Improving Coverage And Access For Immigrant Latino Children: The Los Angeles Healthy Kids Program

Improving Coverage And

Access For Immigrant Latino

Children: The Los Angeles

Healthy Kids Program

Despite its successes in improving access, financial sustainability has

limited this program’s ability to cover all eligible children, especially

those over age five.

by Ian Hill, Lisa Dubay, Genevieve M. Kenney, Embry M. Howell, Brigette Courtot, and Louise Palmer

ABSTRACT:A large number of California counties have recently taken bold steps to extend health insurance to all poor and near-poor children through county-based Children’s Health Initiatives. One initiative, the Los Angeles Healthy Kids program, extends coverage to unin-sured 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 State Children’s Health Insurance Program). A four-year evaluation of Healthy Kids finds that the program has improved access for more than 40,000, most of whom are immigrant Latino children, who have almost no access to employer coverage. However, sustaining this effective pro-gram has proved to be challenging. [Health Affairs27, no. 2 (2008): 550–559; 10.1377/ hlthaff.27.2.550]

C

popula-tion of any state—almost 2.5 million, which is almost a quarter of the

na-tion’s total.1_{Such immigrants numbered about one million in Los Angeles}

in 2004, by far the greatest concentration of any U.S. city. Uninsurance rates among noncitizen children are more than five times higher than rates for citizen

children in Los Angeles (LA) County (42 percent and 7.3 percent, respectively).2

Uninsurance appears to be even higher among undocumented children in Los An-geles—an estimated 60 percent in 2000. Many of these children suffer problems accessing needed health care; for example, immigrant children with noncitizen parents are five times as likely to have no usual source of care and, despite being Ian Hill ([email protected]), Genevieve Kenney, and Embry Howell are principal research associates at the Urban Institute, in Washington, D.C. Louise Palmer is a research associate there. Lisa Dubay is an associate professor of health policy and management, Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland. Brigette Courtot, formerly with Urban, is a policy analyst at the National Women’s Law Center.

more likely to be in fair or poor health, receive fewer services compared with their citizen counterparts.3

Undocumented immigrants have been largely ignored in national health care reform debates. However, a large number of counties in California have recently taken bold steps to extend coverage to all children, regardless of their immigration status, through a series of county-based Children’s Health Initiatives. This paper presents results from a four-year evaluation of the impacts of such an initiative in LA County.

Background And Policy Environment

The roots of the Los Angeles Children’s Health Initiative lie in Proposition 10— the California Children and Families First Act of 1998—which added a fifty-cent tax on cigarettes and targeted revenues to support efforts to improve development of children from birth through age five. With roughly 160,000 annual live births, LA County receives the largest allocation of Proposition 10 dollars, and the com-mission that directs how these monies are spent—First 5 LA—voted in 2002 to devote $100 million to the creation of Healthy Kids, believing that good health, en-abled by appropriate access to care, is a key component of successful early child-hood development. Los Angeles was the fourth county in California to adopt such a Children’s Health Initiative (CHI).4

A multidisciplinary committee was convened to design Healthy Kids; it re-viewed alternative policies for outreach, enrollment, benefits, service delivery, cost sharing, and crowd-out. Ultimately, the program was modeled after Healthy Families, California’s State Children’s Health Insurance Program (SCHIP). In July 2003, uninsured children from birth through age five in families with income be-low 300 percent of the federal poverty level who are ineligible for Medi-Cal (Cali-fornia Medicaid) or Healthy Families became eligible for coverage. The program was expanded in May 2004 to cover all uninsured children through age eighteen with philanthropic donations raised by the CHI. Because Medi-Cal and Healthy Families already cover citizen children in families with incomes up to 250 percent of poverty, the largest group being offered coverage through Healthy Kids is un-documented children. Key components of Healthy Kids include the following: outreach and enrollment assistance provided by a diverse network of community-based agencies with multilingual staff; comprehensive medical, dental, and behav-ioral health benefits delivered on a capitated basis through a network managed by the nonprofit LA Care health plan; sliding-scale monthly premiums and copay-ments for selected services; and a three-month “waiting period” for children who already possess employer-sponsored insurance at application.

