Presents highlights from evaluations of a comprehensive health insurance coverage program for children, launched by Children's Health Initiatives and supported by the California Endowment, in Los Angeles, San Mateo, and Santa Clara counties

Christopher Trenholm

Dana Hughes

Embry Howell

Ian Hill

English

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Three Independent Evaluations of Healthy Kids Programs Find Dramatic Gains in Well-Being of Children and Familiesby Christopher Trenholm (Mathematica), Embry Howell (Urban Institute), Ian Hill (Urban Institute), and  Dana Hughes (University of  California, San Francisco)This brief presents highlights from rigorous, independent evaluations of the Healthy Kids programs in three California counties, Los Angeles, San Mateo, and Santa Clara. Launched by Children’s Health Initiatives (CHIs) in these counties between 2001 and 2003, the three Healthy Kids pro-grams provide children with comprehensive health insurance coverage, including a broad range  of medical and dental care, prescription drugs, and mental health services. Children are eligible for Healthy Kids if they are ineligible for California’s two major state insurance programs, Medi-Cal and Healthy Families, and live in families with incomes up to 300 percent of the federal poverty level (FPL) in Los Angeles and Santa Clara counties, and 400 percent of the FPL in San Mateo County. Most of the children enrolled in Healthy Kids have family incomes at or below the poverty level. This brief describes some of the many positive impacts that Healthy Kids programs have had on children, including improvements in their access to and use of medical services and reductions in their unmet need for care. (For more information on these and other study findings on the three programs, see http://www.urban.org and http://www.mathematica-mpr.com/health/chi.asp.) Impact of Healthy Kids on Participating Children and Families Healthy Kids programs ensure high quality care for children who would otherwise lack access to  affordable health insurance coverage. Three of the largest programs—in Los Angeles, San Mateo,  and Santa Clara counties—currently provide coverage to about 60,000 children living in widely varying communities in California. Before enrolling in Healthy Kids, few of these children had  coverage for basic outpatient services, such as preventive and primary care, specialty dental care,  or prescription medications. Moreover, many of these children never had any health insurance  coverage, placing them at long-term risk for poor health care access and limited use of key services, such as preventive care. Three ongoing, independent evaluations of the Healthy Kids programs in Los Angeles, San Mateo, and Santa Clara counties find overwhelming evidence that the programs improved medical care  access and use among children who participated, which, in turn, improved the well-being of both  the children and their families. Access to Health Care ImprovesAccess to health care is fundamental to ensuring that children remain healthy and avoid unnecessary or prolonged illnesses, excess morbidity and missed school days. Two basic indicators of whether children have good health care access are (1) whether they have a usual source for health care, such as a local clinic or private doctor’s office; and (2) whether they have had a recent medical visit. I N  B R I E FNOVEMBER 2007 • NUMBER 1Since 2001, Children’s Health Initiatives (CHIs) have emerged  in 25 of California’s 58 counties  to expand health insurance cover-age for children. These innovative  initiatives typically have two parts: (1) a new insurance product called Healthy Kids that covers children who are ineligible for Medi-Cal and Healthy Families, California’s public programs for children in families with incomes up to 250 percent of the federal poverty level; and (2) comprehen-sive outreach campaigns that find and assist families with enrolling children into any available pro-gram. In these 25 counties, which include nearly three-quarters of all uninsured children in the state, Healthy Kids programs currently provide more than 85,000 children with comprehensive health insur-ance coverage (Stevens, Rice, and Cousineau 2007). This brief is funded by the David and Lucile Packard Foundation and reports findings from evalu-ations of CHIs in three Healthy Kids counties: Los Angeles, San Mateo, and Santa Clara.I N  B R I E F2In Brief Number 1  •  November 2007Figure 2: Impact of Healthy Kids on Having  a Medical Visit in Past Six Months**/* Difference is statistically significant at p-value < 0.01/0.05.  Los Angeles reflects children ages 0 to 5; San Mateo and Santa Clara reflect children ages 0 to 18.Figure 1: Impact of Healthy Kids on Having  a Usual Source for Medical Care** Difference is statistically significant at p-value < 0.01.  Los Angeles reflects children ages 0 to 5; San Mateo and Santa Clara reflect children ages 0 to 18.1The relatively high proportion of children having a medical visit in the past six months seen in Los Angeles, 76 percent among children with Healthy Kids coverage, is due in large part to the Los Angeles evaluation’s focus on children under age six, who are more frequent users of health care than older children.Across all three Healthy Kids programs, children enrolled in Healthy Kids experi-enced dramatic improvements in both of these indicators when compared to similar children without Healthy Kids coverage. The proportion of children having a usual source of care was significantly higher with Healthy Kids, reaching about 90 percent in each county (Figure 1). Likewise, the pro-portion of children having a medical visit in the past six months was significantly higher among Healthy Kids enrollees, reaching 54 to 76 percent depending on the county (Figure 2).1  For example, in Santa Clara County, the proportion of children with a medical visit rose from 32 percent without Healthy Kids to 54 percent with Healthy Kids. This increase in visits is evident for all types of services examined—including preventive care, sick-child visits, and visits to specialists.Unmet Health Care Needs Decline Children with unmet medical needs— meaning a need for preventive, sick-child, or specialist care that has gone unaddressed —are more likely than other children to  be at risk for poor health and increased morbidity. In all three programs, children enrolled in Healthy Kids experienced dramatically lower levels of unmet medical needs when compared to similar children without Healthy Kids coverage (Figure 3). In Los Angeles County, for example, 19 percent of children enrolled in Healthy Kids had an unmet medical need in the  past six months compared to 32 percent  of similar children without Healthy Kids —a difference of 13 percentage points.  