Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings Prepared for CALIFORNIA HEALTHCARE FOUNDATION by Annette Gardner, Ph.D., M.P.H. James G. Kahn, M.D., M.P.H. Institute for Health Policy Studies University of California, San Francisco September 2004 About the Authors Annette Gardner, Ph.D., M.P.H., is a senior research associate at the Institute for Health Policy Studies (University of California, San Francisco) where she has conducted research on California’s safety net since 2001. Her research focuses on county-level programs to increase access to health care for the uninsured (financing, coverage and service expansions), as well as the role of clinic consortia in strengthening the safety net. She can be contacted at algard@itsa.ucsf.edu or 415.514.1543. James G. Kahn, M.D., M.P.H., is a professor of health policy and epidemiology at UCSF. His research focuses on economic issues in the provision of health care services to vulnerable populations and on health insurance issues. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information about CHCF, visit us online at www.chcf.org. This report was produced under the direction of CHCF’s Health Insurance Program, which works to serve the public by increasing access to insurance for those who don’t have coverage and helping the market work better for those who do. Visit www.chcf.org/programs for more information about CHCF and its programs. ISBN 1-932064-80-X ©2004 California HealthCare Foundation Contents 4 I. Introduction 6 II. Methods 8 III. Summary of Findings 11 IV. Local Programs to Increase Access to Care 18 V. Key Leaders and Stakeholders 21 VI. Funding Programs to Increase Access to Care 24 VII. Barriers to Expansions 26 VIII. County Coverage Expansions 28 IX. Follow-up Interviews 31 X. Conclusion: Future Expansions 34 Appendices Appendix A: Responding Counties Appendix B: Funding Stream Definitions Appendix C: Funding Used to Finance Access Programs Appendix D: Survey Instrument 42 Endnotes I. Introduction IN CALIFORNIA, COUNTIES ARE RESPONSIBLE FOR addressing the health care needs of the uninsured, a challenge that includes reducing barriers to care and ensuring appropriate use of services. The last several years have witnessed significant initiatives in many counties to create and launch county-level health care access initiatives, such as insurance expansions targeted to children (for example, the Healthy Kids programs of Santa Clara and San Francisco Counties) and service expansions (for example, new clinic facilities). The California HealthCare Foundation commissioned researchers at the UCSF Institute for Health Policy Studies to investigate how willing counties are to develop new initiatives and what factors were involved to support or hinder their efforts. This report details the findings of a survey completed in 2004 and compares those results with the original survey of 2002. In 2002, UCSF administered a 58-county survey to inventory access programs and key determinants, as well as assess county unmet needs to launch access programs. The total number of counties responding was 44. Overall, the goal was to increase the understanding of how funders and policymakers might best support counties in their efforts to expand access and thus increase the likelihood of program success. This study broadened understanding of county-level efforts to increase access to care for the uninsured by surveying efforts throughout the state. California counties as a whole have made progress in connecting people to insurance and services. A major challenge is to create insurance coverage programs in an environment that supports coverage expansion in theory but in practice fails to provide adequate resources to launch and/or maintain these efforts. Thus, counties are exploring various strategies, weighing expansion or strengthening of their health systems against coverage approaches. Since UCSF conducted this study in 2002, California counties have experienced some serious financial setbacks that could stymie their efforts to increase access to care for the uninsured. The recent repeal of the vehicle license fee tax increase and hence potential $4 billion shortfall to counties will intensify local debates on the allocation of resources. It is critical to know how these conditions influence counties that were intending to pursue coverage expansions. Many counties are continuing to pursue coverage for children using their Prop 10 4 | CALIFORNIA HEALTHCARE FOUNDATION funds (tobacco tax funds dedicated to children’s competing priorities and budget constraints slow services). Additionally, the 2002 survey surfaced spending. The results of the funding questions some questions on the type of coverage suggest a “leave no stone unturned” approach; expansion approaches being used and actual counties are diversifying their strategies. How- number of enrollees. ever, the question remains as to whether these funding sources are adequate to address the cost To address these issues and deepen our under- of expansions and increase in the uninsured. The standing of county capacity to engage in good news is that access to care for the uninsured significant reform under adverse economic as an issue continues to increase in importance conditions, from March to June 2004, the and has a constituency to support it at the local Institute for Health Policy Studies (IHPS) level (Boards of Supervisors, county agencies, administered a modified version of its 2002 access coalitions, and Prop 10 commissions). survey on county capacity to meet the health care needs of the uninsured. The survey was sent to officials in all 58 California counties. There were two study aims: (1) to inventory county programs to increase access to health care for the uninsured and (2) to assess current constraints and opportu- nities for insurance coverage programs. This survey provides an updated and more detailed inventory of coverage expansions and their respective funding sources, as well as information on key stakeholders and barriers to increased access. The recent data is compared to responses collected in 2002. In June, IHPS conducted follow-up interviews with representatives from 6 counties that indicated high willingness to pursue coverage expansions for children and/or adults in their 2004 survey. This report examines survey responses from 44 California counties and the six follow-up interviews. Overall, the prospects for increasing access to health care for the uninsured at the county level are encouraging despite significant financial constraints. Continued growth can be anticipated in insurance