A Tale of Two Counties: Expanding Health Insurance Coverage for Children in California

ATale of Two Counties: Expanding HealthInsurance Coverage for Children in CaliforniaEMBRY M. HOWELL and DANA HUGHESUrban Institute; University of California at San FranciscoDuring difficult economic times, many California counties have expandedhealth insurance coverage for low-income children. These Children’s HealthInitiatives (CHIs) enroll children in public programs and provide new healthinsurance, Healthy Kids, for those ineligible for existing programs. This arti-cle describes the policy issues in implementing the Santa Clara and San MateoCounty CHIs, as well as the children’s enrollment levels and utilization of ser-vices. These CHIs are among the first of the thirty California counties planningor implementing such initiatives. Their success depends on leadership fromcounty agencies that have not traditionally worked closely together, as well asthe development of a diverse public and private funding base. This effort to pro-vide universal coverage for all children is important to national policymakersdesiring similar goals.Keywords:Child health insurance, immigrant health, California.Asthe nation continues to struggle with agrowing number of uninsured people, the only bright spotis children. The State Children’s Health Insurance Program(SCHIP), enacted in 1997, along with expansions of Medicaid in thel980s and 1990s, led to fewer uninsured children at the same timethat the number of uninsured adults rose (Bhandari and Gifford 2003;Hoffman, Carbaugh, and Cook 2004; Kenney, Haley, and Tebay 2003;Rhoades and Cohen 2003; Strunk and Reschovsky 2004).Studies also show pronounced differences in access and use betweenchildren with and without health insurance (Holl et al. 1995; Stoddard,Address correspondence to:Embry M. Howell, Urban Institute, 2100 M St. N.W.,Washington, DC 20037 (email: ehowell@ui.urban.org).The Milbank Quarterly, Vol. 84, No. 3, 2006 (pp. 521–554)c©2006 Milbank Memorial Fund. Published by Blackwell Publishing.521 522E.M. Howell and D. HughesSt. Peter, and Newacheck 1994), but SCHIP and the expansions of Med-icaid have improved access to care and service use for newly insuredchildren (Dick et al. 2004; Lave et al. 1998; Van Landeghem and Brach2004). While the assumed relationship between increased availabilityof insurance coverage and the improved health status of children hasnot been demonstrated definitively, studies have shown a relationshipfor some populations (for reviews of this literature, see Hadley 2003;Starfield and Shi 2004).Despite this progress, many children in the United States are still notinsured. Since 1998 the greater number of immigrants into the UnitedStates has accounted for much of the growth of the uninsured (Fronstin2005). In particular, immigrant children, especially Hispanic immigrantchildren, are far more likely to be uninsured than other children are. Thegreatest problem is that many such children are undocumented andtherefore do not qualify for Medicaid or SCHIP (Capps et al. 2004).“Undocumented” children are those who are not residing in the UnitedStates legally, although children born in this country may be documentedwhen their parents are not.Even when children are eligible for public programs, immigrant par-ents face numerous barriers to enrolling them, such as lack of familiaritywith insurance and limited proficiency in English (Alker and Urrutia2004; Doty 2003; Fix and Capps 2002; Hughes et al. 2000; Reardon-Anderson, Capps, and Fix 2002; Weathers et al. 2004). In addition, manyimmigrant parents worry that enrolling their children might constitutea“public charge,” thereby inhibiting their ability to obtain permanentresidency (Perry, Stark, and Valdez 1998).California’s children face many of the same barriers to obtaining healthinsurance and adequate health care as do children across the nation(Grossman-Swenson and Dominguez-Arms 2004; Manos et al. 2001;Tomas Rivera Policy Institute 2002). Among California’s uninsured chil-dren, 60.8 percent are documented and thus eligible for either Medi-Cal(Medicaid) or Healthy Families (SCHIP). The remainder are ineligiblebecause of their documentation status or because their household incomesare too high (Brown and Lavarreda 2005). Although the state does notoffer full public coverage to undocumented children, they are entitledto Emergency Medi-Cal for two months for medical emergencies andto preventive care through the Child Health and Disability PreventionProgram. Expanding Health Insurance for Children in California523Overview of Children’s Health InitiativesBecause of the many children who are not entitled to existing publiccoverage or who are eligible but not enrolled, a growing number ofcounties in California are sponsoring new initiatives to increase healthinsurance coverage for children (California Endowment 2004; Gardnerand Kahn 2004; Harper 2003; Testa et al. 2003). These programs, re-ferred to as “Children’s Health Initia