This study provides consistent evidence, from three very diverse states with heterogeneous populations and distinct programs (Florida, Kansas, and New York), that the State Children's Health Insurance Program (SCHIP) increased access to and satisfaction with health care among enrolled low-income children and that vulnerable children-minorities, children and adolescents with special health care needs, and children who were uninsured for long periods of time-shared in these improvements. We highlight some areas to target for future improvement, such as reducing the high levels of unmet needs among special-needs children and increasing preventive care, especially for Hispanic children.

BACKGROUND:The State Children's Health Insurance Program (SCHIP) was enacted in 1997 to provide health insurance coverage to uninsured low-income children from families who earned too much to be eligible for Medicaid.OBJECTIVES:To develop a "baseline" portrait of SCHIP enrollees in 5 states (Alabama, Florida, Kansas, Indiana, and New York) by examining: 1) SCHIP enrollees' demographic characteristics and health care experiences before enrolling in SCHIP, particularly children with special health care needs (CSHCN), racial and ethnic minority children, and adolescents; 2) the quality of the care adolescents received before enrollment; and 3) the changes in enrollee characteristics as programs evolve and mature.METHODS:Each of 5 projects from the Child Health Insurance Research Initiative (CHIRI) surveyed new SCHIP enrollees as identified by state enrollment data. CHIRI investigators developed the CHIRI common core (a set of survey items from validated instruments), which were largely incorporated into each survey. Bivariate and multivariate analyses were conducted to ascertain whether there were racial and ethnic disparities in access to health care and differences between CSHCN and those without. Current Population Survey data for New York State were used to identify secular trends in enrollee characteristics.RESULTS:Most SCHIP enrollees (65% in Florida to 79% in New York) resided in families with incomes < or =150% of the federal poverty level. Almost half of SCHIP enrollees lived in single-parent households. A majority of SCHIP parents had not had education beyond high school, and in 2 states (Alabama and New York) approximately 25% had not completed high school. The vast majority of children lived in households with a working adult, and in a substantial proportion of households both parents worked. Children tended to be either insured for the entire 12 months or uninsured the entire 12 months before enrolling in SCHIP. Private insurance was the predominant form of insurance before enrollment in SCHIP in most states, but 23.3% to 51.2% of insured children had Medicaid as their most recent insurance. HEALTH CARE USE AND UNMET NEEDS BEFORE SCHIP: The vast majority of all SCHIP enrollees had a usual source of care (USC) during the year before SCHIP. The proportion of children who changed their USC after enrolling in SCHIP ranged from 29% to 41.3%. A large proportion of SCHIP enrollees used health services during the year before SCHIP, with some variability across states in the use of health care. Nevertheless, 32% to almost 50% of children reported unmet needs. CSHCN: The prevalence of CSHCN in SCHIP (between 17% and 25%) in the study states was higher than the prevalence of CSHCN reported in the general population in those states. In many respects, CSHCN were similar to children without special health care needs, but CSHCN had poorer health status, were more likely to have had unmet needs, and were more likely to use the emergency department, mental health care, specialty care, and acute care in the year before enrolling in SCHIP than children without special health care needs. RACE AND ETHNICITY: A substantial proportion of SCHIP enrollees were black non-Hispanic or Hispanic children (Alabama: 34% and <1%; Florida: 6% and 26%; Kansas: 12% and 15%; and New York: 31% and 45%, respectively). Minority children were poorer, in poorer health, and less likely to have had a USC or private insurance before enrolling in SCHIP. The prevalence and magnitude of the disparities varied among the states. QUALITY OF CARE FOR ADOLESCENTS: Seventy-three percent of adolescent SCHIP enrollees engaged in one or more risk behaviors (ie, feeling sad or blue; alcohol, tobacco, and drug use; having sexual intercourse; and not wearing seat belts). Although almost 70% of adolescents reported having had a preventive care visit the previous year, a majority of them did not receive counseling in each of 4 counseling areas. Controlling for other factors, having a private, confidential visit with the physician was associated with an increased liked likelihood (2-3 times more likely) that the adolescent received counseling for 3 of 4 counseling areas. TRENDS OVER TIME: New York SCHIP enrollees in 2001, compared with 1994 enrollees in New York's SCHIP-precursor child health insurance program, were more likely to be black or Hispanic, older, from New York City, and from families with lower education, income, and employment levels. A greater proportion of 2001 enrollees was uninsured for some time in the year before enrollment, was insured by Medicaid, and lacked a USC. Secular trends in the low-income population in the state did not seem to be responsible for these differences. Program modifications during this time period that may be related to the shift in enrollee characteristics include changes to benefits, outreach and marketing efforts, changes in the premium structure, and the advent of a single application form for multiple public programs.CONCLUSIONS:SCHIP enrollees are a diverse group, and there was considerable variation among the 5 study states. Overall, SCHIP enrollees had substantial and wide-ranging health care needs despite high levels of prior contact with the health care system. A sizable minority of SCHIP enrollees has special health care needs. There is racial and ethnic diversity in the composition of enrollees as well, with racial and ethnic disparities present. The quality of care adolescents received before enrollment in SCHIP was suboptimal, with many reporting unmet health care needs and not receiving recommended counseling. The characteristics of SCHIP enrollees can be expected to change as SCHIP programs evolve and mature.POLICY IMPLICATIONS:1) Benefits should be structured to meet the needs of SCHIP enrollees, which are comparable to Medicaid enrollees' needs in many respects. 2) Provider networks will have to be broad if continuity of care is to be achieved. 3) Multiple outreach strategies should be used, including using providers to distribute information about SCHIP. 4) The quality of care delivered to vulnerable populations (eg, minority children, CSHCN, and adolescents) should be monitored. 5) States and health plans should actively promote quality health care with the goal of improving the care received by SCHIP enrollees before enrollment. 6) States will have to craft policies that fit their local context. 7) Collecting baseline information on SCHIP enrollees on a continuous basis is important, because enrollee characteristics and needs can change, and many vulnerable children are enrolling in SCHIP.

