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EXECUTIVE SUMMARY

This report, the third in a series of five annual reports from the Evaluation of the San Mateo County Children's Health Initiative (CHI), provides an overview of the Initiative as well as a detailed look at particular aspects of the program and access to specific services. During 2005 the initiative took on several new challenges, such as an increased focus on improving retention in public programs, increasing use of preventive care, and improving access to dental and mental health care. This annual report provides some new data on several of these and other issues that are important to the continued development of the initiative.

Using several data sources, the evaluation investigated issues that are of special interest to the CHI. These include: the demographic and health status characteristics of Healthy Kids served by the CHI; how demographic characteristics and service use have changed over time; characteristics of high cost users of services and how they differ from other children; access to dental services; access to mental health services; the role of schools in outreach and enrollment; and the factors influencing employer decisions to offer insurance for dependents. The data for the analysis come from the annual site visit conducted in October 2005; health plan administrative enrollment and utilization data; and interviews with employers.

Key findings include

• The growth in the Healthy Kids program continued at a slow pace in 2005, particularly for the youngest children (ages 0-5), despite special efforts to enroll more children in this age group. Growth in the 6-18 age group continued at a moderate pace, creating a challenge to the premium financing for these enrollees.
• There was a moderate increase (of 4 percentage points) in the proportion of children who were in the higher income group (250-400 percent of the federal poverty level), and over 13 percent of children continuously enrolled in Healthy Kids from 2003-2004 were in this group. Penetration of coverage within this population was a specific priority for the CHI during the last year.
• The use of preventive medical care, as well as dental and vision care, increased from the first to the second year of enrollment in Healthy Kids. In addition, overall use of ambulatory care increased from those who enrolled in 2003 to those who enrolled in 2004.
• Ten percent of publicly insured children account for a sizable proportion of expensive medical (although not dental) care, particularly hospital and emergency room care. These children, defined as "high cost users," account for a substantial portion of the total cost for all children enrolled in the Healthy Kids, Healthy Families, and Medi-Cal programs (39.9 percent, 48.4 percent, and 72.8 percent, respectively). High cost users are more often chronically ill and have frequent contact with the health care system. Since it is possible to identify them through the claims/encounter data, this group could be targeted for more intensive contact by Certified Application Assistors (CAAs) or health plan staff, to assure that they are receiving coordinated care and that they have good access to the specialty care that they need. This might have the additional benefit of reducing high cost emergency room and hospital care.
• About 40 percent of Healthy Kids enrollees do not use dental services, indicating potential access problems and the need to educate parents about the importance of such care. Still, a relatively high percentage of the youngest children (ages 0-5) used services. In addition, Healthy Kids enrollees are more likely to visit a private dentist than to utilize public providers. This finding is in contrast to a widely held perception that access to private dental providers for publicly insured children is limited in the county.
• Children with mental health diagnoses are much more expensive than their peers, and these higher costs pertain to both mental health and other health services. Not all children receiving mental health services under Healthy Kids or Healthy Families are having their care coordinated by the San Mateo Health Department Mental Health Services department, but those who are in that system are the most expensive children.
• School-based outreach and enrollment assistance is a high priority for the CHI. The increased proportion of Healthy Kids enrollees who are from higher income families is likely a result of this school-based approach, which may reduce the stigma of applying for a public program. Because of the variation in intensity and type of school-based outreach/enrollment from school district-to-district, the CHI could learn from this variation by documenting which districts yield the greatest number of applications and new enrollees.
• Based on a limited sample of employer interviews (and complementing similar findings from the evaluation's client survey and focus groups with parents), there is no evidence that employers of low wage workers have altered policies relating to offering insurance coverage to dependents because of the availability of public coverage for low income children in San Mateo County.

In the coming year, the evaluation of the San Mateo CHI will collect new data to address a range of evaluation questions. The second wave of the client survey is currently underway, with an over-sample of children ages zero to five. Data from this survey will be used to measure the impact of the Healthy Kids program on access to care, use of services, and health status. The survey will also provide information on prior insurance coverage and parent satisfaction with the program. In addition, another site visit and two client focus groups will provide qualitative information to help monitor the progress of the CHI and interpret the findings from the client survey analysis. Administrative data on enrollment trends will also be analyzed. Finally, the data from the Health Plan of San Mateo, such as that included in this annual report, will be used to continue to monitor trends in enrollee characteristics and use of services across the three public health insurance programs for children in San Mateo County.

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

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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