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The Children's Health Insurance Program and the Goldilocks Effect

  • Peter G. Szilagyi
    Correspondence
    Address correspondence to Peter G. Szilagyi, MD, MPH, Mattel Children's Hospital, University of California at Los Angeles (UCLA), Los Angeles, CA 90095.
    Affiliations
    Mattel Children's Hospital, University of California at Los Angeles (UCLA), Los Angeles, Calif
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      Did you ever read the story of Goldilocks to your children? In one version of this story, Goldilocks is a tired, hungry, and lost little girl who encounters a house owned by 3 bears. She finds 3 bowls of porridge and judges whether each is too hot, too cold, or just right. She then finds 3 chairs, and determines whether each is too big, too small, or just right. Finally she is tired and finds 3 beds, and she assesses whether each bed is too hard, too soft, or just right. After she eats the porridge, sits in the chair, and lies on the bed that are all “just right,” she falls asleep. The 3 bears return home, angry that the little girl has used their belongings, but fortunately she escapes and in this version of the story there is a happy ending.
      The Goldilocks Effect is the concept that something should lie within certain reasonable boundaries (ie, not too cold, not too hot—but “just right”). So for example in market economics, a “Goldilocks Market” occurs when the pricing of commodities lies somewhere between a bull or bear market (ie, at a level that is “just-right”). As another example, a recent study of infant cognition suggests that infants are able to process information that is not too simple, and not too complex (ie, at just the right level of complexity for their level of brain development).
      • Kidd C.
      • Piantadosi S.T.
      • Aslin R.N.
      The Goldilocks effect in infant auditory attention.
      This has been dubbed the “Goldilocks Effect” for infant cognition.
      As a pediatrician and a health services researcher with decades of experience studying the Children's Health Insurance Program (CHIP) and health insurance for children, I have often wondered about the Goldilocks Effect for child health insurance. Instead of the triple metric of a bowl of porridge, a chair, and a bed, we can use the Triple Aim metric
      • Berwick D.M.
      • Nolan T.W.
      • Whittington J.
      The triple aim: care, health, and cost.
      of whether a program provides “just the right” health outcomes for the population, just the right patient care experience, and at just the right costs. What is the Goldilocks Effect for CHIP?
      CHIP arose out of a concern about the plight of uninsured children and the evidence that uninsured children fared worse than insured children on a variety of health metrics. With the experience that some state-level experiments in prototype health insurance programs appeared to improve health care for uninsured children at a relatively low cost, in 1997, with bipartisan support, Congress passed Title XXI of the Social Security Act to establish the State CHIP. At the time, this landmark legislation represented the biggest expansion of health insurance for children since the establishment of Medicaid in 1965. In 2009, the CHIP Reauthorization Act reauthorized CHIP through fiscal year 2019; however, in context of the Affordable Care Act, federal funding for CHIP has been extended only through 2015. With more than 8 million children covered by CHIP, the future of CHIP represents a key Goldilocks question—can the United States get it “just right” for provision of health insurance for low-income children?
      Many rigorous studies have evaluated CHIP within key domains of the Triple Aim framework, even before the Triple Aim concept was disseminated. During the 1990s a series of studies across a variety of states demonstrated substantial improvements in access to primary and specialty care, quality of care, and some components of health outcomes.
      • Szilagyi P.G.
      • Dick A.W.
      • Klein J.D.
      • et al.
      Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP).
      • Brach C.
      • Lewit E.M.
      • VanLandeghem K.
      • et al.
      Who's enrolled in the State Children's Health Insurance Program (SCHIP)? An overview of findings from the Child Health Insurance Research Initiative (CHIRI).
      This was observed for the CHIP population overall and for subgroups of the population.
      • Szilagyi P.G.
      • Shenkman E.
      • Brach C.
      • et al.
      Children with special health care needs enrolled in the State Children's Health Insurance Program (SCHIP): patient characteristics and health care needs.
      The current supplement of Academic Pediatrics presents findings from the most recent federally mandated evaluation of CHIP, which involved an elegant and rigorous study design and a comprehensive evaluation of 3 domains—1) programmatic design and states' experience with CHIP, 2) health insurance coverage, and 3) the effects of CHIP on enrollee access, receipt of care, and content of care. As described by these studies and commentaries, the overall message is an extremely positive one with very substantial improvements in health care access and quality for the overall CHIP population and for key subgroups, and also a substantial effect on reducing the proportion of children who would have been uninsured without CHIP.
      This evaluation of CHIP did not assess all aspects of the Triple Aim, nor did it find that we got it “just right” in every case. First, the evaluation did not assess, in detail, the issues of costs. Second, health care and health outcomes were not perfect, even under CHIP. This second point highlights a critical point about CHIP and health insurance in general. A health insurance program, by itself, cannot be expected to optimize health care quality, health experiences, and health outcomes.
      • Eisenberg J.M.
      • Power E.J.
      Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality.
      Rather, health insurance is a necessary, but not sufficient platform that is needed—a critical first step. To optimize health care and outcomes, the health care system itself must transform using evidence-based and patient-centered innovations. These transformations extend well beyond the potential effect of a health insurance program. In other words, we are asking too much of CHIP if we really expect the program to optimize quality and outcomes; rather we should ask whether CHIP has improved access, quality, and outcomes to a reasonable degree. The answer is a resounding yes. Thus, even as we focus on providing appropriate health insurance for children,
      • Keller D.
      • Chamberlain L.J.
      Children and the Patient Protection and Affordable Care Act: opportunities and challenges in an evolving system.
      we must work just as hard at transforming the entire health care system, not just the health insurance platform. Even if we “get it just right with CHIP,” there is much work that remains to be done for children's health care beyond CHIP.
      The story of Goldilocks has a happy ending. Will we have a happy ending for the millions of children who live within low-income families and are insured by CHIP or potentially insured by a program like CHIP? As CHIP evolves and perhaps eventually becomes part of the overall health insurance system rather than a stand-alone program, we must remember the lessons from CHIP. I believe that the overwhelming evidence, bolstered by the articles in this supplement to Academic Pediatrics, demonstrate that CHIP has transformed the health insurance environment for low-income children and improved their health care. We must remember the lessons from CHIP as we strive for the Goldilocks Effect in insuring and meeting the health care needs of our nation's children.

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