Background. Children with special health care needs ( CSHCN) often require more extensive services than children without special needs. The State Children's Health Insurance Program ( SCHIP) in many states typically provides less extensive benefits and services than do state Medicaid programs. To design SCHIP to address the needs of CSHCN adequately, it is important to measure the degree to which children who enroll in SCHIP have special health care needs and to assess their health status and unmet health care needs. Little is known about the characteristics or preenrollment experience of CSHCN who enroll in SCHIP.Objectives. To use data from the Child Health Insurance Research Initiative to measure the prevalence of CSHCN in SCHIP in 4 states, describe their demographic and health care features at enrollment, and compare their sociodemographic characteristics, health status, prior health care experiences, and unmet needs versus children without special health care needs.Methods. Children ( 0 - 18 years old) newly enrolled in SCHIP in 4 states were eligible for the study: New York, Florida ( adolescents only), Kansas, and Indiana ( CSHCN only). Telephone interviews were conducted shortly after enrollment and identified CSHCN by using the Child and Adolescent Health Measurement Initiative CSHCN screener. A common set of core questions assessed demographic characteristics, health status, special health care need status, insurance experience, access, use, quality of health care, and unmet needs during the year before enrollment. Bivariate and multivariate analyses were used to compare characteristics of CSHCN with characteristics of children without special needs.Results. Interviews were completed for parents of 5296 children enrolled in SCHIP in the 4 states. By using the Child and Adolescent Health Measurement Initiative CSHCN screener, the prevalence of CSHCN among SCHIP enrollees was 17% ( New York), 18% ( Florida), and 25% ( Kansas), higher than the prevalence of CSHCN reported in the general population in those states. More than half of CSHCN reported the use of a chronic medication. Demographic characteristics of CSHCN were similar to those of children without special needs, although CSHCN were more likely to reside in single-parent households. Although CSHCN had poorer health status than children without special needs, many CSHCN were reported to be in good health, suggesting a wide spectrum of severity of illnesses within the CSHCN group. Although CSHCN were more likely than children without special needs to have been insured before SCHIP, a large proportion of CSHCN were nevertheless uninsured for at least 12 months before SCHIP ( New York, 56%; Florida, 68%; Kansas, 24%; Indiana, 25%). Although most SCHIP enrollees had a usual source of care ( USC) before SCHIP and there was some variation across states, between 4% and 13% of CSHCN lacked a USC on enrollment, and 23% to 38% of CSHCN changed their USC after enrollment in SCHIP. The majority of all SCHIP enrollees ( including CSHCN) had used some health care during the year before SCHIP including preventive, acute, or specialty care. A high proportion of all SCHIP enrollees, including > 30% to 40% of CSHCN, were reported to have unmet health care needs at enrollment in SCHIP. A variety of unmet needs were reported by CSHCN including specialty care, mental health care, dental care, and prescription medications. Nevertheless, the vast majority of CSHCN as well as children without special needs rated the quality of their medical care before SCHIP highly on several specific quality measures. Findings from multivariate analyses were similar to bivariate results with CSHCN in several states having higher use of care and more unmet health care needs before enrollment.Conclusions. SCHIP is enrolling many CSHCN, with the prevalence of these children occurring at least as high as the prevalence of CSHCN in the general population. CSHCN enrolled in SCHIP represent a heterogeneous population with a wide range of health status and health care needs. Although most CSHCN were already connected to the health care system with a USC and prior health care visits, many had unmet health care needs before enrolling in SCHIP.Implications for Monitoring and Improving SCHIP for CSHCN Enrollees. 1) SCHIP benefit packages need to adequately cover services required by CSHCN such as prescription medications and specialty, mental health, developmental, and home services; 2) because utilization of care will be high among this large group of children, alternative methods of financing and managing care should be considered such as risk adjustment and special programs that involve case management and care coordination; 3) coordination of care across programs ( such as between SCHIP and the state Title V Maternal and Child Health Services program, a component of which serves CSHCN) and ensuring adequate access to primary care and specialty providers might improve access to services for CSHCN; and 4) it is critical to monitor the quality of care for CSHCN enrolled in SCHIP, because these children are among the most vulnerable children covered by public health insurance programs and many of them are enrolling in SCHIP.

