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Show health care and its quality as a result of programs like CHIP. In implementing CHIP, states had several options including creation of a new CHIP program, potentially with enrollment caps, or expansion of Medicaid entitlement programs. One tradeoff in implementation was between greater control of the budget with a new, non-entitlement program versus simpler administration and less need for coordination among the various public insurance programs with a Medicaid expansion. Prior to CHIP, Utah's Healthprint had already extended Medicaid benefits beyond the federal requirement (Utah Health Policy Commission, 1997). Utah's version of CHIP is mainly a new program which provides benefits "more like PEHP1 than Medicaid", with two levels of cost-sharing depending on income. The goal of Utah's CHIP is to reduce the percentage of Utah's uninsured children from the 8% achieved by Healthprint to 3% by 2001. It is estimated that about 60,000 children will be covered by the Utah CHIP (Westover, 1998). It has 5 strategic objectives: 1) Reduce the percentage of Utah children, from birth to 19 years of age, who are uninsured; 2) Improve access to health care services for Utah children enrolled in the Utah CHIP; 3) Ensure that children enrolled in the Utah CHIP receive timely and comprehensive preventive health services; 4) Ensure that CHIP-enrolled children receive high quality health care services; and 5) Improve health status among children enrolled in the Utah CHIP (Leavitt & Betit, 1998). A program evaluation of the CHIP is federally mandated. In addition, as anticipated by the nature of incrementalist public policy (Lindblom, 1959), the variety of local stakeholders including enrollees, providers, public interest groups, insurance companies, legislators, administrators, health policy experts, and others have multiple, perhaps disparate reasons to monitor the process and outcomes of this program. The Utah CHIP will be evaluated from at least two levels: 1) relative to its stated performance goals, and 2) by a "systematic assessment ... of the impact of program policies, service quality, and cost on health outcomes of [the] CHIP population" (Leavitt & Betit, 1998). The evaluation is proposed to collect certain baseline and annual performance measures, and to compare selected health status and quality of life indicators among CHIP enrollees and versus other HMO enrollees and commercially insured groups. Outcome measures are projected to include numbers of additional children covered, ethnic and rural/urban distribution, actual utilization, costs of the program, quality of care such as the HEDIS2 measures (National Committee for Quality Assurance, 1998), satisfaction with care using the Consumer Assessment of Health Plans Survey, or CAHPS (Agency for Health Care Policy Research, 1996), dental claims, and other administrative data. A health status survey will be developed and administered by the state Department of Health. Other measures of health outcomes which might suggest themselves include deafness related to ear infections, teen pregnancies, and child death rates. CHIP and Access to Primary Care Increased access to primary care is implicit in the goals of the Utah CHIP. It is explicit in the performance measures, e.g., "By June 30, 2000, at least 60 percent of three, four, five, and six year old children who were continuously enrolled in the Utah CHIP program during the preceding year, will have received one or more well-care visits with a primary health care provider during the previous year" (Leavitt & Betit, 1998). Primary care is "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community" (Donaldson, Yordy, Lohr, & Vanselow, 1996). Achieving accessible primary care requires that a variety of barriers be overcome. In 1996, the Institute of Medicine defined access to primary care as the extent to which "a patient can initiate an interaction for any health problem with a clinician (e.g., by phone or at a treatment location) and includes efforts to eliminate barriers such as those posed by geography, administrative hurdles, financing, culture, and language" (Donaldson et al., 1996). Recently, Gold reviewed comparative conceptualizations of access (Gold, 1998). Lack of access may mean that services may be unavailable, as in the three Utah counties with no resident physicians. Or, services may be available but inaccessible due to administrative barriers such as clinic hours which exclude working people, language barriers, acceptability barriers such as reluctance to visit mental health facilities 1 Public Employees Health Plan, which administers health insurance for many Utah public employees. Benefits are less comprehensive than Medicaid benefits. z HEDIS is the acronym for the Health Plan Employer Data and Information Set. 51 |