coverage programs for uninsured children, suggesting new possibilities in program types and willingness by a growing number of counties to engage in coverage expansions. However, there may be limited growth in coverage programs for adults. Also, some counties may be stalled in their efforts to enroll people in existing or new coverage programs. Last, service expansions may be slowing as Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 5 II. Methods RESEARCHERS POSTED AN INTERNET-BASED SURVEY and invited responses from representatives of county health agencies (including public health and human services) in all 58 California counties. Our goal was one completed survey per county, with particular emphasis on those counties that had completed a survey in 2002. The first section of the survey asked about county programs to expand access to the uninsured that are underway or being proposed. Researchers asked respondents to identify the resource streams used to fund these services or programs and whether counties would deploy these resources to the four main types of access programs in the future. Addition- ally, respondents were asked to indicate which organizations and stakeholders played an important role in launching these programs, including whether their county had a coalition that focuses on access. Last, they were asked to list local barriers to increasing access to care that are not readily addressed through capacity building as well as the county’s top health issue. The 15-minute survey was completed by agency staff in 44 counties (75.9 percent). While comparable to the 2002 data, seven surveys were completed by counties that did not respond in 2002. Responses appear representative of California counties, including: counties from across the state; rural and urban; provider and non-provider; and all Medi-Cal managed care models. (See Appendix A for a list of responding counties.) Table 1. Respondent County Characteristics (n = 44) CHARACTERISTIC COUNTIES Location Rural 26 Urban 18 Medi-Cal Model Fee-for-Service 22 Two-Plan 12 COHS 8 GMC 2 County Health Care Provider* Yes 13 No 31 Local Coalition Yes 26 No 14 Don’t Know 4 *County-run hospital present. 6 | CALIFORNIA HEALTHCARE FOUNDATION As in 2002, it was found that some counties had difficulties completing the survey because they had to consult multiple staff in the agency, particularly for the funding questions. In 2002 and 2004, some counties reported coverage programs for children and adults that were state- initiated (for example, Healthy Families) or were not insurance programs per se (for example, outreach and enrollment programs). These programs were excluded in the reporting of the data. Quantitative tabulation (ratios and percentages) was done electronically by Zoomerang.com. Qualitative data were clustered by question by Zoomerang. The researchers reviewed these data by county and cross-tabulated most responses by Medi-Cal managed care model, county provider status, presence of a coalition, and urban/rural classification. For the qualitative data, the research team created categories that best described the data and counted the data accordingly. Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 7 III. Summary of Findings County Approaches ■ Diverse. Most counties use diverse approaches to increase access to care. All responding counties in the 2002 and 2004 surveys reported having one or more types of access programs underway, with an average of 4.8 program types per county. ■ Growth. There has been moderate growth in insurance coverage expansions “in place” for children (13 counties, up from 9) and adults (11 counties, up from 7) since 2002. Children’s coverage programs include Healthy Kids programs, California Kids (Cal Kids), Kaiser Permanente’s Child Health Plan-1, and expansions of county programs for the Medically Indigent. Adult coverage programs tend to be more diverse in their target populations and smaller in scope. Moreover, there are more programs for children being “proposed” than for adults (12 counties versus 6), fueled in large part by the availability of Prop 10 funding. The data suggest that growth in coverage expansions will continue to occur but children’s programs will dominate (25 counties). Many respondents (28 counties) indicated some reluctance to pursue coverage expansions for adults in the future. The interview data from 6 counties corroborate this finding. Respondents identified more reasons for launching a children’s coverage program than an adult program, particularly: availability of funding, feasibility, high political support, and low funding needs (compared to adult programs). ■ Medi-Cal managed care plans. These plans appear useful in launching coverage programs for children and adults. Twelve of the 22 Two-Plan, COHS, and GMC counties offered an insurance program for uninsured children whereas only 1 Fee-for-Service county had a coverage program for children “in place.” However, this is not a strictly limiting factor: some counties without a public plan are proposing coverage expansions for children (8 counties) and adults (4 counties). This suggests that there are new possibilities to insuring people such as building on the California Kids (Cal Kids) program or transforming a county’s program for the Medically Indigent into a commercial insurance product. 8 | CALIFORNIA HEALTHCARE FOUNDATION ■ Access coalition. Presence of an access Key Organizations and Stakeholders coalition was noted as playing an “important ■ Public sector. There continues to be role” or “very important role” by many respon- significant public sector and nonprofit dents (29 counties), as in 2002, and counties participation in mobilizing, launching, and with a coalition had more coverage expansions supporting access initiatives at the local level. underway than those counties without However, most responsibility for spearheading coalitions. While many of these counties also access initiatives continues to rest with the have a Medi-Cal managed care plan (Two-Plan county health department (29 counties said or COHS), there are a significant number of it played a “very important” role). Fee-for-Service (FFS) counties that have access coalitions (11 counties). ■ Boards of Supervisors. The findings from the 2004 survey are mixed on the importance ■ Urban vs. rural. Urban counties with of the Board of Supervisors, ranging from coverage programs (11 counties) outnumbered “minor role” (30 percent) to “important role” rural counties with insurance programs for (23 percent) and “very important role” (36 uninsured children and adults (three