Evaluation of the San Mateo County Children's Health Initiative

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Note: This report is available in its entirety in the Portable Document Format (PDF).

EXECUTIVE SUMMARY

This report, the second in a series of five annual reports from the Evaluation of the San Mateo County Children's Health Initiative (CHI), provides a new look at the initiative as it enters its third year of operation. Since the CHI began active outreach and enrollment in January 2003, the program has achieved several important milestones:

• Established a stable governance structure with broad input from key government agencies and several key private sector stakeholders;
• Developed a broad funding base for the initiative, raising over $7 million in 2004;
• Established 40 outreach and enrollment sites around the county where 26 full-time enrollment assistors work to enroll children in public health insurance;
• Developed a new insurance product, Healthy Kids, to cover children not eligible for other health insurance. This program had served 7,821 children as of March 2005. There has been some attrition over the course of the program, so the total number of children enrolled in March 2005 was about 5,400.

Using several data sources, the evaluation investigated the demographic and health status characteristics of children enrolled in Healthy Kids (comparing them with enrollees in the Healthy Families and Medi-Cal programs); their access to care; their use of services; their parents' satisfaction with the program; and the cost of their care. The data for the analysis come from an annual site visit conducted in October 2004; health plan administrative enrollment and utilization data; focus groups with parents of children enrolled in Healthy Kids conducted during late 2004 and early 2005; interviews with providers conducted during late 2004; aggregate data on hospital visits and costs from local hospitals; and a client survey conducted with a sample of 411 parents of Healthy Kids enrollees.

In addition, the evaluation explored several issues of particular concern to the CHI Coalition, including (1) the possibility of substituting Healthy Kids coverage for other forms of public or private health insurance; (2) reasons for limited private provider participation in the program; and (3) the impact of the program on the financial status of hospitals in the county. Key findings include:

• The Healthy Kids program has experienced sustained enrollment growth since the CHI began, and Healthy Families enrollment has also grown, in contrast to Medi-Cal enrollment for children. During 2004, Healthy Kids enrollment grew by 18 percent, Healthy Families by 5 percent, and Medi-Cal for children by only 1 percent.
• Healthy Kids enrollees are predominantly very low income, undocumented children in large, extended immigrant families who have resided in San Mateo County for some time. Based on administrative and client survey data, we estimate that 78.3 percent of enrollees have family incomes at or below 150 percent of the federal poverty level (FPL); about 90 percent are undocumented; 48 percent live in households that include at least one nonparent adult; and 44 percent are from families that have been living in the county for four or more years. These enrollees are older than Healthy Families and Medi-Cal children on average, with 78 percent between the ages of 6 and 18, compared with 72 percent of Healthy Families enrollees and 59 percent of Medi-Cal enrollees.
• Although the health status of Healthy Kids enrollees is generally better than that of Medi-Cal children, about a third have medical problems, a third have dental problems, and a fifth have mental health problems.
• There is little evidence of "crowd-out" from private insurance. Only 14 percent of higher-income and 6 percent of all Healthy Kids enrollees have access to affordable private insurance.
• Many Healthy Kids (22 percent) participants were enrolled in Emergency Medi-Cal prior to Healthy Kids enrollment. However, Healthy Kids coverage is far more comprehensive.
• In the client survey and focus groups, parents report that access to care for Healthy Kids enrollees is generally good, but there are some areas where access could be improved. For example, although a large majority (88 percent) report a usual source of medical care, only 72 percent report a usual source of dental care and only 41 percent report access to their doctor when offices are closed.
• Still, 70 percent of parents are very satisfied with the care their children receive. There are several areas where they would like to see improvement, including better clarity of the program materials they receive.
• Use of services by Healthy Kids enrollees is lower than it is for Medi-Cal and national norms, particularly for preventive care. According to data from the Health Plan of San Mateo, only 33 percent of Healthy Kids enrollees had a preventive care visit, compared with 42 percent of Healthy Families enrollees and 38 percent of Medi-Cal enrollees.
• The average annual cost of care for Healthy Kids participants ($442) is substantially lower than that for Medi-Cal and below the reimbursement being provided for their care in premiums to the Health Plan of San Mateo.
• Many private providers are unaware of the Healthy Kids program, and many of those who are aware have experienced difficulties participating in other public programs and are therefore reluctant to participate in Healthy Kids.
• The CHI has had a positive though limited impact on the financial status of area hospitals. Between 2002 and 2004, the number of hospital stays, emergency room visits, and outpatient visits for uninsured children declined by 23 percent, 2 percent, and 59 percent respectively, while the frequency of all three services increased for publicly insured children.

Based on these findings, areas requiring increased attention from the San Mateo CHI in the coming months include:

• A continued focus on the administrative barriers to enrollment and retention in each of the three public programs, particularly Medi-Cal.
• A consideration of options to recoup federal and state matching funds for children who could have services covered by Emergency Medi-Cal.
• An examination of why the anticipated growth in Medi-Cal did not occur.
• Development of new ways to assure parents that their immigration status will not be affected when they apply.
• An examination of use and cost of services from the Health Plan of San Mateo, to ensure that Healthy Kids enrollees are receiving adequate preventive services and that the premiums paid to the plan are fair in relationship to the cost of services received.
• Continued attention to the causes of low private-provider participation in Healthy Kids and other public programs, particularly among dentists.
• An examination of the areas in which parents were less satisfied with services, including limited after-hours care, limited access to dental care, and the need for improved clarity in the parents they receive.

During the coming year, the evaluation will continue monitoring the issues outlined above, using administrative data and in-depth interviews with stakeholders. In addition, the issue of substitution for private insurance coverage will be further explored through focus groups with employers in the county. Finally, a second round of the client survey will be used to study the impact of Healthy Kids on access to care, use of services, and health status. In this round, parents of young children age 0 through 5 will be over-sampled in order to analyze special issues for this population. Some of these data—such as extensive data on utilization and cost of care from encounter data for the three public programs—provide a unique data source for policymakers both within and outside San Mateo County.

Note: This report is available in its entirety in the Portable Document Format (PDF).

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Disclaimer: The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.