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Introduction to State Health Policy

Insuring More Kids

State Issues & Options Under Title XXI


Laura Tobler, Policy Specialist, National Conference of State Legislatures, Denver, CO.

Shelly Geshan, M.P.P., Project Manager, National Conference of State Legislatures, Washington, DC.

Wendy Wolf, M.D., Senior Policy Fellow, Office of the Administrator, Agency for Health Care Policy and Research, Rockville, MD.

Under Title XXI of the Balanced Budget Act of 1997, Congress allocated approximately $4.8 billion annually to provide health insurance to uninsured children. According to some estimates, new Federal funds, coupled with State matching funds, will enable the State Children's Health Insurance Program (SCHIP) to cover up to 5 million uninsured children.

The objectives of this session were to:

  • Provide a brief overview of the basic facts about Title XXI and the flexibility provided to States under the statute to design programs to achieve its underlying goal of improving the status of children's health.
  • Identify and discuss approaches for monitoring the success of implementation strategies and the quality of health care provided under SCHIP.

The Balanced Budget Act of 1997 has given State legislatures the opportunity to become partners in crafting their own State plan to meet the needs of uninsured children in their States.

Laura Tobler and Shelly Geshan from the National Conference of State Legislatures discussed the important decisions and challenges States face with respect to SCHIP, including:

  • Whether to participate in the program.
  • Whether to expand the State Medicaid program, establish a separate insurance plan option, or combine the two approaches.
  • How to design and implement a plan that improves access to appropriate services and improves the health status of children in the State.

In addition to choosing the most appropriate option, States face other challenges associated with SCHIP, including:

  • Addressing access and service-delivery issues.
  • Serving the needs of children with chronic illness or disability.
  • Conducting outreach to families and enrolling eligible children.
  • Coordinating with other public and private sector programs.
  • Developing mechanisms for evaluation.

Providing health insurance through SCHIP does not ensure that families and children will access and use the system appropriately. Even if access is achieved, there is no guarantee that children will receive appropriate, high-quality care.

Dr. Wendy Wolf, Senior Policy Fellow in the Office of the Administrator, Agency for Health Care Policy and Research, discussed the importance of this issue. She explained that assessing quality health care for children requires a special focus and identified a set of key elements that help to define quality medical care for children. These key elements include:

  • Accessibility.
  • Continuous, comprehensive, and coordinated care.
  • Clinically effective (timely and up-to-date) services.
  • Child-centered care that includes families in the decisionmaking process.
  • Community-oriented, culturally competent care.
  • Accountability.


Geshan S, McDonough J. Family Coverage Under the State Children's Health Insurance Program. 1998. Washington, DC: National Conference of State Legislatures.

Landon BE, Tobias C, Epstein AM. Quality Management by State Medicaid Agencies Converting to Managed Care. JAMA 1998 Jan;279(3):211-6.

Lave JR, et al. Impact of a Children's Health Insurance Program on Newly Enrolled Children. JAMA 1998 Jun;279(22):1820-5.

Weinick RM, et. al. Children's Health Insurance, Access to Care and Health Status: New Findings. Health Aff 1998 Mar/Apr;17(2):127-36.

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