counties). percent). The findings from the interviews However, many of these urban counties with representatives from 6 counties suggests (10 counties) have a Medi-Cal managed care that support by the Board of Supervisors can plan. On the other hand, many rural counties be key to launching a coverage expansion without a Medi-Cal plan are proposing program, including “no resistance” to coverage coverage expansions for children and/or adults expansions and participation in the planning (8 counties). Other differences are limited; and implementation of a program. rural counties were more active in some areas like consumer education and transportation ■ Coalitions. Similar to 2002, many (26 assistance than urban counties. counties) indicated they had a coalition that specifically focuses on access issues. As noted ■ Steady systems. Similar to 2002, nearly all above, 29 counties thought the coalition study counties have established and/or main- played an “important role” in launching or tained their systems or programs to enroll supporting access initiatives generally. and retain people in existing public insurance programs (39 counties). Many counties (23) ■ Private sector. With the exception of private indicated they had experienced an increase funders (foundations), which were thought to in outreach/enrollment/retention activities play an “important role” (15 counties), private since 2002. sector stakeholders were noted as playing a “minor role” (including insurers, private ■ Service expansion. Service expansions in the providers, and the business community). majority of study counties suggest a continued willingness to meet the strong and sometimes growing health services demand among the uninsured. Many (22 counties) indicated they had increased services since 2002. However, some service expansions, such as “increase in providers,” are experiencing less activity than in 2002. Also, counties were equally split on whether they were considering expanding services in the future (20 counties each). Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 9 Financing Access Initiatives grants (HCAP). Except for the use of Prop 10 ■ The findings from the interviews with 6 funds for children’s coverage expansions, there counties suggests that many counties are does not appear to be one widely used funding “stretched” financially, though to different approach. Similarly, very few respondents degrees. However, these counties indicated indicated their county had developed a that they are committed to expanding sustainable model for funding coverage coverage, particularly for children, and will expansions. pursue these expansions even in the face of county cutbacks. Assisted in large part by the Barriers to Expansion availability of Prop 10 funding and an existing ■ While funding limitations were mentioned by provider safety net, these counties demonstrate 8 counties, “rural issues,” such as poor trans- significant political willingness to allocate and portation between areas, were the most highly maintain funding for coverage programs. rated barrier to access initiatives (32 counties). ■ The majority of funding streams dedicated to This was followed by “competing priorities” access initiatives are state funds that may be and “cultural/social barriers” (25 counties vulnerable to significant cutbacks. However, respectively). One interpretation is that political newer, discretionary funds like Prop 10 funds benchmarks like policymaker commitment (tobacco tax funds dedicated to children’s have been achieved in many counties, as have services) and foundation grants are being resolving service delivery issues, leaving dedicated to access initiatives, with an average challenges that are more practical and of 5.5 funding streams being used (or intended systemic. Interestingly, five of the six county to be used) by counties. interview respondents mentioned state-level factors that had impeded their efforts to ■ Counties have access to a number of resources launch coverage expansions (for example, and strategies, including securing federal funds proposed cuts to the Medi-Cal program). like HRSA Cap Grants, leveraging existing funds like Prop 10 funds to attract new fund- ■ Access to health care services for the uninsured ing, and increased grant-writing. However, is considered “very important” by 26 counties, these funding streams are vulnerable to other having increased in importance in many competing priorities and counties are engaging counties since 2002 (27 counties). It is in multiple strategies, with an average of 3.5 likely to continue to be an important issue strategies being adopted by counties. for county officials. It was the second most important health issue mentioned by ■ The findings from open-ended survey respondents (10 counties), after diseases questions and interviews with 6 counties and/or chronic conditions (14 counties). suggest funding for coverage expansions varies The six interviews corroborated this finding; in type and number. Some counties use two however, counties may vary in their strategy or three funding streams such as Prop 10 to address the needs of the uninsured, with (Children and Families First Commission) some counties more committed to universal and County General Fund Support and other coverage and others committed to increased counties cobble together multiple funding access more broadly defined. streams including Prop 10, County General Fund Support, funding from the Local Initiative, foundation funding, and federal 10 | CALIFORNIA HEALTHCARE FOUNDATION IV. Local Programs to Increase Access to Care Overview of Activity at the County Level In 2002 and 2004, UCSF researchers asked study informants to indicate whether their county had implemented or was proposing to launch a variety of coverage and services expansions. Counties were also asked if there was “no activity” in each area. While only a snapshot of activity, these data provide baseline information against which to compare later on. Also, the “proposed” response category gives us a sense of what to anticipate in the near future. As demonstrated in Table 2 on the following page, access is being taken seriously in nearly all responding counties. All 44 counties reported access initiatives underway, with an average of 4.8 program types in place per county (“proposed” = 2.0 and “no activity” = 4.9).1 The following discussion details each expansion category. Insurance coverage. As indicated in Table 2, we are seeing increased coverage for children and coverage for adults following close behind. However, unlike 2002, in 2004 there are more “proposed” programs for covering children (12 counties versus 4), speaking to the presence of new funding mechanisms like the California HealthCare Foundation’s Step By Step Initiative and Prop 10 funding. Also, fewer counties in 2004 report “no activity” or limited intention to insuring children (19 counties). See Table 3 on page 13 for a listing of counties that have coverage programs “in place” and “proposed” for children and adults. The 2004 findings include all the “in place” coverage programs for children: 7 Healthy Kids programs (Los Angeles, Riverside, San Bernardino, San Francisco, San Joaquin, San Mateo, and Santa Clara); 3 Cal Kids2 programs (Orange, Solano, and Marin); 1 county that uses an insurance approach to their programs for the Medically Indigent (Contra Costa); and 2 counties that have insurance programs targeted to families (Alameda and San Diego). Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 11 Table 2. County Innovations in Place or Proposed to Increase Access to Care for the Uninsured In Place Proposed No Activity PROGRAM 2002 2004 2002 2004 2002 2004 Insurance coverage for children 20% 30% 9% 27% 70% 43% (Healthy Kids, CalKids, MI) (9) (13) (4) (12) (31) (19) Insurance coverage for adults 16% 25% 9% 14% 74% 55% (e.g., IHSS Workers) (7) (11) (4) (6) (32) (24) Managed care for the county indigent Not 30% Not 16% Not 52% Asked (13) Asked (7) Asked (24) Premium subsidies for small employers Not 2% Not 5% Not 70% Asked (1) Asked (2) Asked (31) Information on coverage options 75% 61% 11% 5% 14% 16% (33) (27) (5) (2) (6) (7) Outreach/enrollment/retention in 84% 89% 5% 5% 12% 0% public insurance programs (36) (39) (2) (2) (5) (0) Consumer education 91% 61% 9% 18% 0% 14% (e.g., use of prevention services) (40) (27) (4) (8) (0) (6) Facilities expansions 36% 39% 34% 30% 30% 30% (e.g., clinics) (16) (17) (15) (13) (13) (13) Increase in providers 27% 20% 49% 25% 24% 45% (e.g., specialists) (11) (9) (20) (11) (10) (20) Increase in clinic hours 27% 32% 32% 18% 41% 36% (e.g., weekends) (12) (14) (14) (8) (18) (16) Assistance with transportation 44% 36% 21% 9% 35% 48% (e.g., mini-vans) (19) (16) (9) (4) (15) (21) Appointment system changes 43% 36% 23% 18% 34% 25% (19) (16) (10) (8) (15) (11) “Insurance-like” programs Not 20% Not 9% Not 55% (e.g., bundling of county health services, Asked (9) Asked (4) Asked (24) lower out-of-pocket fees) 12 | CALIFORNIA HEALTHCARE FOUNDATION Table 3. County-Level Insurance Coverage for Children and Adults Ineligible for Public Insurance C H I L D R E N A D U L T S In Place (13) Proposed* (12) In Place (11) Proposed (6) • Alameda (Family Care) • Del Norte† • Alameda • El Dorado • Contra Costa (Basic Care) • El Dorado† • Contra Costa • Lassen • Los Angeles (Healthy Kids) • Kern • Los Angeles† • San Bernardino • Marin (CalKids) • Mendocino • Napa • Santa Barbara† • Orange† (CalKids) • Plumas • Sacramento • Sutter • Riverside (Healthy Kids) • Sacramento • San Diego • Tuolumne • San Bernardino (Healthy Kids) • San Benito • San Francisco • San Diego (Child Health Plan-1‡, FOCUS§) • San Luis Obispo† • San Joaquin • San Francisco (Healthy Kids) • Santa Barbara • San Mateo • San Joaquin (Healthy Kids) • Santa Cruz†# • Santa Clara • San Mateo (Healthy Kids) • Sonoma† • Solano • Santa Clara (Healthy Kids) • Ventura • Solano (CalKids) * The 2004 survey precluded reporting of coverage expansions that were “in place” and “proposed” such as the coverage expansions for youth that are underway and being proposed in Santa Clara, Orange, and Los Angeles. Combining the 2004 survey results and information on counties in the planning stages from the Child and Family Coverage Technical Assistance Center, in all likelihood the number of “proposed” coverage expansions for children ranges from 16 to 23 counties. † Step by Step Planning and Implementation Grantees. Except for Ventura and Fresno, most respondents appeared to be familiar with the Step by Step programs being proposed in their county. ‡ Child Health Plan-1, a Kaiser Permanente program available to children with incomes between 250 and 300 percent of FPL, is accepting enrollees from San Diego County. § The FOCUS program is unique in that it receives no public support and is an employer-based health insurance program for low-income employees and their families. The program is closed to enrollment at this time. # Since the 2004 survey findings were tabulated, Santa Cruz has implemented its insurance program for children. Managed care for the county indigent. This Access to information. While many study was a new category in the 2004 survey. The counties may not offer coverage for children findings corroborate the observation in 2002 and/or adults, most counties in 2002 and 2004 that counties do have some flexibility with their try to connect people to public and private CHIP/CMSP programs and are willing to engage insurance programs by providing information in reforms such as enrolling the indigent in on options (27 counties). managed care plans (13 counties). Outreach, enrollment and retention. Mirroring Premium subsidies for small employees. This the 2002 results, many study counties have was a new category for the 2004 survey. There outreach/enrollment/retention programs in place, is limited activity to provide premium assistance probably driven in large part by the Healthy to small employers, reducing the barriers to Families program (39 counties). coverage for adults and their dependents (1 county). Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 13 Consumer education. Similar to 2002, most Key Factors for Having Programs study counties in 2004 reported being involved “In Place” in educating consumers on accessing the health In 2002, we sorted the data by Medi-Cal care system, such as using preventive services managed care model, provider status (whether a (27 counties). county has a public hospital), and presence of an Service expansions. There continues to access coalition, to examine whether these factors be quite a bit of activity underway or proposed were important in launching a particular type of in all types of service expansions, though many access initiative. For the 2004 survey, we added like “increase in providers” and “assistance with another variable — rural/urban — and ran a series transportation” have a higher level of “no of cross-tabulations to see which variables might activity.” Expansions related to clinics appear be important for the proposing and implement- to be an area of increased activity compared ing the 13 access program types described above to the 2002 data (14 to 17 counties). (see