Ian Hill

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

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 Childrens Health Initiatives. One initiative, the Los Angeles Healthy Kids program, extends coverage to uninsured 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 Childrens 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 program has proved to be challenging.

Do Access Experiences Affect Parents' Decisions to Enroll Their Children in Medicaid and SCHIP? Findings from Focus Groups with Parents

Objective: The Covering Kids and Families (CKF) program seeks to expand health insurance coverage for children by supporting community-based outreach and enrollment. For the evaluation of CKF, researchers conducted focus groups to explore parents’ experiences accessing health care for their children, and to assess whether these experiences affected decisions to enroll their children in Medicaid or the State Children’s Health Insurance Program (SCHIP). Methods: In May and June 2003, 13 focus groups were conducted in 5 cities—Everett, MA; Denver, CO; Los Angeles, CA; Mena, AR; and San Antonio, TX. In each community, groups were conducted with parents of children insured under Medicaid or SCHIP and parents of uninsured children. Three groups were conducted with Spanish-speaking parents in two communities—Denver and Los Angeles. Results: Access to primary care was considered good by most parents with children in Medicaid and SCHIP. Among parents of uninsured children, there was more variation in perceptions of access to care. For parents of both uninsured and insured children, access to dentists and specialists was more problematic. Spanish-speaking families reported numerous barriers to care due to language differences and perceived discrimination. All focus group participants said that they placed great value on health insurance. Conclusion: Even when parents encountered problems accessing care, very few indicated that this discouraged them from enrolling their children into Medicaid or SCHIP, or from renewing their children’s public coverage.

The Impact of New Health Insurance Coverage on Undocumented and Other Low-Income Children: Lessons from Three California Counties

Three California counties (Los Angeles, San Mateo, and Santa Clara) expanded health insurance coverage for undocumented children and some higher income children not covered by Medi-Cal (Medicaid) or Healthy Families (SCHIP). This paper presents findings from evaluations of all three programs. Results consistently showed that health insurance enrollment increased access to and use of medical and dental care, and reduced unmet need for those services. After one year of enrollment the programs also improved the health status of children, including reducing the percentage of children who missed school due to health.

Effects of Managed Care on Service Use and Access for Publicly Insured Children With Chronic Health Conditions

OBJECTIVE. Our goal was to estimate the effects of managed care program type on service use and access for publicly insured children with chronic health conditions. METHODS. Data on Medicaid and State Childrens Health Insurance Program managed care programs were linked by county and year to pooled data from the 1997–2002 National Health Interview Survey. We used multivariate techniques to examine the effects of managed care program type, relative to fee-for-service, on a broad array of service use and access outcomes. RESULTS. Relative to fee-for-service, managed care program assignment was associated with selected reductions in service use but not with deterioration in reported access. Capitated managed care plans with mental health or specialty carve-outs were associated with a 7.4-percentage-point reduction in the probability of a specialist visit, a 6.3-percentage-point reduction in the probability of a mental health specialty visit, and a 5.9-percentage-point decrease in the probability of regular prescription drug use. Reductions in use associated with primary care case management and integrated capitated programs (without carve-outs) were more limited, and integrated capitated plans were associated with a reduction in unmet medical care need. We failed to find significant effects of special managed care programs for children with chronic health conditions. CONCLUSIONS. Managed care is associated with reduced service use, particularly when capitated programs carve out services. This finding is of key policy importance, as the proportion of children enrolled in plans with carve-out arrangements has been increasing over time. It is not possible to determine whether reductions in services represent better care management or skimping. However, despite the reductions in use, we did not observe a corresponding increase in perceived unmet need; thus, the net change may represent improved care management.

CHIP and Medicaid: Evolving to Meet the Needs of Children.

OBJECTIVE To examine the evolution of Childrens Health Insurance Program (CHIP) and Medicaid programs after passage of the Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA), focusing on policies affecting eligibility, enrollment, renewal, benefits, access to care, cost sharing, and preparation for health care reform. METHODS Case studies were conducted in 10 states during 2012-which included key informant interviews and consumer focus groups-and a national survey of state CHIP program administrators was conducted in early 2013. RESULTS Despite the recession that persisted during much of the study period, many states expanded childrens coverage by raising upper income eligibility limits or by covering new groups made eligible by CHIPRA. Simplifying rules and procedures for enrollment and renewal continued to be a major priority for CHIP and Medicaid, and CHIPRA played a direct role in spurring innovation. CHIPRAs outreach grants played an important role in supporting and supplementing state outreach efforts. Important legacies of CHIPRA are the laws mandatory requirements for comprehensive dental benefits coverage and mental health parity for all types of CHIP programs. Although most states already offered generous coverage of these benefits, the mandate may have protected them from cuts during the economic downturn. Federal Maintenance of Effort rules were a crucial protection for CHIP, especially during the recession when state budget shortfalls could have led to program cuts. CONCLUSIONS Passage of the Affordable Care Act has raised questions surrounding the future role of CHIP in a reformed health care system. A growing number of stakeholders have recommended a 2-year extension of federal CHIP funding to allow complex transition issues to be resolved.

Are there differential effects of managed care on publicly insured children with chronic health conditions

The authors use variation across states and over time in managed care (MC) programs for publicly insured children to examine whether effects differ for children with chronic health conditions (CWCHC) and those without. The authors pool data from the 1997 to 2002 National Health Interview Survey and link county, year, and health status information on type of MC programs implemented. Findings show that the effects of MC are concentrated on CWCHC and that CWCHC experience reductions in use of specialist, mental health, and prescription drugs. Capitated programs with mental health or specialty carve-outs are associated with a greater number and larger decreases in service use compared to integrated capitated programs. While it is not possible to determine whether MC programs resulted in more appropriate use of services, corresponding reductions in perceived access were not observed, suggesting that net effects of MC on service use represent improvements in care coordination.

Inequality and Innovation: Barriers and Facilitators to 17P Administration to Prevent Preterm Birth among Medicaid Participants

Objectives Strategies to prevent preterm birth are limited. 17 Alpha-Hydroxyprogesterone Caproate (17P) injections have been shown to be effective, but the intervention is under-used. This mixed methods study investigates barriers and facilitators to 17P administration among Medicaid and CHIP participants enrolled in Strong Start for Mothers and Newborns, a federal preterm birth prevention program. Methods Twenty-seven awardees with more than 200 sites in 30 states, the District of Columbia, and Puerto Rico enrolled approximately 46,000 women in Strong Start from 2013 to 2016. Participant data, including data on preterm birth and 17P, was collected for each woman. Intensive interviews (n = 211) conducted with Strong Start program staff and providers (n = 314) included questions about 17P provision. Results Of women whose data included a valid response regarding 17P initiation, 3919 had a prior preterm birth and current singleton pregnancy; 14.95% received 17P. Barriers to 17P administration include late entry to prenatal care, administrative burden of preauthorization, cost risks to providers, limits in scope of practice for non-physician providers, and social barriers among participants. Facilitators for provision include streamlined work flows and the option of home administration. Conclusions for Practice A universal insurance authorization process could mitigate many barriers to 17P use. Providers need continuing education regarding the effectiveness of 17P, and expanding scope of practice for non-physician prenatal care providers would increase access. Targeted program interventions can help to overcome social barriers Medicaid participants face in accessing care. Streamlined work processes and the option of home health services are two effective program-based facilitators for providing 17P to a Medicaid population.