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BACKGROUND The outcomes for very low birth weight infants vary among neonatal intensive care units (NICUs), but the reasons for this variation are not well understood. We used the database of a large neonatology research network to determine whether either admission characteristics of the infants or specific characteristics of the units such as annual patient volume and the presence of a pediatric residency program could account for observed differences in neonatal mortality rates among units. METHODS We studied 7672 infants with birth weights from 501 to 1500 g treated during 1991 and 1992 at 62 NICUs participating in the Vermont Oxford Network Database. RESULTS Overall, 14.7% of the study infants died within 28 days of birth (interquartile range 9.9% to 18.1%). The ratio of the number of observed deaths at an NICU to the number of deaths predicted based on the characteristics of infants treated at the NICU (standardized neonatal mortality ratio, [SNMR]) varied significantly among units (range 0 to 1.69, z = 4.24). There was no association between annual patient volume and either mortality rate (r = .17) or SNMR (r = .22). Observed mortality rates (17% vs 13%) and SNMR (1.04 vs .87) were both higher at the 24 hospitals with pediatric residency training programs than at the 38 hospitals without such programs. Hospitals with residency programs had higher average annual patient volumes (104 vs 66). In an analysis simultaneously adjusting for patient characteristics, volume, and presence of a residency program, neither volume (odds ratio [OR] per 10 additional cases treated 1.01, 95% confidence interval [CI], .98 to 1.04) nor presence of a pediatric residency program (OR 1.18, 95% CI, .94 to 1.47) was significantly associated with neonatal mortality risk. CONCLUSION There are differences in neonatal mortality rates among NICUs that cannot be explained by differences in the measured admission characteristics of the infants, suggesting that the effectiveness of medical care varies among units. Neither the annual volume of very low birth weight infants treated in a unit nor the presence of a pediatric residency training program was independently associated with neonatal mortality rates for very low birth weight infants.

Having fewer children in a class is attractive to both parents and teachers. One recent national poll found that 70% of adults believe that reducing class size would result in big improvements in public schools.1 Fewer than 10% believed that it would make no improvement at all. A 1997 Education Week survey found that 83% of teachers and 60% of principals agree that class size in elementary schools should not exceed 17 students, compared with a national average of 25 students per class.2 Teachers feel that smaller classes encourage increased studentteacher interaction, allow for more thorough evaluation of students, and promote greater teaching flexibility.3 However, because of the additional teachers and facilities required, reducing class size is costly. In California, for example, school districts claimed nearly $1 billion in state funds for class size reduction in 1996–97 alone.4