Table 5). The findings are divided by factors important to “in place” programs and factors “Insurance-like” programs. This was a new that are important to “proposed” programs. It is category in the 2004 survey. We inventoried important to note, however, that there is overlap county programs that on the surface resemble in some of these factors; that is, many counties insurance programs; that is, they have enrollees that have a Medi-Cal managed care plan also and bundle county services but do not have have a county-run hospital, making it difficult insurance premiums. Interestingly, there is to clearly attribute change in a county access moderate activity in this area (“in place” and program to a particular factor in some cases. “proposed”), suggesting interim strategies to For example, 8 Two-Plan counties also have an coverage expansions (9 counties). access coalition, making it difficult to ascribe Other programs. Eighteen counties cited “other” more responsibility for one factor than another approaches to increasing access to care for the (see Table 4). However, there are some cases uninsured, including: where one factor dominates, suggesting it plays a role in formulating or implementing a particular ■ Expansions on existing coverage programs type of access approach. (2 counties and 4 programs) ■ Dental expansions Table 4. Key County Factors by Medi-Cal Model (2 counties and 2 programs) Location Provider? Access Coalition? ■ Service expansions MODEL Urban Rural Yes No Yes No Don’t Know (2 counties and 2 programs) FFS 2 20 2 20 11 9 2 ■ Pharmacy expansions Two-Plan 10 2 9 3 8 3 1 (3 counties and 3 programs) COHS 4 4 2 6 6 2 0 GMC 2 0 0 2 1 0 1 14 | CALIFORNIA HEALTHCARE FOUNDATION Table 5. Key Factors in Determining Access Approaches — In Place Programs, 2004 Medi-Cal Model Provider Access Coalition Location FFS Two-Plan COHS GMC Yes No Yes No Urban Rural IN PLACE PROGRAM (22) (12) (8) (2) (13) (31) (26) (14) (18) (26) Insurance coverage for children 1 8 3 1 9 4 11 1 11 2 (not incl. S-CHIP or Medi-Cal) Insurance coverage for adults 0 6 3 2 7 4 9 1 9 2 (e.g., IHSS Workers) Managed care for the county 4 3 5 1 3 10 9 3 6 7 indigent Premium subsidies for small 0 0 0 1 0 1 1 0 1 0 employers Information on coverage options 12 7 8 2 8 19 20 5 12 15 Outreach/enrollment/retention 18 12 7 2 12 27 24 12 16 23 in public insurance programs Consumer education 15 8 3 1 7 20 14 10 8 19 (e.g., use of prevention services) Facilities expansions 7 6 4 0 8 9 10 4 9 8 (e.g., clinics) Increase in providers 6 3 0 0 4 5 5 2 4 5 (e.g., specialists) Increase in clinic hours 6 6 2 0 5 9 9 3 6 8 (e.g., weekends) Assistance with transportation 9 5 2 0 5 11 12 2 6 10 (e.g., mini-vans) Appointment system changes 6 7 3 0 9 7 8 0 9 7 “Insurance-like” programs 2 6 1 0 5 4 3 1 6 3 (e.g., bundling of county health services, lower out-of-pocket fees) Medi-Cal Model same for coverage programs for adults, with 11 Insurance coverage. In 2002, we found that Two-Plan, COHS, and GMC counties offering counties with a public plan (Two-Plan and coverage programs for adults. No FFS counties County Organized Health System, or COHS) reported having a coverage program for adults. were more likely to have an insurance program While many counties with a public plan (Two- for children and/or adults compared to Fee-for- Plan or COHS) are also provider counties and/or Service (FFS) counties. The preliminary results have a local access coalition, many of these from the 2004 survey are similar. Of the 22 counties (10 out of 13 counties) with “in place” Two-Plan, COHS, and Geographic Managed coverage programs for children rated the County Care (GMC) counties, 12 offered an insurance Medi-Cal Plan as “very important” in launching program for uninsured children whereas only 1 or supporting access initiatives. Similarly, many FFS county (Marin) had a coverage program for Two-Plan and COHS counties (14 counties) children “in place.” The results were roughly the indicated they had experienced increased activity Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 15 in insurance coverage for children since 2002 Provider Status compared to FFS counties (6) and provider We also cross-tabulated the coverage/services data counties (7). Last, more counties with a public by county provider type, specifically whether a plan indicated they were considering future county had a public hospital or not. coverage programs for children (14 counties) compared to FFS counties (10) and provider Coverage expansion. In 2002, more counties counties (9). In short, having a public plan is with public hospitals reported having more important for launching a children’s coverage coverage programs for children and adults than program but it may not be the limiting or only non-provider counties. This was probably due factor. Counties without a public plan can also to the fact that most provider counties also had consider expansions via the CalKids program or public plans (10 out of 15 counties). However, their program for the Medically Indigent. in 2004, this trend was not so pronounced, with some non-provider counties having or proposing Managed care for the county indigent. More coverage programs (for example, 4 non-provider counties with public plans had programs in place counties have youth coverage programs “in (9 counties) compared to FFS counties (4) though place”). Additionally, representatives from the difference isn’t as great as that seen with counties without a public hospital indicated they coverage for children and adults. This approach have experienced an increase in activity to cover holds potential for all types of counties. children (7 out of 20 counties) and adults (3 out Premium subsidies for small employers. No or of 6 counties). Having a public hospital may be minimal activity across all county types. less important than other factors. Access to information. There were modest Managed care for the county indigent. This was differences among the four Medi-Cal model a new category in the 2004 survey. More counties types in 2002 and 2004, with all types of without a county hospital had programs “in counties reporting access initiatives underway. place” than provider counties (10 versus 3). Information, outreach, and education. There Premium subsidies for small employers. This were modest differences among the four model was a new category in the 2004 survey. There types of counties in 2002 and 2004, with all was minimal activity in this area. types of counties reporting efforts to reduce the Information, outreach, and education. Like barriers to coverage programs. the Medi-Cal