Study Data And Methods

The four-year Healthy Kids program evaluation, conducted by the Urban Insti-tute and its partners, the University of Southern California; the University of

Cali-fornia, Los Angeles; Mathematica Policy Research; and Castillo and Associates, comprises case studies of implementation, parent focus groups, longitudinal household surveys, administrative data monitoring, and analyses of insurance im-pacts. This paper synthesizes findings from several of these components. Detailed information on case-study, focus-group, and survey methods has been published elsewhere.5

The impact analysis was based on data from a longitudinal household survey of parents of Healthy Kids enrollees. The representative sample included children ages one through five who either were newly enrolled in Healthy Kids during March–July 2005 (“new” enrollees) or were enrolled during March–July 2004 and had been in the program for one year (“established” enrollees). Both groups were surveyed twice: in 2005 (Wave 1); and in 2006 (Wave 2). A quasi-experimental longitudinal design was used to assess the impact for young children of enroll-ment in Healthy Kids on access to care and use of services. Under this approach, the change in outcomes for new and established enrollees between the Wave 1 and Wave 2 surveys was estimated, and the change in outcomes for the established en-rollees was subtracted from the first difference, thereby removing the effect of non-program-related factors such as maturation, flu epidemics, and changes in the health care system. The difference-in-difference thus reflects only the impact

of the program on outcomes.6_{Multivariate logistic regressions were performed to}

adjust for differences between the new and established enrollees at two periods of time and to identify the impact of the program.

Study Results

Our results address four critical policy areas: outreach and enrollment; crowd-out; impact on access to care; and sustainability.

nOutreach and enrollment.Early case studies suggest that Healthy Kids out-reach workers succeed by contacting large numbers of families in a variety of set-tings, including doctors’ offices; health and Women, Infants, and Children (WIC) clinics; Head Start and child care settings; schools; and various community-based organizations. These workers assist families with applications to Medi-Cal and Healthy Families (accounting for 80 percent of all submitted applications), not just Healthy Kids (20 percent of applications). Enrollment in Healthy Kids grew quickly during the program’s first two years, especially after older children (ages 6–18) were included (Exhibit 1), and peaked at approximately 45,000 children in the summer of 2005 (nearly 8,000 of whom were under age six). Focus groups with parents of Healthy Kids enrollees found that the application and renewal processes were “easy,” the assistance they received from outreach workers was “very helpful,” and the turnaround time for application processing was “quick.” Many parents reported being initially concerned about applying for Healthy Kids, but the vast majority in-dicated that trustworthy outreach workers dispelled their fears of “public charge.”7

popu-lation of children; according to survey findings, it succeeded. For example, 86 per-cent of new enrollees lived below the federal poverty level, and 91 perper-cent were noncitizens. In addition, a large majority of children were Latino, lived in families where Spanish was spoken at home, had parents who had lived in Los Angeles for less than three years, lived in two-parent families, and lived in families where there was at least one full-time worker (Exhibit 2).

nCrowd-out.Case-study informants reported that it was extremely rare to en-counter parents who had any employer-sponsored health insurance, much less de-pendent coverage for their children. The household survey confirmed this: only 3 percent of Healthy Kids enrollees had employer coverage before enrolling in the pro-gram, which implies that very few parents dropped such coverage to enroll their children in Healthy Kids (Exhibit 3). More than 80 percent of enrollees lacked com-prehensive health insurance coverage prior to enrolling; 30 percent had no coverage

whatsoever, and 53 percent only had limited-scope Emergency Medi-Cal.8

The vast majority of Healthy Kids enrollees have no access to employer cover-age, let alone access to affordable covercover-age, which explains why so few children had employer coverage prior to enrolling in the program. Despite the fact that most children live in families with a full-time worker, just 9.9 percent of enrollees lived in families with an offer of employer-sponsored dependent coverage. Only half of those parents (5.4 percent) worked for employers that subsidize the pre-mium for dependent coverage. Overall, only 2.9 percent of Healthy Kids enrollees had access to employer coverage that is subsidized by the employer and that al-ready covers a parent. This limited access to employer coverage translates into high rates of uninsurance among parents. Fully 82.9 percent of enrollees had at least one uninsured parent at the time of the survey.

nImpact on access to care.The Healthy Kids network is built around existing “safety-net” clinics and hospitals in the county because its designers believed that these providers had more experience serving the target population of disadvantaged

Thousands of enrollees 20 10 30 7/03 0 EXHIBIT 1

Cumulative Enrollment In Healthy Kids (Los Angeles County, California), By Month And Age Group, July 2003 Through December 2006

SOURCE:LA Care Health Plan, 2006.

