Publications by Embry M. Howell for Health Policy Center

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More about Embry M. Howell's areas of expertise can be found on this Urban Institute expert's page.

This report synthesizes findings from case studies conducted in 2001 and 2002 in ten states selected for the Congressionally Mandated Evaluation of SCHIP: California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas (Hill et al. 2002). Discussion addresses such issues as program design, outreach and enrollment strategies, benefits, service delivery systems, cost sharing, crowd out prevention, parental coverage, financing, and coordination of SCHIP and Medicaid. Overarching conclusions identify lessons learned from effective implementation.

The Los Angeles Healthy Kids program provides health insurance to low income children in the county who have no other source of coverage (including undocumented children and children above the income limits for Medi-Cal and Healthy Families). These findings from a longitudinal survey of parents of young children in the program indicate that access to medical and dental care for enrolled children increased dramatically over time, use of the emergency room went down, and parents perceived improvements in the health status of their children. This analysis is one piece of a broader Urban Institute evaluation of the program.

In 2005 The Children's Trust of Miami-Dade County initiated HealthConnect in Our Community, designed to improve the health of children and adolescents in the county. The program uses community workers to reach out to underserved children and their families. The Urban Institute and three local consultants conducted a formative assessment the program's first year of operation. In a six-day site visit we interviewed 26 individuals, observed program operations in 19 separate locations, and conducted five focus groups, three with clients and two with program staff. This report summarizes the findings from the evaluation, and provides recommendations for improving the program.

In early 2003 San Mateo County, California launched the Children's Health Initiative (CHI), to ensure that all children have access to comprehensive health insurance coverage. Healthy Kids covers uninsured children below 400 percent of poverty and primarily serves poor, undocumented Latino children. A survey of parents of Healthy Kids enrollees found that in the first year of enrollment, children experienced improvements in access to and use of medical and dental care; a reduction in missed school days due to health problems; reduced unmet need; increased parent confidence in getting care and satisfaction with quality; and reduced financial worries. Moreover, use of preventive and dental services continued to improve during the children's second and third years of continuous enrollment.

A large number of California counties have taken bold steps to extend health insurance to all poor and near-poor children through county-based Children's Health Initiatives. The Los Angeles Healthy Kids program extends coverage to uninsured children in families with incomes below 300 percent of the federal poverty level who are ineligible for Medi-Cal (California Medicaid) and Healthy Families (its SCHIP). A four-year evaluation of Healthy Kids finds the program has improved access for more than 40,000 children, most of whom are immigrant Latinos, who have almost no access to employer coverage. However, sustaining this program has proved to be challenging.

A longitudinal survey of parents of enrollees in the Los Angeles Healthy Kids Program has found that the program had significant positive impacts on children’s health and access to care. Children experienced improvements in access to and use of ambulatory, specialty and dental care; reduced unmet need; increased parent confidence in getting care and satisfaction with quality; and reduced financial worries. Most important, children’s health status improved, as perceived by parents and according to several measures. Healthy Kids covers uninsured children below 300 percent of poverty who are ineligible for Medicaid or SCHIP, and primarily serves poor, undocumented Latino children.

This brief presents data on mental health coverage benefits and enrollees' access to and use of mental health services through the Healthy Kids program in San Mateo County, California. The prevalence of mental health conditions among enrollees is similar to national levels, but despite the generous mental health benefits offered under the program, only a small fraction of enrollees with mental health conditions receive care. Reasons why more children do not use mental health services are explored. The brief also shows that enrollees with mental health needs have higher use of other health services compared to all Healthy Kids members.

This brief presents highlights from rigorous, independent evaluations of the Healthy Kids programs in three California counties, Los Angeles, San Mateo, and Santa Clara. The three Healthy Kids programs provide children with comprehensive health insurance coverage. 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. 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.

As part of a multi-year evaluation of the Healthy Kids program in Los Angeles, we analyzed service utilization of Healthy Kids enrollees ages 0 to 18 using health plan encounter and claims data and assessed these data for completeness. Results suggest that actual service rates are higher than administrative data indicate. Other evidence from the evaluation suggests that some services are likely reimbursed by Restricted/Emergency Medi-Cal, and other services are provided just prior to enrolling in Healthy Kids. As a result, some encounters are not captured in health plan data for Healthy Kids, and will present challenges for ongoing program monitoring.

This study examines the costs and service use for children enrolled in public health insurance in San Mateo County, California using encounter data from the Health Plan of San Mateo. In that county, the financing burden for children’s public health insurance programs is concentrated in the top tenth of health care users, while the other 90% of children are very inexpensive. This finding suggests that early identification and greater efficiency in care management for high-cost children could free up funding to expand public insurance services to more low-cost children. As states evaluate the feasibility of public health care for all children, it is important to examine the distribution of costs and services within existing programs, in order to better plan services for the highest cost children.

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