model data, there was a modest Service expansions. In 2002, Two-Plan counties difference between the two types of counties, reported more activity underway in many service with many counties of both types reporting expansion areas compared to COHS and FFS initiatives underway in 2002 and 2004. counties. However, many of these counties are Service expansions. As would be expected, of also provider counties and have a public hospital. the 13 counties that have a county-run health In 2004, service expansions of all types are fairly care delivery system, 8 counties indicated they common in all types of counties. Medi-Cal have service expansions “in place.” Unlike 2002, model type may play a limited role in this regard. non-provider counties had service expansions Insurance-like programs. Two-Plan counties are underway in many categories (9 counties). the most active in this area, though it could be Also, 11 counties were “proposing” facility those counties with a public hospital. expansions. This may be an area where counties have greater flexibility in contracting with private-sector providers. 16 | CALIFORNIA HEALTHCARE FOUNDATION Insurance-like programs. This was a new Service expansions. Counties with coalitions category in the 2004 survey. Provider and non- were moderately more involved in service provider counties were equally active, which spoke expansions than counties without coalitions. to the relative ease of bundling county services. However, 10 of these counties also provide county-run health care services. Presence of an Access Coalition Insurance-like programs. Counties with access We were also interested in the role played by coalitions were the only ones active in this area, local coalitions that focus on access and whether though it might be due to having county-run they make a difference in the level of activity health care services (3 counties). being reported. Insurance coverage. Counties with an access Urban Versus Rural Counties coalition have significantly more coverage activity We were also interested in whether being an underway targeted to adults and children than urban or rural county made a discernable those counties without a coalition. While the difference to the access approaches undertaken. difference is striking, many counties that have There were modest differences across all an access coalition also have a public Medi-Cal programs types, with urban counties sometimes Plan (14 out of 20). Though these results are being more active in some areas (insurance inconclusive, counties with insurance programs coverage and some service expansions) and for children “in place” indicated that a local rural counties being more active in other areas coalition played an “important role” or “very (outreach/enrollment/retention and some service important role.” More counties with an access expansions). Many urban counties with coverage coalition also reported increased activity to insure expansions also had Medi-Cal managed care plans children than counties without a coalition (15 (9 counties). The most noticeable difference was versus 4). Similarly, many counties that have in the number of rural counties “proposing” a local coalition indicated they were considering coverage expansions, with 8 counties without a pursuing coverage programs for children and Medi-Cal managed care plan indicating they adults (7). In short, having an access coalition were considering or planning coverage may facilitate coverage expansions, particularly expansions. for children. Managed care for the county indigent. Similar to the coverage expansions, counties with a coalition were more active in this area. Premium subsidies for small employers. There were limited differences, with no counties engaging in this activity. Information, outreach, and education. Though counties with and without access coalitions indicated they are very involved in these activities, counties with an access coalition were more active in providing “information on coverage options” compared to counties without an access coalition. Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 17 V. Key Leaders and Stakeholders TO BETTER UNDERSTAND THE ORIGINS OF THESE access programs and whether there has been any change in the key players since 2002, we asked study respondents in the 2004 survey to indicate the importance of key organizations or stakeholders in mobilizing, launching, and supporting access initiatives. As described in Table 6 on the following page, with the exception of the important role being played by Prop 10 Commissions, there have been modest changes since 2002. Public agencies and policymakers continued to be cited as playing an “important role” or “very important role.” Of the 16 counties that said the Board of Supervisors played a “very important role,” 10 counties had a children’s coverage program “in place.” While the Boards of Supervisors continued to play a “very important role,” more counties in 2004 thought Supervisors played a “minor role” than in 2002, including two counties with a coverage program for children. Nonprofit organizations such as community health centers and CBOs continued to play an “important role.” With the exception of private funders, the private sector including insurers, providers and the business community played “no role” or a “minor role.” The only noticeable change was a decrease in the perceived importance of the Community at Large, shifting from an “important role” in 2002 to a “minor role” in 2004.3 18 | CALIFORNIA HEALTHCARE FOUNDATION Table 6. Importance of Roles in Mobilizing, Launching, and Supporting Initiatives No Role Minor Important Very Important N/A O R G A N I Z AT I O N / S TA K E H O L D E R 2002 2004 2002 2004 2002 2004 2002 2004 2002 2004 Board of Supervisors 7% 7% 20% 30% 28% 23% 43% 36% 2% 5% (3) (3) (9) (13) (12) (10) (19) (16) (1) (2) County Health Agency 2% 0% 2% 7% 25% 27% 70% 66% 0% 0% (1) (0) (1) (3) (11) (12) (31) (29) (0) (0) County Human Services Agency 2% 2% 16% 16% 27% 45% 41% 34% 11% 2% (1) (1) (7) (7) (12) (20) (18) (15) (5) (1) County Medi-Cal plan 14% 14% 14% 5% 16% 23% 25% 30% 27% 30% (e.g., LI, COHS) (6) (6) (6) (2) (7) (10) (11) (13) (12) (13) Non-county community 5% 5% 12% 11% 36% 39% 36% 41% 7% 5% health centers (2) (2) (5) (5) (16) (17) (16) (18) (3) (2) Community-based organizations 2% 0% 14% 25% 48% 50% 36% 23% 0% 2% (1) (0) (6) (11) (21) (22) (16) (10) (0) (1) Local coalition 7% 11% 5% 9% 43% 36% 34% 30% 11% 14% (3) (5) (2) (4) (19) (16) (15) (13) (5) (6) Prop 10 Commission Not 5% Not 11% Not 48% Not 34% Not 2% Asked (2) Asked (5) Asked (21) Asked (15) Asked (1) Private insurers 34% 32% 20% 27% 18% 14% 2% 9% 20% 18% (15) (14) (9) (12) (8) (6) (1) (4) (9) (8) Private providers 14% 27% 41% 27% 32% 25% 7% 7% 5% 14% (6) (12) (18) (12) (14) (11) (3) (3) (2) (6) Private funders 23% 23% 30% 25% 33% 34% 7% 7% 7% 11% (e.g., foundations) (10) (10) (13) (11) (14) (15) (3) (3) (3) (5) Business community 39% 41% 39% 39% 9% 7% 2% 0% 9% 14% (17) (18) (17) (17) (4) (3) (1) (0) (4) (6) Community-at-large 16% 27% 36% 41% 39% 18% 2% 2% 5% 11% (7) (12) (16) (18) (17) (8) (1) (1) (2) (5) Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 19 Similarly, we asked respondents in 2002 and Table 8. Presence of an Access Coalition 2004 to identify the agency or organization 2002 2004 responsible for spearheading access initiatives in Yes 53% 59% their counties. Again, public sector involvement (23) (26) dominates, lead by the local health care or public No 35% 32% health agency. However, the county agency is (15) (14) joined by many other organizations as indicated Unsure 12% 9% in Table 7. Community clinics or related (5) (4) organizations like clinic consortia were more frequently mentioned in 2004 than 2002. In summary, while public sector players, Table 7. Key Organizations in Launching Access particularly the health care agencies, are the Initiatives key players in spearheading access initiatives, 2002* 2004 † they are joined by many stakeholders from the Health care or health services agency 26% 58% public and nonprofit sector. With the exception of private funders, United Way, hospitals and Prop 10 commission 10% 47% safety-net clinics, the private sector continues to Community health centers or 8% 21% be largely unrepresented in access initiatives. related organizations Public health department 10% 18% Medi-Cal public plan 5% 18% Coalitions or collaboratives 13% 16% * Respondents were not required to answer this question in 2002 but they were in 2004, resulting in a significantly larger sample of respondents in 2004 (38 counties). † These represent very rough estimates. Some respondents listed organizations that were not easily categorized because of an ambiguous name. We inquired about the existence of cross- organization coalitions that focus specifically on access issues in the 2002 and 2004 surveys. The findings in Table 8 are very similar to the 2002 findings, with 55 to 60 percent of responding counties indicating their county has an access coalition. As we indicated in our earlier study, these coalitions may serve as a good target for capacity building activities, mobilizing support, and creating momentum for change. 20 | CALIFORNIA HEALTHCARE FOUNDATION VI. Funding Programs to Increase Access to Care IN 2002 AND 2004, WE ASKED RESPONDENTS TO check those funding streams used to finance access programs. Listed in order of highest response rate in Table 9, we see that there are few changes from 2002, with Prop 10 funds once again in the lead. Counties rely on multiple funding streams (average of 5.4). The only noticeable changes are the increased importance of private foundation funds and federal funds. New funding streams such as hospital, United Way, and Local Initiative (LI) funds are also of importance. Eight respondents included “other” funding streams including state and federal funding, specific foundations, and local funders. (See Appendix B for a description of these funding streams.) If we separate each funding stream by its origin — federal, state, county/local and private — we see that funding for access initiatives is coming mostly from the state and local levels, though federal funding is increasingly important. Business community contributions are modest, with limited increase since 2002. We were also interested in knowing whether funding streams varied by county type, particularly those counties undertaking coverage expansions for children or adults, Medi-Cal model, presence of an access coalition, and provider type. Our cross- tab analysis indicated that there were a few differences among county types. Interestingly, more counties with an access coalition said they used foundation funds and federal funds compared to those counties without a coalition. Additionally, more FFS counties rely on Realignment funding than counties with a Medi-Cal managed care plan. Last, nearly all county types were pursuing foundation funding. (See Appendix C.) Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 21 Table 9. Key Funding Streams for Access Initiatives Responses Response Rate FUNDING STREAM 2002 2004 2002 2004 Prop 10 — Children and Families First Commission 35 35 81% 80% Realignment Funds 33 29 77% 66% CHIP/CMSP (Medically Indigent) 33 29 77% 66% Tobacco Settlement Funds 23 24 53% 55% Private Foundation Funds 22 27 51% 61% Other County General Funds 20 19 47% 43% Federal funds (e.g., HRSA Cap Grants) 18 29 42% 66% Hospital or hospital district funds N/A* 14 N/A 32% United Way N/A 10 N/A 23% Business community contributions 5 7 12% 16% Other 15 7 35% 16% Local Initiative or COHS Savings N/A 6 N/A 14% *Not asked during 2002 survey. In the 2004 survey, we asked respondents to respondents. Additionally, the findings suggest characterize the resources to which they had that many counties are employing multiple access. The findings in Table 10 mirror the strategies (3.5 strategies). Interestingly, though findings in Table 9, providing a more nuanced the business community is perceived as playing description of how counties are securing funds. a minor role in access initiatives, it is being Leveraging Existing Funds and Increased Grant approached by a significant number of counties Writing were checked off by most of the (14) to fund these initiatives. Last, eight Table 10. Resources/Strategies to Fund Access Programs, 2004 R E S O U R C E / S T R AT E G Y Responses Response Rate Leveraging existing funds, like Prop 10 funds, to attract new funding 35 80% Increased grant writing (e.g., local foundations) 34 77% Recommending allocation of Tobacco Settlement funds 22 50% Securing federal funds (e.g., HRSA HCAP grants) 18 41% Approaching the business community 14 32% Using Healthy Families unused funds to leverage federal funds 11 25% Applying savings from other areas (e.g., from the Local Initiative) 7 16% Other 8 18% Tapping into existing county funds that haven’t been used in the past 6 14% 22 | CALIFORNIA HEALTHCARE FOUNDATION respondents mentioned “other” strategies to In summary, while counties still have some which their county had access, some of which funding sources from which to choose and they may merit monitoring for the future such as local are working to