1/05

1/04 7/04 7/05 1/06 7/06

40

Enrollees ages 6–18

Enrollees birth to age 5

families. Case-study informants were generally satisfied with this approach, al-though some were concerned that the network lacked sufficient specialty and be-havioral health providers. Focus groups revealed that most parents, too, were happy with their children’s providers, saying that their doctors were “easy to find” and ex-pressing particular satisfaction that they mostly “spoke their language.” Yet some were frustrated with long wait times both for appointments and in clinics, some EXHIBIT 2

Demographic Characteristics Of Healthy Kids (Los Angeles County, California) Enrollees At Wave 1, 2005

Characteristic New enrollees (%) Established enrollees (%)

Percent of federal poverty level <100 100–199 200–299 85.9 11.9 2.2 84.8 14.2 1.0 Race/ethnicity Latino Asian, not Latino Other, not Latino

87.6 8.9 3.5 87.5 10.9 1.6 Citizenship Citizen Noncitizen 9.3 90.7 6.4 93.6 Language spoken in child’s home

Spanish Korean English Other

More than 1 language

72.9 4.6 3.2 1.5 17.8 70.4 6.7 2.2 1.5 19.3 Parental education attainment

Less than high school High school graduate Any college or training

52.0 25.4 23.0 52.2 20.7 27.1 Parent’s spouse/adult partner in household

Yes No 83.5 16.5 86.7 13.3 Parental employment Full time Part time Unemployed 65.0 26.1 8.9 72.4 20.3 7.3 Age (years)a 1 2 3 4 5 10.4 14.8 20.4 22.9 32.6 2.4 11.3 19.4 31.2 35.8 Years in LA County (parents)a

Less than 3 years 3–5 years More than 5 years

69.3 21.4 9.2 45.9 43.0 11.1

SOURCE:Survey of Los Angeles Healthy Kids enrollees (Wave 1, 2005 and Wave 2, 2006).

NOTES:Average age of new enrollees was 4.0 years; of established enrollees, 4.6 years. For new enrollees, N = 547; for established enrollees, N = 535.

wished that there were more dentists and specialists to choose from, and many were confused about what services and prescription drugs were covered under the plan.

Care was taken to structure Healthy Kids cost sharing so that it would not cre-ate barriers to enrollment or service use for the poorest families. After implemen-tation, nearly all case-study informants agreed that premiums were not keeping families from enrolling—nearly 90 percent of applicants are poor enough to be

ex-empt from premiums.9_{But some worried that copayments might create hardships}

for families, especially those with disabled or chronically ill children who need and use more care. Focus groups with parents reinforced these impressions; most parents described copayments as “affordable,” except those whose children had special health care needs. Without exception, however, parents said that their out-of-pocket costs are much lower under Healthy Kids than when their children were uninsured.

The evaluation’s parent survey confirms that Healthy Kids improved young children’s access to and use of care. The likelihood that a new enrollee had a usual source of care went from 73.6 percent prior to enrollment in Healthy Kids to 93.1 percent after enrollment—an increase of 19.5 percentage points (Exhibit 4). The difference-in-difference estimate indicates that enrollment in Healthy Kids re-sulted in a 14.7-percentage-point increase in the likelihood of having a usual source of care. Consistent with this, enrollment in Healthy Kids also resulted in a 7.4-percentage-point increase in the probability of having an ambulatory care visit. Surprisingly, there was no significant increase in the likelihood that new en-rollees had a preventive care visit in the past six months. However, new enen-rollees who had no usual source of care were examined separately, and strikingly differ-ent patterns were observed: these children experienced large increases in use of services. The likelihood of having an ambulatory care visit increased from 43.3 percent to 65.4 percent, and that of having a preventive care visit increased from 40.5 percent to 61.4 percent, both statistically significant differences. For both of these outcomes, new enrollees who had a usual source of care in Wave 1 showed patterns that were similar to those of established enrollees (data not shown). EXHIBIT 3

Children’s Insurance Status Prior To Enrolling In The Healthy Kids Program (Los Angeles County, California), 2005

SOURCE:Survey of Los Angeles Healthy Kids enrollees (Wave 1, 2005).

