Toward Universal Child Coverage in California: Findings from Healthy Kids Program Evaluations

1. Toward Universal Child Coverage in California: Findings from Healthy Kids Program Evaluations 24 June 2006 Presented to: Child Health Services Research Annual Meeting Ian Hill Embry Howell Genevieve Kenney Brigette Courtot Gregory Stevens Michael Cousineau Eriko Wada Moira Inkeles Patricia Barreto Chris Trenholm

2. Presentation Outline • Background on California’s Children’s Health Initiatives • Overview of Evaluations in Los Angeles, San Mateo, and Santa Clara Counties • Evaluation Highlights Regarding: • Outreach and Enrollment • Demographics and Insurance Status • Health Service Use and Cost • Impacts on Access to Care • Lessons Learned and Future Challenges

3. Evaluation and Funding Partners • Evaluation Partners – The Urban Institute, Mathematica Policy Research, USC, UCLA, UCSF, Castillo & Associates, Aguirre International • Funding Partners – First 5 LA, The California Endowment, The David and Lucile Packard Foundation, San Mateo Children's Health Initiative Partners

4. California’s Children’s Health Initiatives (CHIs) The Problem: • Roughly 790,000 Uninsured Children in California in 2003 • Two-thirds estimated already eligible for Medi-Cal or Healthy Families • Remaining one-third largely undocumented The Response: • Since 2001, 31 of California’s 58 Counties Initiated CHIs; 17 operational/14 in planning

5. Implemented Planning California Kids Program California’s Children’s Health Initiatives Source: University of Southern California, 2006

6. Typical CHI Program Characteristics • Upper Income Eligibility Limit of 300% FPL • Children Ages 0-18 Ineligible for Medi-Cal or Healthy Families (SCHIP) (ie, Mostly Undocumented Children) • Universal Community-based Outreach Model • Benefits Modeled after SCHIP • Managed Care Delivery System • Nominal Sliding Scale Premiums and/or Copayments • Multiple Funding Sources

7. Overview of Evaluation Components

8. Evaluation Highlights: Program Development • Funding from First 5 Organizations often served as basis for expansion to children ages 0-5 • For children ages 6-18 additional funding sought from broad range of donors, including County govt., health plans, philanthropies, provider organizations and community groups • Active coalitions of same collaborated on policy and program design • CHIs typically mirror Healthy Families

9. Evaluation Highlights:Outreach and Enrollment Case Studies found: • Emphasis on grass roots, community-based outreach in variety of settings • Hands-on application assistance model • “Something for everyone” approach Focus Groups found: • Vast majority of parents say process is easy • Few parents reluctant to apply; outreach workers dispel fears of “public charge”

10. THE URBAN INSTITUTE Los Angeles Department of Health Services Outreach Contacts by Location Source: Urban Institute/USC Analysis of LAC DHS data.

11. Distribution of Applications Submitted with Assistance by Los Angeles DHS, by Program n=28,780 Source: Urban Institute/USC Analysis of LA County DHS data, 2005

12. Healthy Kids Enrollment Trends in Los Angeles, San Mateo, and Santa Clara Counties January 2001 to October 2005 Enrollment Cap enacted Enrollment Cap enacted Sources: L.A. Care Health Plan; Santa Clara County government web site. http://www.sccgov.org/portal/site/scc; Health Plan of San Mateo.

13. THE URBAN INSTITUTE Socioeconomic Characteristics of Los Angeles Enrollees (Ages 1-5) 100-199 3-5 High school Years parent in LA county Level of Poverty Parental Education Source: Urban Institute Survey of LA Healthy Kids Enrollees, 2005 13

14. THE URBAN INSTITUTE Ethnicity and Language ofLos Angeles Enrollees (Ages 1-5) Other Language spoken at home Ethnicity Source: Urban Institute Survey of LA Healthy Kids Enrollees, 2005 14

15. Insurance Status Prior to Enrolling in the LA Healthy Kids Program (Ages 1-5) Source: Urban Institute Survey of LA Healthy Kids Enrollees, 2005

16. Access to Employer-Sponsored Coverage Among Healthy Kids Enrollees Has an offer of dependent coverage through 9.9% employer Has an offer of dependent coverage and employer 5.4% pays some or all of premium Has an offer of dependent coverage, employer pays 2.9% some or all of premium, and at least one parent has employer-sponsored coverage Source: Urban Institute Survey of LA Healthy Kids Enrollees, 2005

17. Santa Clara County Findings: CHI Has Had a Significant Spill-Over Effect on Medi-Cal and Healthy Families Enrollment New Entries In Santa Clara County, 2001-2002 Source: Mathematica Policy Research, Inc. analysis of Enrollment Files for the Medi-Cal and Healthy Families Programs. **Difference is significantly different from zero at the .01 level.

18. Santa Clara County Findings: Gains are Evident Throughout the Post-CHI Period Source: Mathematica Policy Research, Inc. analysis of Enrollment Files for the Medi-Cal and Healthy Families Programs. **Difference is significantly different from zero at the .01 level.

19. Access to Care Case Studies found: • Benefit package meeting the needs of children • Copays affordable for most families • Satisfaction with network scope, but potential weak links with developmental and specialty systems • Health utilization seems low, but no reports of access problems Parent Focus Groups found: • Families using services (health, dental, vision, specialty) • Parents satisfied with providers who “speak their language” • Copays affordable for all but parents of CSHCN • Many parents still have and use Emergency Medi-Cal card

20. Health Service Use and CostSan Mateo County Health Plan:Use of Ambulatory Care(Percent With Visit in Year) Source: Urban Institute analysis of San Mateo Health Plan data

21. San Mateo County Health Plan:Average Annual Cost Per Child Source: Urban Institute analysis of San Mateo Health Plan data

22. Impacts in Santa Clara County:Healthy Kids Reduced Unmet Medical Need Percentage ** ** SOURCE: Mathematica Policy Research Inc., tabulations from 2003-04 Survey of Healthy Kids Enrollees (lower-income sample) ** difference is statistically significant at p-value < .01

23. Impacts in Santa Clara County:Healthy Kids Increased Access to a Usual Medical Care Source Percentage ** SOURCE: Mathematica Policy Research Inc., tabulations from 2003-04 Survey of Healthy Kids Enrollees (lower-income sample) ** difference is statistically significant at p-value < .01

24. Impacts in Santa Clara County:Healthy Kids Sharply Raised of Medical Care Use Percentage ** SOURCE: Mathematica Policy Research Inc., tabulations from 2003-04 Survey of Healthy Kids Enrollees (lower-income sample) ** difference is statistically significant at p-value < .01

25. Conclusions • Healthy Kids Programs have reached over 88,000 very low-income, primarily undocumented children of working parents • Community-based outreach and application assistance appears to be enrolling high proportions of eligibles • Most children uninsured prior to Healthy Kids, have little access to ESI, and have uninsured parents • Healthy Kids use fewer services and cost less than Medi-Cal

26. Conclusions (cont.) • Health Kids outreach has a partial “spill over” effect on Medicaid and SCHIP enrollment • Healthy Kids reduces unmet need for medical/dental care • Improves access to and use of this care

27. Financing Challenges, but Hope for Future • Sustaining coverage for older children has been challenging • 11 CHIs have had to enact enrollment caps for 6-18 year olds; over 12,000 kids on waiting lists • Some evidence that caps suppress enrollment of non-affected children However, • Governor’s budget includes $23 million to support CHIs • Ballot initiative would raise tobacco tax by $2.60 per pack to support Health Families/Healthy Kids statewide