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More rural children are covered by State Children’s Health Insurance Programs (SCHIP) than are non-rural children, but eligibility and coverage vary by state. Nearly half of children in rural areas live in low-income families (again, a higher rate than non-rural children), and 44 of the 50 counties with the highest percentage of uninsured children are rural counties. 

Against that statistical backdrop comes a new report on how states are performing on providing heath care to children. U. S. Variations in Child Health System Performance: A State Scorecard from The Commonwealth Fund examines 13 performance indicators of access, quality, costs, equity, and the potential to lead healthy lives, and rank states on each.

Iowa and Vermont were ranked the top states, with Kansas, Wisconsin, and Nebraska also included in the top quartile. Oklahoma was ranked at the bottom. The report also finds that New England, Upper Midwest, and North Central states perform well on indicators of access, quality, and equity, while Western and Southern states perform well on cost but not as well on access and quality.

Iowa and Alabama were the only two states to rank in the top quartile of states in the major three indicators – access, quality, and costs. The report cites as reasons Iowa’s recent policy decisions to expand SCHIP eligibility and to mandate reporting of quality of care by child health plans and local and regional children’s health systems and Alabama’s early and expanded SCHIP program.

It is often said in debates on health care reform that reform is limited in the United States because Americans desire a health care system that provides access, quality, and cost control, but in reality public policy can only provide any two of the three. The data in this report supports that general proposition as it applies to children’s health care systems in most states.

This report, however, lifts up Iowa and Alabama as two states whose children’s health care efforts are exceptions to the conventional wisdom on what can be achieved. The policy examples of Iowa and Alabama, two states with large rural populations, are important for the larger issue of health care reform. With all rural citizens facing issues of health care quality and access, this report provides state-level models of how those issues can be resolved in a cost-effective manner.