Employer coverage 3% Regular Medi-Cal/ Healthy Families 12% Uninsured 30% Emergency Medi-Cal 53% Other coverage 2%

These results speak to the importance of the safety net in Los Angeles in providing access to care for this population of children before Healthy Kids.

Large improvements in access were also observed for dental care. The likeli-hood that new enrollees had a usual source for dental care rose from 34.4 percent prior to enrolling in Healthy Kids to 69.1 percent after enrollment (Exhibit 4). The difference-in-difference estimates indicate that program enrollment increased the likelihood of having a usual source of dental care by 27.5 percentage points. More-over, there was a substantial increase in the probability of having at least one den-tal visit in the past six months.10_{Since the likelihood of having a dental visit}

in-creases as children age, the difference-in-difference estimate produced a smaller (14.4-percentage-point) improvement resulting from enrollment in the program, an estimate that was not statistically significant.

Enrollment in Healthy Kids appears to give parents emotional and financial re-lief. Prior to enrollment in the program, only 31.3 percent of parents felt very confi-dent that they could obtain needed care for their children, compared with 61.4 percent a year after enrollment (Exhibit 4). Similarly, there was tremendous im-provement in the extent to which enrollment in Healthy Kids reduced families’ fi-nancial burdens. More than 70 percent of families felt that obtaining needed care for their children created little or no financial difficulties, up significantly from the EXHIBIT 4

Impact Of Healthy Kids (Los Angeles County, California) On Newly Enrolled Children’s Access To Care And Use Of Services, 2005 And 2006

New enrollees, unadjusted estimate

Adjusted difference-in-differencea Outcome Wave 1 (%) Wave 2 (%) Differencea

Child has usual source of medical care Child had at least one ambulatory care visit

in the past 6 months

Child had at least one preventive care visit in the past 6 months

73.6 68.0 63.8 93.1 67.1 63.0 19.5*** –0.9 –0.8 14.7*** 7.4** 3.5 Child has a usual source of dental care

Child had at least one dental visit in the past six months 34.4 25.6 69.1 50.5 34.7*** 24.9*** 27.5*** 14.4 Child’s parent feels very confident that he or she

can obtain needed care for the child Child’s health care needs created little or no

financial difficulties in the past six months

31.3 50.8 61.4 72.5 30.1*** 21.7*** 21.5*** 12.5***

SOURCE:Survey of Los Angeles Healthy Kids enrollees (Wave 1, 2005 and Wave 2, 2006).

NOTES:Difference-in-difference estimates include controls for being an established enrollee, being a Wave 2 interviewee, age, income, sex, family structure, citizenship, child’s health during infancy relative to other infants, language spoken at home, number of children in the household, parents’ education, household employment status, length of time parent lived in LA County, and the month the child enrolled in Healthy Kids. Columns 1 and 2 are unadjusted means for new enrollees in Wave 1 and Wave 2; column 3 shows the difference between the two time periods. Column 4 represents the adjusted difference net of the experience of established enrollees who had been in the program for a year. Statistical significance was based on a one-tailed test.

a_{Percentage points.}

pre-enrollment period rate of 50.8 percent (Exhibit 4).

nSustainability.Unfortunately, the very success that Healthy Kids experienced with its outreach and enrollment quickly led to severe financial sustainability chal-lenges. In June 2005, with total enrollment nearing 45,000 children, money to sup-port coverage of children ages 6–18 was running short, and policymakers placed an indefinite “hold” (or cap) on enrollment. Recall that funding for children ages 0–5 is supported by First 5 LA’s commitment of $100 million, which continues to comfort-ably support premiums for Healthy Kids’ roughly 8,000 youngsters. Yet older chil-dren, constituting more than 80 percent of all program enrollees, are supported by philanthropic donations, and these monies were rapidly exhausted. LA Care main-tained a waiting list of eligible children, which grew to more than 5,000 children by March 2006, when it was closed. Over time, attrition and further philanthropic do-nations allowed all children to be enrolled from the waiting list. But enrollment for those ages 6–18 has never been reopened to new applicants.

