Highlights efforts by the Healthy Kids programs to provide coverage for California's uninsured children, the utilization of preventive health care, the long waitlists due to funding limitations, and policy implications of anticipated funding deficits

Gregory D. Stevens

Kyoko Rice

Michael R. Cousineau

T. Em Arpawong

English

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  HTTP://COMMUNITYHEALTH.USC.EDU   COVERING CALIFORNIA’S KIDS EVALUATION September 2007  FUNCTIONING AT THE BRINK: THE CHILDREN’S HEALTH INITIATIVES HAVE GROWN BUT MAY NOT SURVIVE GREGORY D. STEVENS, MICHAEL R. COUSINEAU, T. EM ARPAWONG, AND KYOKO RICE   In the midst of health care reform debate at the state and national levels, the Children’s Health Initiatives (CHIs) continue to provide coverage to otherwise uninsured children in California primarily via Healthy Kids.1  Healthy Kids is still the only affordable source of comprehensive coverage for these children, but anticipated funding deficits threaten to close these programs and disenroll thousands of children in the absence of state funding.  This report highlights the experiences of the CHIs as they aim to remain viable while waiting for legislative action.   Healthy Kids programs are operating in 25 of California’s most populated, highest need counties. • Healthy Kids programs currently operate in counties that account for about 80 percent of the State’s total uninsured children (see Figure 1).  • Enrollment in Healthy Kids statewide is currently 83,940 based on the latest data from each county (66,930 children ages 6-18 and 17,010 ages 0-5).  This represents a 1 percent increase from the prior year.  About 8,800 children were waitlisted for Healthy Kids statewide. • The CHI in Placer County is currently in a planning phase, and will become the 26th county to operate a Healthy Kids program.  The CHI is expected to launch by end of summer 2007 and cover up to 850 children.     HK Operational   CalKids    HK Planning Figure 1. Status of Children’s Health Initiatives Statewide by Implementation Phase Many of the CHIs are unable to meet the estimated demand for child health insurance coverage. • Reports from CHI directors or from state representative survey data suggest there were about 201,000 Healthy Kids eligible children in CHI counties at the initiation of these programs.  Overall, CHIs are meeting about 39 percent of the total need for coverage in CHI counties (see Table 1). Table 1. Reported Children Enrolled, Waitlisted, and Eligible for Operational CHIs as of April-July 2007Enrolled Children Waitlisted Children Estimated Total Eligible Enrolled as a Proportion of Total Eligible  0-5 y 6-18 y Total 0-5 y 6-18 y Total 0-18 y 0-18 y Alameda 135 906 1,041 550 2,000 2,550 11,000 9% Colusa 20 20 40 0 18 18 -- -- El Dorado 39 53 92 0 0 0 1,000 9% Fresno 310 904 1,214 0 455 455 8,550 14% Kern 539 944 1,483 0 817 817 2,000 74% Kings 11 0 11 -- -- -- -- -- Los Angeles 6,610 30,647 37,257 0 1,724 1,724 70,000 53% Merced 76 103 179 -- -- -- 3,000 6% Napa 105 640 745 0 0 0 -- -- Orange 34 234 268 0 0 0 17,000 2% Riverside 1,956 4,385 6,341 0 0 0 8,000 79% Sacramento 205 695 900 0 30 30 22,000 4% San Bernardino 1,470 750 2,220 0 0 0 5,000 44% San Francisco 698 3,331 4,029 -- -- -- -- -- San Joaquin 495 2,044 2,539 0 335 335 3,000 85% San Luis Obispo 188 396 584 38 568 606 2,200 27% San Mateo 870 5,545 6,415 0 0 0 7,150 90% Santa Barbara 159 340 499 100 500 600 4,000 12% Santa Clara 1,953 10,794 12,747 0 935 935 18,000 71% Santa Cruz 319 1,685 2,004 0 200 200 2,300 87% Solano 149 1,056 1,205 20 68 88 2,000 60% Sonoma 257 755 1,012 0 350 350 2,700 37% Tulare 309 383 692 -- -- -- 3,000 23% Yolo 68 245 313 0 23 23 6,800 5% Yuba 44 69 113 0 50 50 2,350 5% TOTAL 17,019 66,924 83,943 708 8,073 8,781 201,050 39%  • Despite some recent decreases in Healthy Kids enrollment, Los Angeles continues to maintain both the largest enrollment and waitlist of children.  Still the program reaches only about half (53 percent) of the estimated number of eligible children for Healthy Kids.  Only seven other CHIs are meeting half or more of the estimated need for coverage.    • t from First 5 • portant, but frequently   Philanthropies have helped leverage funding for Healthy Kids premiums from other donors. • ing • re reported to be somewhat   CHIs continue to view philanthropies, health departments, and advocacy groups as key partners.  reflect the near universal difficulty faced by CHIs in engaging business in their activities.  • Financial limitations are the main barriers to expanding coverage further to meet a greater share of need for child coverage.  Outreach and enrollment strategies have remained unchanged across CHIs, with community clinics and schools the primary sources of reaching families of eligible children.  Many of the CHIs have now been operational for more than a year and many have refocused much of their efforts on retaining children in the program.  The most commonly reported strategy to assure continuous enrollment is to pre-populate application forms with family information in order to reduce the burden associated with completing necessary paperwork.    CHIs face sustainability problems, not only for premiums, but for core administration activities. Because of the supporcommissions both locally and statewide, CHIs report few problems maintaining funding for children ages 0-5 years, but two-thirds said sustainability of premiums for older children was fair or poor (see Figure 2).  This is substantiated by analyses that predict premium funding deficits of $175 million for children 6-18 years over the next three years.2 Perhaps the most imoverlooked problem faced by CHIs, is funding for administration.  Only one-third of CHIs reported excellent or very good sustainability of administration activities and more than one-third Is understandably want funding to be directed to purchasing coverage since this is a measurable and reportable outcome.  This has left CHIs without sufficient specific funds for administration.  