Violence against children and youths has always occurred, but it has recently been subject to increased public attention. This heightened attention is spawned by high-profile cases of stranger abductions, sexual assault, child abuse, and homicide, and by statistics suggesting an increase in the number of cases of child victimization. For example, newspapers recently reported that almost twice as many individuals under age 20 (5,500) died from gunshots in 1993 as in 1984. 1 But deaths, while the most dramatic of victimizations, are only the tip of the iceberg. More frequently, children are abused and neglected by parents, assaulted by siblings, or intimidated by other children. When all of these types of victimization are considered as a whole, children suffer far more victimizations than do members of other age groups. Children are more prone to victimization than adults not only because they are smaller and weaker than adults but also because they are dependent on adults for their day-to-day care and can seldom choose where and with whom they will live and spend time. Problems such as neglect, family abduction, and psychological maltreatment are strongly related to dependency, and these are much more common for children than for most adults. As children age, they become more independent, so the types of victimizations that they are most at risk for change, and the risks arise more from associations with other youths than from dependency on adults. 2 The concept of children as victims brings together the disparate studies of child abuse, sexual abuse, kidnapping, and other forms of violence with studies of such victimizations as assaults by siblings and peer violence. This integration highlights the number of victimizations that children face and may make it easier to identify relationships among different kinds of victimization and to design appropriate interventions. 2 Ultimately, however, defining and measuring child victimization as an integrative category of experiences is useful only if doing so leads to a better understanding of the

Public concern about homelessness in the United States has increased in recent years. A late 1995 Gallup poll found that 86% of Americans feel sympathy for the homeless, and 33% report that they feel more sympathy now than they did five years ago. According to the same poll, one reason for this apparent increase in sympathy is that 17% of Americans, primarily women and young adults, believe that they could become homeless.1 The fact that these groups are concerned about homelessness reflects, in part, two decades of increases in the visibility of homeless women and children in the United States. Published reports suggest that most homeless families with children are headed by single women between the ages of 26 and 30 who have never been married and have two children.2 Because shelter is a basic human need, it is not surprising that the effects of homelessness on children and families appear to be harsh and multifaceted. According to one study, homeless women are significantly more likely to have low birth weight babies than are similar poor women who are housed.3 Others report that, compared to the general population of children, homeless children have twice as many health problems, are more likely to go hungry, and have higher rates of developmental delay; and although findings have not been consistent, higher rates of depression, anxiety, and behavior problems have been reported for homeless children.4 Because, however, as discussed in this article, collecting reliable and comprehensive information about the population of homeless families with children is very difficult, accurately estimating the size, scope, and impact of homelessness among families with children in the United States has been almost impossible.5 Estimates of the size and composition of the population of homeless families and children are important, however, to understand the etiology and consequences of homelessness, to design effective programs and policies to address the problem, and to evaluate whether interventions are working. This Child Indicators article focuses on available data on homeless families and children. First, it reviews different definitions of homelessness and

Twenty-five years ago educational services for children with disabilities were frequently fragmented, underfunded, highly segregated, and unreliable. Public schools were often ill prepared and unwilling to provide special and necessary services to children with disabilities. Over the past two decades, efforts to provide an appropriate education for children with disabilities in America—through a series of state statutes, federal court cases, and federal laws—have led to the development of a large special education system to address the needs of these children. This journal issue focuses on the development of that special education system and examines its components, its strengths and weaknesses, and the areas in which improvement is needed. This Child Indicators article examines some of the key federal statistics on the provision of special education services for children with disabilities. Statistics have played a part in shaping special education policy. A highlight of congressional hearings in the 1970s was the finding that 2.5 million children with disabilities in this country were not receiving an education appropriate to their needs, while almost 2 million others were receiving no education at all. 1 As described by Martin and Martin in this journal issue, congressional response to such statistical evidence of underservice of the disabled included passage of Public Law 94‐142, the Education of All Handicapped Children Act, which required that all students with disabilities receive a free public education appropriately tailored to their individual needs. A key element of this statute and its successors was that federal funding be provided to states for special education services based on state reports of the number of students with disabilities receiving special education and related services. This and other aspects of federal legislation have fostered the development of a data collection system to monitor the provision of special education services to disabled students by local and state educational agencies.