The evaluation’s case-study research documented the actions taken to alter out-reach during the enrollment cap. Outout-reach agencies shifted much of their empha-sis to renewing coverage for current enrollees, and they referred older uninsured

children to other potential sources of coverage.11 _{Most important, they tried to}

make it clear to families that enrollment for children ages 0–5 was still open. De-spite these efforts, program enrollment for both older and younger children has dipped (see Exhibit 1), and outreach workers observed that it was much harder to promote a program that provides coverage to only some children in a family.

Clearly, Healthy Kids’ funding shortfall resulted from too many children need-ing coverage and insufficient money to support them. But the evaluation identified other, more complex issues that might have exacerbated the problem. Specifically, many parents in our focus groups and household survey reported that their chil-dren possessed Emergency Medi-Cal coverage, even after enrolling in Healthy Kids. Some focus-group participants also said that they used both forms of insur-ance. One stated: “We use Healthy Kids for doctor visits, and Emergency Medi-Cal for emergencies and hospital care.” Similarly, case studies found that children who enrolled in Healthy Kids through clinics were also likely to have been en-rolled in the Child Health and Disabilities Program (CHDP) Gateway—a pre-sumptive eligibility program that provides Medi-Cal reimbursement for preven-tive services rendered to children who appear eligible for Medi-Cal. These two forms of additional coverage mean that some Healthy Kids enrollees likely had portions of their care paid for by Medi-Cal (Emergency and CHDP), even while the CHI was paying LA Care per capita monthly premiums based on the value of a comprehensive benefit package. Thus, without any mechanism for coordination of benefits, Healthy Kids might not have gotten the full benefit of its investment.

Los Angeles officials are aware of these inefficiencies and have taken steps to address them. Specifically, the premium paid to LA Care has been reduced three times to better reflect the actual cost of covering children. In addition, the CHI

ne-gotiated with Medi-Cal to obtain per child payments to reflect the value of Emer-gency Medi-Cal services received by Healthy Kids enrollees; this negotiation was ultimately successful.

Conclusions And Policy Implications

The Los Angeles Healthy Kids program has succeeded on many levels during its brief history. A four-year evaluation of the initiative has demonstrated that the program extended comprehensive, affordable coverage to more than 40,000 very poor and vulnerable children who have almost no access to employer-sponsored insurance coverage; that community-based outreach effectively reached immi-grant families and helped them overcome fears of public charge; that the culturally appropriate Healthy Kids network brought immigrant children into mainstream systems of care; and that Healthy Kids coverage had numerous positive effects on children’s access to and use of care.

nFitting into broader health reforms. Yet despite this success, the program has also faced very serious challenges, primarily related to financing. Philanthropic donations alone have been unable to maintain the rapidly growing program, and lay-ering Healthy Kids on top of the existing Medi-Cal and Healthy Families programs led to some inefficiencies and dual coverage. In the short term, efforts to raise addi-tional donations may keep the program afloat. A longer-term solution, debated but not favored by anyone, would scale back Healthy Kids to a primary care–only pro-gram, with Emergency Medi-Cal providing “wrap-around” coverage for acute care. But stakeholders and advocates are hoping that a final solution resides in Califor-nia’s broader health care reform proposal, to be put before the voters on a November 2008 ballot initiative, which would extend coverage to all Californians, including children, regardless of citizenship status.

Today, the Los Angeles Healthy Kids program sits at a critical juncture. Devel-opments in the coming months will determine whether it will have the opportu-nity to grow and thrive, with solid state financial support, or whether it will have to be drastically cut. If funding is found for Healthy Kids programs, low-income children will be given access to comprehensive and affordable coverage that should improve their chances of a healthy life and productive school years.

nEvaluation limitations.Two limitations of the evaluation are worth noting. First, the parent survey used for the impact analysis was restricted to children ages 1–5 because of funding constraints; the analysis might have yielded different impacts on access to care if older children had been included. Second, the presence of a strong safety net in Los Angeles and the fact that some children had health insurance (primarily Emergency Medi-Cal) prior to enrolling in Healthy Kids could bias downward the impact of the program were it to be implemented in other areas with a weaker safety net or less reliance on Emergency Medi-Cal. However, the impacts found here are quite comparable to those in San Mateo and Santa Clara Counties,

This research was funded by contracts with First 5 LA and the California Endowment. NOTES

1. K. Fortuny, R. Capps, and J.S. Passel,The Characteristics of Unauthorized Immigrants in California, Los Angeles County, and the United States,March 2007, http://www.urban.org/UploadedPDF/411425_Characteristics_ Immigrants.pdf (accessed 19 November 2007).

