The report, "Securing a Healthy Future: The Commonwealth Fund State Scorecard of Child Health System Performance, 2011," examined U.S. states' performance on 20 key indicators of children's healthcare access, affordability of care, prevention, and treatment. It uses the same methodology as a 2008 Commonwealth Fund report on state variations in child health system performances, plus the Commonwealth Fund's general state health system scorecards. States are ranked relative to the performance of other states based on the most recent data available, typically from 2007 to 2009.

The new report found that children living in the five top-ranked states -- Iowa, Massachusetts, Vermont, Maine, and New Hampshire -- are more likely to be insured and receive recommended medical and dental checkups than children living in poorer performing states such as Florida, Texas, Arizona, Mississippi, and Nevada.

Minnesota ranked first in the "healthy lives" category as a result of low rates of infant and child mortality, obesity, dental problems (toothache, decayed teeth or cavities, broken teeth, or bleeding gums), and children at risk for developmental delays, while Arkansas, Mississippi, and the District of Columbia ranked last, with some of the worst rates on these indicators, according to the report.

Nationwide, more than one-third (35%) of low-income children have not received recommended medical and dental visits, while only one in five higher-income children have not received such checkups, according to the report. Disparities in oral health problems also stand out: In the five states with the largest gaps by income, 43% of children in low-income families had toothaches, decayed teeth or cavities, broken teeth, or bleeding gums in the past six months, compared with 22% of children in higher-income families.

The Children's Health Insurance Program (CHIP) Reauthorization Act of 2009 requires all CHIP programs to provide a comprehensive dental benefit package, the report noted. In addition, states can draw from CHIP funds to offer dental-only supplemental coverage for children who lack adequate dental coverage. However, findings indicate that simply including a benefit is not sufficient: States will need to address the supply of dental care, likely with workforce innovations to meet children's preventive and other oral health needs, the report noted.

"We are entering a new era in American healthcare," said Commonwealth Fund President Karen Davis in a press release announcing the report. "We made a commitment to insuring children a decade ago through Medicaid and CHIP. Now we have not only redoubled those efforts, but also expanded that same protection to their parents through the Affordable Care Act, finally giving the entire family the best chance to be healthy and productive without fear of ruinous medical bills."

Preventive dental care

U.S. children miss about 1.6 million school days each year because of dental disease, the report noted. National health objectives, as set forth by the U.S. Department of Health and Human Services in its Healthy People 2010 initiative, include ensuring that children have a minimum of one dental visit each year. Despite this goal, performance remains uneven across states: Almost one-third of children did not see a dentist for a preventive visit in the bottom-ranked state (Florida), and more than 10% did not have a dental checkup in the top-ranked state (Hawaii).

Five states scored the highest for children who had the most preventive dental care visits: Hawaii, Rhode Island, Vermont, Connecticut, and Iowa.

Nationally, more than a third (35%) of children in families living below the poverty level did not have visits for medical and dental preventive care in 2007, compared with 21% of children in families with higher incomes, the report found.

More than 40% of poor children in the five bottom-ranked states (Nevada, Oregon, Colorado, Florida, and North Dakota) did not receive medical and dental preventive care visits, compared with 22% of poor children in the top four states (Rhode Island, Hawaii, New York, and West Virginia) and the District of Columbia.

Surprisingly, the report found that some minority children fare relatively better than white children in terms of receiving medical and dental preventive visits, with black children more likely to receive preventive visits in two-thirds of the states for which data are available. However, it was not the case for Hispanic children, who were much more likely than other children to go without routine preventive care.

Oral health problems

In 2007, more than one-quarter of children ages 1 to 17 (27%) had at least one of the following oral health problems within the past six months: decayed teeth or cavities, toothache, broken teeth, or bleeding gums, the report found.

Even in Minnesota, the state with the lowest rate of such problems, one out of every five children had oral health concerns. Unmet needs for dental care based on reports of pain and tooth decay or damage were highest in Arizona and Mississippi, where nearly one in three children had such oral health problems. In addition, parents who do not obtain dental care for themselves are less likely to bring their children in for dental care, the report found.

Children in low-income families have more than one-and-a-half times the prevalence of untreated cavities, pain, bleeding gums, or other dental problems than higher-income children in most states, according to the report. In addition, uninsured children are far more likely to live with oral health problems than those with insurance: Rates of such problems were two times higher among uninsured than privately insured children in some states.

Oral health problems are also more prevalent among children with public insurance than those with private insurance, the report noted. A government report found that publicly insured children often do not receive needed dental care, despite being substantially more likely to experience dental disease.

Low dentist participation in Medicaid and CHIP contributes to reduced dental access for low-income children, the study found. Increasing the availability of dental care for children through broader use of midlevel dental providers will likely be instrumental to ensure access to timely, affordable care in all communities, including rural and low-income areas, the report noted.

Notably, the report described Alaska's dental health aide therapist program as a success, serving as a model of how greater use of midlevel dental providers can improve children's access to dental services and the quality of care.

Millions of Medicaid kids still not getting dental care, December 1, 2010

Report: Many W.Va. kids don't get dental care, September 7, 2010

Calif. kids' oral health needs not being met, May 24, 2010

Pew report flunks 9 states on kids' dental care, February 23, 2010

States diverge in caring for the teeth of the poor, June 3, 2008