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Abstract

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.

Introduction

Californians are debating whether an initiative to provide health insurance for all children is feasible. One way to cover more children might be to more effectively manage the care (and, by extension, the cost) of children who use the most health services. These children’s costs make up most of the overall expense of providing subsidized health care to children in California. Yet, little is known about who the high-cost children enrolled in public insurance programs are or how much they cost.

This brief provides data from San Mateo County, which provides subsidized health insurance to any uninsured child whose family’s income is below 400 percent of the federal poverty level. The brief examines two public insurance programs: Medi- Cal, the federal/state program that covers most low-income children in California; and Healthy Kids, a county-based program.¹ More information on the San Mateo Children’s Health Initiative and these programs is available in several reports.²

For this brief, high-cost children are those whose annual costs are in the top 10 percent of health care users in their program. This 10 percent grouping has been used in other studies of adult high-cost users. We examined claims and encounter data from the Health Plan of San Mateo for high-cost and other children in order to classify them and compare their usage and cost of services.

Notes

1.Complete data were not available for kids enrolled in the Healthy Families (SCHIP) in San Mateo County. An analysis of partial data (those Healthy Families children enrolled in the Health Plan of San Mateo) showed that the Healthy Families children resemble Healthy Kids enrollees in their cost and use patterns.

2.For example, see Howell et al. (2004).

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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.

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