in partnership with the Child and Adolescent Measurement Initiative and Family Voices, convened to review existing evidence, practices, and directions in the promotion of quality care for children with public health insurance, were reviewed and synthesized, with expert guidance.  An extensive literature search of both the grey and published literature on the impact or evaluation of SCHIP and/or Medicaid on child health care was performed, focusing on the most recent literature from the years 2005-2007. Specific organizational websites were also strategically reviewed for related recent reports. Findings are currently being prepared for sections of a policy brief and full report for Commonwealth Fund publication that will be disseminated through the Fund’s website, as well as provided to targeted staff/members of Congress and relevant policy and advocacy organizations. Semi-structured key informant interviews will be conducted to test findings and gather further recommendations. We are also in the process of developing a slide pack, also for the Commonwealth Fund.


Depending on the service, in general 25-75% of children in the U.S. do not receive the health care that is scientifically proven and/or that experts recommend to prevent disease, reduce disease complications, and achieve optimal health and development. A higher proportion of minority children are insured by public insurance programs: 46% of Black, 39% of Hispanic, and 55% of American Indian/Alaskan Native children are insured by Medicaid and/or SCHIP. Studies revealed that children of color tend to receive lower quality of care for needs ranging from primary care to asthma care. Studies that did not delineate race or ethnicity showed mixed results regarding quality of care for children enrolled in Medicaid and/or SCHIP compared to privately insured counterparts when it comes to common preventive, acute, and chronic care services. Examples include studies that revealed lower rates of childhood immunizations, well-child visits and common procedure (eg. myringotomies, tonsillectomies) for Medicaid and/or SCHIP patients, whereas others revealed comparable immunization rates among publicly and privately insured children. Some studies found that parents of children with public insurance report high levels of satisfaction with their well-child care experience, whereas others reported similar parents are more likely to report providers “never” listen or spend enough time, and are less likely to report being able to get an appointment when needed. Despite these and similar results, we found examples of well established quality improvement models that have been used successfully (eg. the use of Breakthrough Series Collaboration, guidelines or pathways, pay-for-performance incentives, health information technology, etc.) and could prove beneficial if integrated into state SCHIP and Medicaid programs.


In general, children in the U.S. experience overall poor quality care. Although Medicaid/SCHIP programs have been tremendously successful in improving access to care for millions of children, the actual quality of that care appears to be worse when compared to care provided by private insurance programs, specifically when it comes to common preventative, acute, and chronic health care. Children of color tend to experience health care disparities to similar magnitudes as do adults of color, are more likely to be insured through public programs and to receive poorer quality of care. Disparities in health care delivery and process constitute a fundamental threat to quality. State and federal policy makers must make it a priority to ensure quality services are being provided for children and adolescents enrolled in public insurance programs. Almost 50% of all Medicaid insured are served through managed care plans who also serve privately insured children. A majority of children receive care in private offices, clinics, and hospitals which accept public payers. Therefore states are in the unique position to strongly influence initiatives to improve the quality of care not only for publicly insured children, but for all children.


Lisa Simpson, MB, BCh, MPH, FAAP
Director, Child Policy Research Center at Cincinnati Children’s Hospital Medical Center

Charlie Homer, MD, MPH
President and CEO, National Initiative of Children's Healthcare Quality