Recent years have witnessed an increase both in respect for the environment and in concern about the hazards posed to the environment by the growth of modern society. Children’s health has benefitted from the heightened attention and expanded research and regulatory efforts directed toward identifying and ameliorating environmental hazards. For example, airborne levels of lead, a chemical which can cause illness and lower IQs in children, have dropped by 96% since 1975, thanks primarily to increased regulation. Yet, much more can be done to protect children from environmental health hazards, and there is reason to be concerned that pending legislation, designed to relax environmental safeguards enacted over the past decade, threatens progress in protecting children, and all age groups, from these hazards. In this journal issue, the three articles following this introduction discuss the relationship between children’s health and the environment. The springboard for these articles was a national symposium, Preventing Child Exposures to Environmental Hazards: Research and Policy Issues, sponsored by the Children’s Environmental Health Network in March of 1994. This symposium brought together experts in research, policy, clinical practice, and advocacy to work toward establishing a national research and policy agenda for children’s environmental health. The full proceedings of the symposium are published in Environmental Health Perspectives, Supplement 4, 1995. The articles by Bearer and by Goldman originated in the symposium but have been substantially rewritten for publication in The Future of Children. The third article, by Landrigan and Carlson, was written especially for this journal issue and presents the policy context for actions to protect children from environmental hazards.

Unlike children in most other economically developed countries, children in the United States are not guaranteed health insurance coverage. Indeed, many U.S. children have no health insurance coverage at all. Their lack of coverage restricts their access to health care services: uninsured children have fewer physician visits per year than children with insurance and are less likely to have a usual source of routine health care. 1 In recognition of the importance of health insurance for children’s access to health care, a number of public programs, the largest of which is the federal-state Medicaid program, have been developed to provide health insurance benefits to poor children and others who would not otherwise have access to health care coverage. Indeed, health insurance coverage for all Americans was a key element of the recent effort to reform health care in the United States. 2 Because of the importance of health insurance coverage, many surveys and reports are devoted to gathering and disseminating statistics on the number and proportion of the U.S. population (including children) who have health insurance of various types. However, the statistics they present can appear contradictory. For example, for 1993, there were three major estimates of the number of uninsured children: the Employee Benefits Research Institute (EBRI) estimated that there were 11.1 million children without insurance; the Census Bureau, 9.5 million; and the Urban Institute, 8.7 million. 3 These different estimates were all based on a single data source, the 1994 Current Population Survey (CPS). This Child Indicators article examines the CPS as a source of data on health insurance coverage, the reasons for the different estimates of the numbers of uninsured children, recent trends in health insurance coverage for children, and the growing importance of the Medicaid program as both a current and a potential source of health insurance for children. This analysis suggests that, even though interpretations of CPS data may seem inconsistent, there are some clear trends in health insurance coverage for children. First, the proportion of children 0 to 10 years old who do not have health insurance has declined slightly over the past five years, while the

Medical and technological advances in the care of infants with low birth weight (less than 2,500 grams, or 5 pounds, 8 ounces) and very low birth weight (less than 1,500 grams, or 3 pounds, 5 ounces) have substantially increased the survival rate for these infants and have led to concerns about the demands their care places upon their families and society. The dollar cost of the resources used disproportionately to care for low birth weight children is one measure of the burden of low birth weight. Using analyses of national survey data for 1988 for children ages 0 to 15, this article presents estimates of the direct incremental costs of low birth weight--costs of the resources used to care for low birth weight infants above and beyond those used for infants of normal birth weight. In 1988, health care, education, and child care for the 3.5 to 4 million children ages 0 to 15 born low birth weight between $5.5 and $6 billion more than they would have if those children had been born normal birth weight. Low birth weight accounts for 10% of all health care costs for children, and the incremental direct costs of low birth cost weight are of similar magnitude to those of unintentional injuries among children and in 1988 were substantially greater than the direct costs of AIDS among Americans of all ages in that year.

In 1989, then President Bush and the state governors established six goals for education in America. Goal number one was that “by the year 2000, all children in America will start school ready to learn.”1 There are few who would dispute the importance of this goal. Arriving at school healthy and developmentally ready to participate actively in classroom activities undoubtedly plays an important part in a child’s school experiences. On its face, and certainly in spirit, making sure that children start school ready to learn is a laudable goal.