Evaluating Policy Initiatives for Evaluating Policy Initiatives for Expanding Health Insurance Expanding Health Insurance

and Improving Access for and Improving Access for Uninsured Children in Uninsured Children in

California and Los AngelesCalifornia and Los Angeles

October 21, 2004October 21, 2004USC Division of Community HealthUSC Division of Community Health

cousinea@usc.educousinea@usc.edu(213) 743-1588(213) 743-1588

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Funded byFunded by The California Endowment, The California Endowment,

First 5 California and First 5 LAFirst 5 California and First 5 LA

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Health Insurance Status of Health Insurance Status of Children in California, 2001Children in California, 2001

Uninsured, 9.6%Other Public, 1.2%

Medi-Cal, 22.8%

Private, 61.8%

Healthy Families, 48.0%

Source: 2001 California Health Interview Survey

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Uninsured Children In Uninsured Children In CaliforniaCalifornia

1 Million children (about 10%) in 1 Million children (about 10%) in California are uninsured. California are uninsured.

Two thirds are eligible for existing Two thirds are eligible for existing programs Medi-Cal or Healthy programs Medi-Cal or Healthy FamiliesFamilies

Others are ineligible due to Others are ineligible due to immigration status, family incomeimmigration status, family income

Rate uneven throughout the State - Rate uneven throughout the State - high in parts of Los Angeles County)high in parts of Los Angeles County)

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Variation among California Counties Variation among California Counties in Percent of Uninsured Children in Percent of Uninsured Children

(Source: 2001 CHIS)(Source: 2001 CHIS)

0

5

10

15

20

25

30

35

PE

RC

EN

T

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California Children’s California Children’s Coverage ProgramCoverage Program

A wide ranging plan to achieve 100% coverage of A wide ranging plan to achieve 100% coverage of children in Californiachildren in California

Policy and programmatic strategies, Policy and programmatic strategies, Premium supportPremium support Builds on 18 county-based programs that round out Builds on 18 county-based programs that round out

state and federal child health insurance programsstate and federal child health insurance programs Expansion, simplification, consolidation, ? State only Expansion, simplification, consolidation, ? State only

programsprograms Public program expansion with unknown employer rolePublic program expansion with unknown employer role A plan with basic benefit package and low or $0 A plan with basic benefit package and low or $0

premiums premiums

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The California Endowment (Premium The California Endowment (Premium support and infrastructure) Developmentsupport and infrastructure) Development

State and federal support, unknownState and federal support, unknown Counties – Counties –

Tobacco Settlement First 5 Tobacco Settlement First 5 (Proposition 10)(Proposition 10)

Other Foundations (Blue Shield, Other Foundations (Blue Shield, Packard)Packard)

Local Initiatives (LA Care Health Plan)Local Initiatives (LA Care Health Plan)

Funding

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Purpose of the Purpose of the EvaluationEvaluation

Document the process and outcomes of Document the process and outcomes of the CCP in its effort to expand coverage, the CCP in its effort to expand coverage, improve access and child healthimprove access and child health

Develop a plan once the initiative is Develop a plan once the initiative is underway for collecting quantitative and underway for collecting quantitative and qualitative data from which to answer qualitative data from which to answer policy relevant questions, what works policy relevant questions, what works and and

Natural experiment, 58 countiesNatural experiment, 58 counties Keys and obstacles to successKeys and obstacles to success Enrollment retention, crowd out, costs Enrollment retention, crowd out, costs

and utilization ands qualityand utilization ands quality

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Methods and Methods and StrategiesStrategies

1.1. Longitudinal Analysis of existing Longitudinal Analysis of existing population and administrative data population and administrative data

2.2. Inventory of local projects, and Inventory of local projects, and evaluation and research activitiesevaluation and research activities

3.3. Comparative case studies, CHIsComparative case studies, CHIs Site visits and structured Site visits and structured

interviewsinterviews

4.4. Surveys of elected officials and Surveys of elected officials and populationspopulations

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Is Coverage Is Coverage Expanding?Expanding?

Create models (based on goals of CCP) using Create models (based on goals of CCP) using population survey data for deriving expected population survey data for deriving expected values and use survey data and enrollment values and use survey data and enrollment data for comparing actual enrolled to the data for comparing actual enrolled to the expected number,expected number, Changes in health insurance for children Changes in health insurance for children

and their familiesand their families Track participation in public programsTrack participation in public programs

Data Sources:Data Sources: Population surveys (CHIS, CPS, local surveys)Population surveys (CHIS, CPS, local surveys) Enrollment and administrative data (Medi-Enrollment and administrative data (Medi-

Cal, Healthy Families, Healthy Kids, and Cal, Healthy Families, Healthy Kids, and other state and local programs)other state and local programs)

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Improving Access and Improving Access and Health: What else should Health: What else should

we be measuring?we be measuring? Review of existing data sourcesReview of existing data sources

Vital statistics and population-based Vital statistics and population-based surveyssurveys

First 5 programsFirst 5 programs

Opportunities for data developmentOpportunities for data development

Convening of experts and data Convening of experts and data specialistsspecialists

Consensus-based decision-making Consensus-based decision-making processprocess

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Political Capacity & Political Capacity & CommitmentCommitment

Has CCP expanded support among Has CCP expanded support among policy makers for expanding health policy makers for expanding health access?access?