2. G. Kenney, J. McFeeters, and J. Yee,How Far Can the Healthy Kids Program Go in Closing Coverage Gaps for Children in Los Angeles County? A Baseline Analysis with the 2002/2003 Los Angeles County Health Survey,3 October 2006, http://www.urban.org/UploadedPDF/411466_healthy_kids.pdf (accessed 19 November 2007).

3. Z.J. Huang, S.M. Yu, and R. Ledsky, “Health Status and Health Service Access and Use among Children in U.S. Immigrant Families,”American Journal of Public Health96, no. 4 (2006): 634–640; N.S. Shah and O. Carrasquillo, “Twelve-Year Trends in Health Insurance Coverage among Latinos, by Subgroup and Immi-gration Status,”Health Affairs25, no. 6 (2006): 1612–1619; V.D. Ojeda and E.R. Brown, “Mind the Gap: Par-ents’ Citizenship as Predictor of Latino Children’s Health Insurance,”Journal of Health Care for the Poor and Underserved16, no. 3 (2005): 555–575; and G. Kenney, J. McFeeters, and J. Yee,Access Gaps among Uninsured Children in LA County: Baseline Findings from the 2002/2003 LA County Health Survey,3 October 2006, http://www .urban.org/UploadedPDF/411463_uninsured_children.pdf (accessed 19 November 2007).

4. Twenty-five of California’s fifty-eight counties have operational CHIs. The Los Angeles CHI was co-con-vened by the nonprofit LA Care Health Plan, the California Endowment, and the Los Angeles County De-partment of Health Services.

5. For case-study and focus-group methods, see I. Hill, B. Courtot, and E. Wada,A Healthy Start for the Los An-geles Healthy Kids Program: Findings from the First Evaluation Site Visit,December 2005, http://www.urban.org/ UploadedPDF/411259_healthy_kids.pdf (accessed 19 November 2007); and I. Hill et al.,What Do Parents Say about the Healthy Kids Program? Findings from Focus Groups with Parents of Healthy Kids Enrollees,March 2006, http://www.urban.org/UploadedPDF/410308_parents_say.pdf (accessed 19 November 2007). For survey methods, see E. Howell et al.,A Profile of Young Children in the Los Angeles Healthy Kids Program: Who Are They and What Are Their Experiences on the Program?October 2006, http://www.urban.org/UploadedPDF/411370_ healthy_kids.pdf (accessed 19 November 2007); and E. Howell, L. Dubay, and L. Palmer,The Impact of the Los Angeles Healthy Kids Program on Access to Care, Use of Services, and Health Status,July 2007, http://www.urban .org/UploadedPDF/411503_impact_healthy_kids.pdf (accessed 19 November 2007).

6. This assumes that all of the program effects for established enrollees occurred during the first year of the program, which is likely reasonable for outcomes presented here, but not for other outcomes such as health status.

7. That is, that enrolling in a government-sponsored insurance program would harm their efforts to obtain citizenship.

8. The Omnibus Budget Reconciliation Act of 1986 makes federal funds available to states for coverage of “Emergency Medicaid” for undocumented aliens who need emergency or pregnancy-related care. 9. Families with incomes below 133 percent of poverty pay no premiums; others may request “premium

as-sistance” if they are having trouble making payments.

10. Because of a coding error in Wave 1, only children who had an ambulatory care visit were asked the dental care questions. Consequently, this analysis is limited to these children.

11. For example, the Kaiser Child Health Plan committed support for coverage of up to 1,700 children. 12. C. Trenholm et al., “Three Independent Evaluations of Healthy Kids Programs Find Dramatic Gains in

Well-Being of Children and Families,” In Brief no. 1 (Los Altos, Calif.: David and Lucile Packard Founda-tion, November 2007).