In San Mateo and Santa Clara counties,  the reductions in unmet need were similar  I N  B R I E F3(11 and 14 percentage points, respectively). As with the use of medical care, the reduc-tions in unmet need are evident for all the services examined. Parents’ Confidence Grows Responding to these substantial improve-ments in their children’s health care, par-ents of children enrolled in Healthy Kids  reported far more confidence that they could obtain care for their children when needed than parents of children not enrolled in Healthy Kids (Figure 4). In San Mateo County, for example, 66 percent of par-ents of children enrolled in Healthy Kids reported being “very confident” that their children could obtain needed health care,  as compared with 42 percent of parents  of children without Healthy Kids. Large gains are likewise evident among Healthy Kids families in the other two counties,  Los Angeles and Santa Clara. Looking ForwardThis brief shows how Healthy Kids pro-grams in California have improved the well-being of children and their families. In three diverse counties located in different regions of the state, children with Healthy Kids experienced dramatic improvements in their access to and use of medical care. In turn, children experienced sharp reduc-tions in their unmet need for medical care and parents expressed far more confidence that they could obtain care for their children. In the coming months, additional briefs  will report on other findings from the eval-uations of the Healthy Kids programs in Los Angeles, San Mateo, and Santa Clara counties. These future briefs will explore, for example, the impact of the Healthy  Kids programs on children’s use of dental care and how the programs have affected  important indicators of children’s health, such as the number of missed school days.In Brief Number 1  •  November 2007Figure 4: Impact of Healthy Kids on Parents’ Confidence That Child Can Get Needed Health Care** Difference is statistically significant at p-value < 0.01.  Los Angeles reflects children ages 0 to 5; San Mateo and Santa Clara reflect children ages 0 to 18.** Difference is statistically significant at p-value < 0.01.  Los Angeles reflects children ages 0 to 5; San Mateo and Santa Clara reflect children ages 0 to 18.Figure 3: Impact of Healthy Kids on Unmet Need for Medical Care in Past Six MonthsI N  B R I E F4Mathematica Policy Research, Inc. PO Box 2393Princeton, NJ 08543-2393(609) 799-3535www.mathematica-mpr.comThe University of California,  San FranciscoSan Francisco, CA 94143(415) 476-9000 www.ucsf.eduUrban Institute2100 M Street, NWWashington, DC 20037(202) 833-7200www.urban.orgS T U D Y  M E T H O D SData for this brief were collected from household surveys conducted in Los Angeles, Santa Clara, and San Mateo counties as part of comprehensive evaluations of the Children’s Health Ini-tiatives in these counties. The Los Angeles survey was conducted between April and December 2005 with 1,087 families; the San Mateo survey was conducted between April 2006 and January 2007 with 1,404 families; and the Santa Clara county survey was conducted from August 2003 to July 2004 with 1,235 families. Response rates on these surveys were 86 percent, 77 percent, and 89 percent, respectively. All surveys were conducted via computer-assisted telephone interviews, primarily in Spanish and English. Each survey asked families about a sampled child who had enrolled in the Healthy Kids program. In Los Angeles, the sampled children were under age 6; in the other two counties, the sampled children ranged from ages 0 to 18. While there were some differences in the types of questions asked, and in the wording of some questions across the three surveys, the differences do not affect the results presented in this brief.To measure the impacts of Healthy Kids within each county, two groups of children were  sampled and compared in each county: (1) “established enrollee” children who had been enrolled in Healthy Kids for roughly one year, and (2) “recent enrollee” children who were selected for the sample at the time they were enrolling in Healthy Kids. The established enrollee samples serve as the treatment groups for the studies by providing a measure of the access to and use of health care services among children who have Healthy Kids coverage. Survey questions asked about these children’s access, use, and other health care experiences in their most recent six months in the program. The recent enrollee samples serve as the comparison group for the studies. Survey questions asked about these children’s health care experiences in the six-month period before they enrolled in Healthy Kids, providing a measure of what the experiences of  established enrollee children would have been in the absence of Healthy Kids. Impact estimates are based on regression models that control for important demographic and socioeconomic char-acteristics that might differ between the two groups, such as the child’s age and race/ethnicity, the parents’ income, and the length of time the family has lived in the county.Acknowledgments: The authors of this brief thank the evaluation funders and research teams for their support. The evaluation of the Los Angeles County CHI is funded by First 5 LA and the California Endowment, and conducted by the Urban Institute and partners the University of Southern California, the University of California at Los Angeles, Mathematica Policy Research, and Castillo & Associates. The evaluation of the San Mateo CHI is funded by San Mateo County, the Sequoia Health Care District, the Peninsula Health Care District, First 5 San Mateo County, and the David and Lucile Packard Foundation and conducted by the Urban Institute and partners Mathematica Policy Research, Aguirre International, and the University of California at San Francisco. The evaluation of the Santa Clara CHI is funded by the David and Lucile Packard Foundation and conducted by Mathematica Policy Research and partners the Urban Institute and the University of California at San Francisco. The authors also thank staff at each of the county health plans for their assistance in completing the survey data collection, as well as the many Healthy Kids families who graciously provided their time and attention by completing survey interviews.Reference: Stevens, G.D., K. Rice, and M.R. Cousineau. “Children’s Health Initiatives in California: The Experiences of Local Coalitions Pursuing Universal Coverage for Children.” American Journal of Public Health, vol. 97, no. 4, April 2007.

Three Independent Evaluations of Healthy Kids Programs Find Dramatic Gains in Well-Being of Children and Families

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Three Independent Evaluations of Healthy Kids Programs Find Dramatic Gains in Well-Being of Children and Families

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