Data Source:Data Source: During Phase I, survey of state and local During Phase I, survey of state and local

legislators to assess levels of awareness and legislators to assess levels of awareness and commitment to children’s health policy, and commitment to children’s health policy, and gauge political will and support for the CCP. gauge political will and support for the CCP.

The survey will be repeated in Phase 2 to The survey will be repeated in Phase 2 to ascertain changes.ascertain changes.

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Policy ReformPolicy Reform What programs and resources have What programs and resources have

been mobilized?been mobilized? What regulations adopted?What regulations adopted? What laws changed? State and local What laws changed? State and local

levelslevels Flow from the policy agenda put in Flow from the policy agenda put in

place place

Data SourceData Source:: Environmental and legislative Environmental and legislative

monitoring and scanmonitoring and scan

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Health Systems Health Systems ChangeChange

Research QuestionsResearch Questions:: How has CCP changed health care How has CCP changed health care

systems - providers and local plans?systems - providers and local plans?

Data SourceData Source:: Case Studies of Selected Counties Case Studies of Selected Counties

Interviews with health plans and providersInterviews with health plans and providers Document reviewDocument review Participant observationsParticipant observations

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Network and Support Network and Support SystemsSystems

Research Questions:Research Questions: How has network and collaboration How has network and collaboration

among local organizations within among local organizations within counties affected CHIs?counties affected CHIs?

What is the role of foundations and What is the role of foundations and other funders and how have they other funders and how have they affected CHIs and the CCP?affected CHIs and the CCP?

Data SourceData Source:: Case studies of selected counties Case studies of selected counties

Interviews with health plans and providersInterviews with health plans and providers Document reviewDocument review Participant observationsParticipant observations

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Studying the LA Children’s Studying the LA Children’s Health InitiativeHealth Initiative

Outreach and enrollmentOutreach and enrollment UtilizationUtilization QualityQuality PartnershipsPartnerships

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Child Health Policy Child Health Policy Research CollaborativeResearch Collaborative

USC, Division of Community Health (lead, California)USC, Division of Community Health (lead, California) – –

USC, TomUSC, Tomáás Rivera Policy Institutes Rivera Policy Institute – –USC, Department of USC, Department of Preventive Medicine, Institute for Prevention ResearchPreventive Medicine, Institute for Prevention Research - -..

USC Children’s Hospital Los Angeles, Division of USC Children’s Hospital Los Angeles, Division of Research on Children Youth and Families, Research on Children Youth and Families,

University of California San Diego, Department of Family University of California San Diego, Department of Family and Preventive Medicineand Preventive Medicine - -

Johns Hopkins University, School of Public HealthJohns Hopkins University, School of Public Health - - Urban Institute, (lead, Los Angeles)Urban Institute, (lead, Los Angeles)

Mathematica Mathematica UCLA Center for Healthier Children, Families and CommunitiesUCLA Center for Healthier Children, Families and Communities USCUSC

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Research Team Research Team (both California and LA Studies)(both California and LA Studies)

USC.USC. Michael R. Cousineau, Principal Investigator, Gregory Stevens, Michael R. Cousineau, Principal Investigator, Gregory Stevens, Ph.D., Eriko Wada, MPP and Lori Nascimento, MPHPh.D., Eriko Wada, MPP and Lori Nascimento, MPH

USC, Department of Preventive Medicine, Institute for Prevention USC, Department of Preventive Medicine, Institute for Prevention ResearchResearch - - Tom Valente, Ph.D. and Lourdes Baezcandi-Garbanati,Ph.DTom Valente, Ph.D. and Lourdes Baezcandi-Garbanati,Ph.D Urban Institute,Urban Institute,

USC, TomUSC, Tomáás Rivera Policy Institutes Rivera Policy Institute - - Harry Pachon, Ph.D, Harry Pachon, Ph.D, Jongho Lee, Jongho Lee, Ph.D., and Hayley Buchbinder, MPP & MPH Ph.D., and Hayley Buchbinder, MPP & MPH Mathematica, Ian Hill, Mathematica, Ian Hill,

USC Children’s Hospital Los Angeles, Division of Research on USC Children’s Hospital Los Angeles, Division of Research on Children Youth and Families, Department of PediatricsChildren Youth and Families, Department of Pediatrics - - Michele Michele Kipke, Ph.D., Ellen Iverson, Ph.D., and Angela Hegeman, Ph.DKipke, Ph.D., Ellen Iverson, Ph.D., and Angela Hegeman, Ph.D

UCLA, Neal Halfon, MD, Moira Inkeles, Ph.D., Patrica Barreto, MDUCLA, Neal Halfon, MD, Moira Inkeles, Ph.D., Patrica Barreto, MD University of California San Diego, Department of Family and University of California San Diego, Department of Family and

Preventive MedicinePreventive Medicine - - Richard Kronick, Ph.D. and Tom Gilmore, Ph.DRichard Kronick, Ph.D. and Tom Gilmore, Ph.D Johns Hopkins University, School of Public HealthJohns Hopkins University, School of Public Health - - Tom Oliver, Ph.D. Tom Oliver, Ph.D.