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Note: This report is available in its entirety in the Portable Document Format (PDF).
EXECUTIVE SUMMARY
In January, 2003 partners in San Mateo County, California launched the Children's Health Initiative (CHI), a program designed to ensure that 100 percent of the County's children have access to comprehensive health insurance coverage. The partners—key public and private organizations in the county1--have assembled a diverse funding base for the initiative. In spite of an economic downturn in the county and across the state, over $7 million from public and private sources was raised to fund the CHI for calendar year 2004.2 The goal is to provide health insurance coverage to at least 14,600 uninsured children in the county through two strategies: (1) increasing the number of children enrolled in existing public health insurance programs, Healthy Families and Medi-Cal; and (2) establishing a new health insurance product, Healthy Kids, for children who are not entitled to other forms of public or employer-based insurance.
In order to accomplish this ambitious goal, the county partners have conducted "in reach" at existing health and social services sites where families of uninsured children come for services; held numerous outreach/enrollment events to advertise the availability of insurance and to sign children up; and used outreach partners throughout the county, including schools and Community Based Organizations, to identify and enroll uninsured children. They also designed the Healthy Kids insurance product to mirror the benefits of Healthy Families, and to be administered by the Health Plan of San Mateo, an existing health plan that provides services to Medi-Cal and some Healthy Families enrollees. The partners designed and implemented these features over the period mid-2001 to early 2003, with enrollment in Healthy Kids beginning in January 2003. Rapid implementation was facilitated by several factors, including previous positive working relationships among the partners and existing models in neighboring Santa Clara and San Francisco Counties.
The Urban Institute—along with consultant Dana Hughes of the University of California at San Francisco; Mathematica Policy Research; and the Aguirre Group—were chosen to evaluate the San Mateo County CHI. The evaluation, beginning in May 2003, spans five years, and includes multiple evaluation components and data sources. This first annual report includes data from a comprehensive site visit in October, 2003; aggregate data on demographic characteristics, health service use, and cost from the Health Plan of San Mateo; and aggregate data from the members of the Hospital Consortium on services and uncompensated care. Future evaluation reports will include data from these same sources, as well as information from two rounds of client surveys; a population-based survey sponsored by the First 5 San Mateo Commission; and focus groups of parents, providers, and employers. Highlights of findings from the first annual report are organized according to the evaluation research questions, as follows.
How did health insurance coverage change for children in San Mateo County?
In its early months, the CHI achieved rapid enrollment growth in the Healthy Kids program. This growth is a reflection both of the pent up demand for children's health insurance by low income uninsured children in the county, as well as effective outreach to find and enroll them. By mid-2003, the CHI had enrolled 2,584 children into Healthy Kids. Rapid growth continued throughout the first year, and by January 2004, 4,893 children were enrolled in Healthy Kids (more than double the year one enrollment target). Enrollment in the Healthy Kids program far exceeded anticipated levels during this first year. We conclude that "in-reach" in clinics, as well as intensive school and community outreach, were very good approaches to enrolling the Healthy Kids target population. The successful outreach for Healthy Kids is a product of intensive and sustained collaboration among the CHI partners.
The case for rapid increased enrollment in Healthy Families and Medi-Cal is not so clear. The CHI seeks only to enroll children in Healthy Kids if they are ineligible for the other programs or for private insurance. While Healthy Families did grow during the first 6 months following CHI implementation, it had been growing equally rapidly during the year prior to implementation. Medi-Cal child enrollment actually fell slightly in the early months of the CHI. It is possible that—with cuts in state Healthy Families outreach—Healthy Families' growth might actually have been lower without the CHI. Also, we heard of some improvement in employment in the San Mateo County service sector in 2003; this, along with some programmatic changes related to Medi-Cal recertification, could be reasons for the Medi-Cal enrollment declines. For obvious reasons, it is important to make certain that uninsured children who are eligible for Medi-Cal or Healthy Families are enrolled in these programs, so we recommend that the "screen and enroll" process be monitored periodically to ensure that limited Healthy Kids dollars are reserved for children ineligible for other programs.
Who is served by the San Mateo County CHI?
Most Healthy Kids are from poor immigrant families. About 80% of Healthy Kids enrollees have Spanish as their primary language, the majority have incomes below 150% of the poverty level, and fully 92% are undocumented. Healthy Kids enrollees are primarily school aged children and adolescents, which mirrors the age profile for Healthy Families. In contrast, Medi-Cal enrollees are more often pre-school aged children.
What services did Healthy Kids enrollees receive as part of the initiative? Did the CHI affect access to care for children who enrolled? Did the CHI affect where services were received?
The purpose of enrollment in health insurance is to give children new access to health services. Using administrative data from the Health Plan of San Mateo for the first six months of the Healthy Kids program (continuous enrollees for the period mid-February 2003 to mid-August 2003), we found relatively low rates of service use, when compared to the other two public programs (Healthy Families and Medi-Cal) and to national benchmarks. For example, only 16% of the 532 Healthy Kids enrollees studied had a preventive care visit during their first six months on Healthy Kids Rates of use of other ambulatory care were higher, and there may be miscoding of visits and other data anomalies that bias these comparisons. For example, slightly over half of children in all three programs had at least one ambulatory care visit over six months.
