Creative reform of health care policy and systems is likely to occur first among states. Partnerships within state governments and between public and private entities are critical in formulating policies to encourage and sustain improvements in care. In an effort to engage states in quality improvement, the Fund recently supported Vernon Smith, Ph.D., of Health Management Associates, to convene a cross-section of state government leaders from public health, Medicaid, the State Children's Health Insurance Program, mental health, and education. Despite the fiscal and administrative challenges facing state governments, officials are optimistic that improvement in quality of care for young children is possible, Smith found. These leaders' recommendations include developing specific child health quality measures, monitoring performance on an ongoing basis, making information about the quality of care easily available, rewarding superior performance, and using performance measures in purchasing and program decisions.

State Medicaid programs are the most important part of the public safety net of health services available to low-income children: each year, more than 50 percent of low-income American children receive care covered by Medicaid. Since these children are at great risk for poor developmental outcomes, the program has focused on improving the quality of developmental services and preventive care within Medicaid. The Fund's support of eight state Medicaid programs has led to innovations in the provision of well-child care, as well as changes in state policy to support these improvements.