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Lessons learned from California's insurance expansions for kids
California officials have learned much in recent years about how to provide health insurance for children. The California HealthCare Foundation (CHCF) says the state has significantly expanded enrollment in its Medi-Cal and Healthy Families programs and many counties have developed Children's Health Initiatives to cover those children who are ineligible for state programs. As a result, the number of uninsured children in California has dropped by nearly 20% over the last five years.
CHCF senior program officer Len Finocchio says while there is popular support for continuing to expand coverage until all children in California have insurance, nearly 1 million remain uninsured. A CHCF November 2006 issue brief synthesized key lessons from successful initiatives and from potential reforms that have been identified but not yet implemented.
Mr. Finocchio tells State Health Watch that he believes his findings often can be generalized to other states, especially to the degree that their policies and procedures need to be simplified. "I'm sure there is a lot of work for other states to do."
The lessons in expanding children's coverage have been grouped into three categories—simplify, automate, and follow the leaders.
• Simplify. While there are several California public programs whose aim is to insure children, not all eligible children enroll, and those who do initially often fail to renew their coverage. Mr. Finocchio says part of the problem is that each of the programs has its own eligibility rules, documentation requirements, and application processes that vary from county to county, offering a daunting challenge to the average family. Proven ways to simplify public health insurance programs are to simplify federal and state policies on eligibility; streamline the application, enrollment, and renewal processes; and reach out, redesign the paperwork, and provide assistance.
• Automate. "The effective use of information technology [IT] can improve enrollment processes so that information flows more quickly and efficiently and the enrollment steps are presented coherently," Mr. Finocchio says. "Efficiencies gained through IT solutions are not a substitute for policy reforms that would actually reduce unnecessary complexity." Mr. Finocchio refers to an independent study that found that applicants and administrators prefer electronic applications to paper ones. "Computerized forms are designed to eliminate many common mistakes found in applications that are completed by hand," he says. "Every required field must be completed before submission and small discrepancies (such as zip codes that don't match the county of residence) must be addressed. Six improvement techniques Mr. Finocchio suggests are to improve enrollment efficiency with electronic applications; integrate state and county data systems, taking older technology into account; use technologies that provide real-time connection to key enrollment databases; move toward on-line enrollment; ensure that policy keeps pace with technology, and vice versa; and foster political will for a statewide technology strategy.
• Follow the leaders. Mr. Finocchio says some California counties have achieved extraordinary results with innovative coverage programs. They have been particularly effective at forming collaborations to consider the needs and suggestions of everyone involved, including families, eligibility workers, health plans, community-based organizations, hospitals, and schools. Four reforms that can work are working together; delivering the right marketing message to the right people in the right places at the right time; creating inspiring goals and realistic plans to achieve them; and taking a customer service approach to health plan enrollment.
There are obstacles that must be overcome, Mr. Finocchio says, if states are to expand health coverage for children. First, the application and enrollment process has an important influence on families' decisions to apply for coverage. And another important factor in determining whether families apply for coverage is their perception of and experience with the program. Thus, a study of consumer decision making found that many more families would enroll in Medi-Cal if they believed that doctors would treat them with respect and that someone in the doctor's office spoke their language.
The ease with which families can get access to care is another important attribute of coverage programs. "Children don't just need health insurance," Mr. Finocchio says, "they need access to providers." Given that in California there are 46 Medi-Cal providers per 100,000 beneficiaries, well below the federal minimum standard of 60-80 providers, enrollment in Medi-Cal and Healthy Families can improve access to physician services, but does not eliminate access problems. The most basic requirement, according to the issue brief, is a sufficient supply of doctors who accept public health insurance as payment, including specialists and dentists. Also, children in remote rural areas need adequate transportation to care sites.
As more children enroll, Mr. Finocchio says, public health insurance programs will need additional funding. Rather than the typical state general fund and federal match, there may be a more efficient way to organize and finance the system, he says, and the state should consider potential savings in managed care, look for economies of scale, and reduce costs by streamlining administrative processes.
"There are unquestionably some challenges to providing adequate insurance coverage for California's children, including funding and access to providers," Mr. Finocchio concludes. "However, there are also opportunities for improvement. Examples of successful initiatives at the state, county, and agency levels offer basic lessons to guide future efforts. Heeding them can help California make substantial progress toward providing accessible health coverage to children throughout the state."
Mr. Finocchio tells State Health Watch that a lack of political will often is a barrier to making coverage improvements, as are the disparate ways that people must enroll in various programs, either electronically or by hand. "If there were an overarching state leadership for change it would happen," he declares.
Mr. Finocchio says the key success factors for California to expand coverage included automated enrollment, outside groups developing innovative processes and pressuring the state to use them, a strong advocacy presence, and the presence of individual legislators and governors who want to be sure that kids have coverage.
He tells SHW the push for universal coverage for kids has been under way in his state for five or six years and has reached the point that there is a sense of inevitability that California will provide coverage for children even if plans for still-broader coverage fail. He says when universal coverage of children is achieved, CHCF will look at the system in place and how well it provides access to care and will work with the state government to make it as user-friendly as possible.
The issue brief is available on-line from www.chcf.org. Contact Mr. Finocchio at (510) 587-3131.