Healthy Kids enrollees had relatively low use of the emergency room and hospital in their first six months on the program, a sign that when they are obtaining health care it is in appropriate locations. This also may be a sign that their health status is relatively good, when compared, for example, to Medi-Cal children.
It will be important to monitor use over time to determine whether these initial patterns are stable, or whether they reflect initially low use of services by a newly-insured group. It will also be important to further understand the relatively low proportion of children receiving preventive care, to determine whether it indicates a need for parental education about the importance of preventive care.
Did the CHI affect the cost of care?
Healthy Kids enrollees were the least expensive of the three public programs, followed by Healthy Families and then Medi-Cal child enrollees. Publicly insured children in San Mateo County appear to be much less expensive that the average child nationally. Until data are collected in the year three round of the client survey, it will not be apparent whether the cost of care is lowered with the CHI, or whether there has been a shift in the burden of paying for that care.
Did the CHI enhance the delivery and stability of the community health care system?
Very preliminary data for the early months of the CHI show some decline in hospital admissions and emergency room visits for uninsured children, and in uncompensated care at the San Mateo Medical Center. These preliminary statistics are potentially promising, but it is too soon to attribute a strong affect of the CHI on the finances of the medical center or other hospitals, since the CHI was very new during the period studied. Given declining federal and state dollars for local health services, the CHI may help to stabilize the financing of the San Mateo County health system for low income people, a pattern that will be monitored in future years of the evaluation.
Has the CHI increased community-wide collaboration to address issues of the uninsured?
Our process analysis found that San Mateo County has a high degree of cross-agency and cross-county collaboration. While this collaboration was a precursor to, and indeed led to, the CHI, it also appears to have been strengthened as a result of the CHI effort.
Factors in Success. The factors in the success of the first year of the San Mateo County CHI provide lessons for other jurisdictions that want to develop similar initiatives. In our interviews, we heard about three prominent factors that were key to the first year of successful implementation. First it was critical to have a core group of involved partners from diverse organizations—public and private—dedicated to common goals. We heard repeatedly of the commitment, passion, optimistic attitude, and gifts of in-kind time and resources from the San Mateo County CHI partners.
Second, it was important to learn from other similar projects, and translate their experience into local circumstances. San Mateo County particularly benefited from the examples of Santa Clara and San Francisco counties. These counties provide models for design and development that San Mateo County CHI partners closely observed as they proceeded with key decisions.
Finally, and perhaps most importantly, the San Mateo County CHI succeeded in developing a diverse funding base for the initiative, even in difficult financial times. This broad collaboration across sectors brought in private sources of financing. The CHI also successfully tapped some unique local funding sources (such as the hospital districts and tobacco tax financing) that may or may not be available in other places. Creating such a diverse funding base requires political skills and attention to the concerns and requirements of each funder.
Future Challenges. Based on our process analysis, we also identified some particular challenges on which the San Mateo County partners may want to focus attention as they enter the second year of the CHI. First, in order to improve the health status of low income children in the county, it may be necessary to adapt outreach and educational approaches. While "in-reach" has been successful and should be continued, the CHI may not be fully reaching children who are not yet seeking health care. Also, there does not seem to be a strong effort in place to follow up with the parents of children who are enrolled, in order to educated them about the importance of preventive care. Fortunately, there is a firm base upon which to build such outreach and education, although new partners may be useful.
Our site visit raised questions about the strength of the private provider network, in general, and the availability of dental services specifically. It is important that there be dentists and private physicians actively participating in CHI deliberations, in order to solicit help in CHI efforts. For example, private providers both could identify children in their practices who need health insurance coverage, as well as assure access by continuing to provide care to them once they are enrolled. Thus, further initiatives to involve private providers are critical to expanding access to care, especially for higher income families who may need health insurance coverage but be reluctant to enroll their children in Healthy Kids if their providers do not participate.
Another area for consideration is the complexity of the enrollment and funds transfer processes. Partners are already beginning to fine-tune these processes that were set up for expediency to begin rapid CHI implementation, and there are good reasons for continuing some apparently complex procedures that are working well. Still a thoughtful examination of them, perhaps in comparison to the way that similar processes are handled in neighboring counties, could lead to some efficiency.
Finally, in terms of challenges facing the CHI, external factors will have an important influence on how the CHI proceeds. It goes without saying that one looming issue for the CHI is the future of the Health Plan of San Mateo. In addition, the way that the state addresses its budget issues, both in financing Medi-Cal and Healthy Families, will provide major challenges to the CHI. The partners are fully aware of these issues and are working collectively to both monitor developments and to seek solutions.
Note: This report is available in its entirety in the Portable Document Format (PDF).
1 The key partners are: the county's Health Services and Human Services Agencies: the Health Plan of San Mateo; the First 5 San Mateo Commission; the Peninsula Community Foundation; the Hospital Consortium of San Mateo; and the San Mateo County Central Labor Council.
2 The major funding sources, in order of size, are the county, the First 5 San Mateo County Commission (using Proposition 10 tobacco tax revenue), two local hospital districts, and private foundations.
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