A. Premiums for Children 0-5 Years D. Administration C. Outreach and Enrollment Activities B. Premiums for Children 6-18 Years ExcellentVery Good GoodFair/Poor Figure 2.  Reported Financial Sustainability of CHI Operational Activities (37 percent) said it was fair or poor.  Donors to the CH• When asked how helpful funding from The 2.42.22.11.71.31.00.82.51.81.9 1.91.81.10.9Philanthropies County Boardof SupervisorsCountyAgenciesState Grants Businesses City Councils Federal GrantTCEFirst 5Not at All (0)Not Very (1)Somewhat (2)Figure 3. Helpfulness of California Endowment and First 5 Funding in Leveraging FundsVery (3)California Endowment (TCE) and First 5 was in leveraging funds from others, the response was overwhelmingly positive (see Figure 3). CHIs reported that TCE and First 5 fundwas somewhat or very helpful in leveraging funds from other philanthropies (average of 2.4 and 2.5--out of 3 points), county supervisors and county agencies. First 5 funds wehelpful (average 1.8) in leveraging support from businesses.  Funding, however, was not often obtained from city councils or federal grants regardless of TCE and First 5 support. • When asked how helpful organizations were in meeting CHIs’ goals of health insurance for all children,local First 5 offices and TCE were ranked near the top (average of 2.8 and 2.5--out of 3 points).  The statewide coalition of CHIs (known as the Coalition of Children’s Health Initiatives) also ranked highly (average of 2.5).  Legislators’ offices and the local United Way were ranked lowest. United Way is specifically funded to help generate support for the CHIs from businesses; thus, this score may, in part,    C ve with time. • CHIs report effective communication, involving members in discussion and developing trust.  Weak areas are efficient decision making and engaging in quality assessment and improvement (see Figure 5). • Not surprisingly, CHIs that have been operational  for one year or longer report higher functioning than those implemented less than one year.  For example, long-term CHIs averaged 2.1 vs. 1.8 for newer CHIs (out of 3 points) for communication. • Compared to long-term operational CHIs, newly operational CHIs reported a higher average level of capacity to engage in quality improvement activities.    Health plans serving CHIs are implementing efforts to increase preventive care utilization. • Nine (9) CHIs reported that their health plan has an initiative to encourage children under the age of five to obtain dental care services and to encourage local dentists to accept public insurance clients. • Six (6) CHIs reported that their health plan promotes services to screen and treat overweight children.  These health plans provide resources to providers, such as distributing BMI wheels and calculators, and offer physician training on effective counseling and treatment for overweight children.  • Three (3) CHIs are focusing on member education to encourage preventive visits.  One produced a “Utilization Promotion DVD” for new members, and another offers incentives to members for obtaining their well-child and well-adolescent check-ups.   Policy implications • The success of Healthy Kids programs has stemmed from the sustained and collaborative efforts of CHIs, their cohesive and effective coalitions, and their partnerships with First 5 organizations, advocacy groups and many other organizations.  Many philanthropies have helped to sustain these programs and leverage other support; but they too have their programmatic and financial limits and are considering end dates for Healthy Kids premium support, leading most CHIs to reach their financial brink.   • Despite the recent line-item veto by the governor of California of funding for outreach and enrollment, and ongoing presidential opposition to the expansion of the SCHIP program, there are opportunities for the California legislature to assure that children who are currently covered by Healthy Kids do not return to the pool of uninsured by expanding public coverage to all children regardless of immigration status.   • The value of coverage for these children should not be overlooked.  Data suggest that coverage for these children statewide would increase preventive health care utilization, reduce hospitalizations for conditions that can be managed in primary care (e.g., asthma), and improve health.2-5   1. Stevens GD, Rice K, Cousineau MR. Children's Health Initiatives in California: the experiences of local coalitions pursuing universal coverage for children. Am J Public Health. Apr 2007;97(4):738-743. 2. Howell EM, Trenholm C. The effect of new insurance coverage on the health status of low-income children in Santa Clara County. Health Serv Res. Apr 2007;42(2):867-889. 3. Howell EM, Hughes D. A tale of two counties: expanding health insurance coverage for children in California. Milbank Q. 2006;84(3):521-554. 4. Howell E, Hughes D, Kenney G, Sullivan J, Rubenstein J. Evaluation of the San Mateo County Children's Health Initiative: Second Annual Report. Washington, DC: The Urban Institute; August 2005. 5. Cousineau MR, Stevens GD, Pickering T. Preventable Child Hospitalizations in California Counties with Child Health Insurance Expansion Initiatives. Alhambra, CA: USC Center for Community Health Studies; July 2007.     Funding for this research provided by HI coalitions communicate and respond to changes well, but also appear to improFigure 4. CHI Coalition Functioning Across Eight Domains of Group Dynamics Note: The closer the line to the outside edge of the octagon, the better the performance Operational 1+ YearsNewly Operational1.51.71.81.81.92.11.21.6 1.41.61.51.61.61.71.81.4CommunicationRespond to changesDevelop trustAll members discussTalk to actionUse abilities of allEfficient decisionsEngage in QIFirst 5 California   and The California Endowment  

Covering California's Kids: Functioning at the Brink: The Children's Health Initiatives Have Grown but May Not Survive

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Covering California's Kids: Functioning at the Brink: The Children's Health Initiatives Have Grown but May Not Survive

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