expand these choices; that is, measures, privatization of county clinics and they are shifting their sights to private donors ancillary services, and Medi-Cal Administrative such as foundations. Additionally, counties are Activities (MAA) funding. resourceful in how they secure these dollars; using strategies like leveraging, grant writing, Next, we asked respondents in the 2004 survey to and influencing the allocation of funds. Also, indicate how they were intending to deploy these there is still some willingness to deploy these resources and whether they would fund coverage resources for coverage programs but it appears and service expansions. The findings in Table 11 to be limited to children’s programs. Finally, reinforce the findings described above, namely, many counties were not proposing service children’s coverage programs are more likely to expansions, which spoke to diminishing resources be undertaken than adult coverage programs. or decreased unmet need due to increased Outreach/enrollment/education programs were spending in this area in recent years.4 holding steady. Service expansions are anticipated in less than half of the respondent counties. Table 11. Programs Being Considered by Respondent Counties, 2004 PROGRAM YES NO DON’T KNOW Insurance coverage for children 57% 27% 16% (25) (12) (7) Insurance coverage for adults 16% 64% 20% (7) (28) (9) Outreach/enrollment/retention 66% 32% 2% (29) (14) (1) Service expansions 45% 45% 9% (e.g., clinics, providers) (20) (20) (4) Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 23 VII. Barriers to Expansions IN 2002, WE ASKED RESPONDENTS TO IDENTIFY THE barriers that could not be addressed through capacity-building resources such as structural hurdles, low political commitment, etc. We clustered responses by six types of barriers: ■ Funding/resource limitations (15) ■ Health care delivery system (8) ■ Political barriers (7) ■ Providers (6) ■ Public insurance (5) ■ Target population/consumer (5) ■ Geography (3) To get a more precise understanding of how many counties are challenged by these barriers, we asked respondents in the 2004 survey to check of those barriers that applied to their county. Interestingly, as described in Table 12, rural issues are important in urban and rural counties, outweighing the other barriers. The second most cited barrier, competing priorities, suggests that there is increased competition for increasingly limited resources. Also, political barriers are less of a barrier than other barriers, suggesting that engagement and commitment of local policymakers have been addressed in many counties though it remains a significant barrier in others. Twelve respondents mentioned “other” barriers, primarily lack of resources or fund- ing (8 counties) and lack of services; for example, declining specialist participation in indigent care (4 counties). 24 | CALIFORNIA HEALTHCARE FOUNDATION Table 12. County-level Barriers to Increasing Access to Care for the Uninsured: 2004 B A R R I E R T O A C C E S S I N I T I AT I V E S Responses Response Rate Rural issues (e.g., poor transportation between areas) 32 74% Competing priorities 25 58% Cultural/social barriers (e.g., language barriers) 25 58% Health care delivery system (e.g., difficulty in developing coverage contracts) 20 47% Political barriers 17 40% Other 12 28% Low stakeholder engagement (e.g., lack of coalition focused on access) 11 26% Limited technical expertise 9 21% Additionally, we asked respondents to identify Additionally, we asked respondents whether their top health issue because this may influence access to health care for the uninsured had their choice of access initiatives. While diseases changed in importance since 2002 when the and chronic conditions like obesity and cancer state budget was less of an imminent threat to were most frequently cited (14 counties), access county budgets and the earliest coverage to health care services (9) and access to insurance expansions were just being launched. Many coverage (5), and access more generally (4) were respondents (25 counties) indicated that access mentioned by counties. Other issues included: to health care had increased in importance. adequate funding (6 counties), availability of A lesser number (16 counties) indicated “no health care services (3), and demographics, such change” since 2002. Two respondents indicated as an aging population (1). that access to health care for the uninsured had decreased in importance since 2002. To get a sense of the relative importance of access to health care services for the uninsured to other In summary, while access to care for the health issues, we asked respondents to rate access uninsured is high on the county health agenda, to health care services on a scale of 1 to 4, where systemic and geographic barriers may impede 1 means not important and 4 means very progress in this area. Growing competition from important. The results in Table 13 suggest that other sectors and increased willingness to seek access to care for the uninsured continued to resources from new funding sources suggest carry significant weight. counties are under greater fiscal pressure than they were in 2002. However, access to care for the uninsured continues to grow in importance Table 13. Importance of Access to Care for in the face of these constraints, increasing the Uninsured Relative to Other Health Issues likelihood of hard trade-offs if economic relief is not forthcoming. RESPONSES R AT E Not important 0 0% Less important 2 5% Important 16 36% Very important 26 59% Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 25 VIII. County Coverage Expansions IN THE 2004 SURVEY, WE ASKED RESPONDENTS TO describe their coverage expansions that were underway and those being considered. Specifically, we asked them to describe the target populations, funding sources, and role of the Medi-Cal managed care plan where applicable. Though these results were not representative of counties as a whole (23 out of 44 respondents completed this section of the survey), they corroborated many of the findings above, including: ■ Most programs underway for children tend to resemble Santa Clara’s Healthy Kids program though there are other expansions (for example, dental or CalKids). ■ Programs for adults are more varied by target population. Some adult coverage programs are CMSP/CHIP expansion and some are targeted to IHSS workers. ■ Additionally, most children’s programs involve multiple funding sources but this is not always the case for adult coverage programs, with foundation support not being mentioned. ■ Though the Medi-Cal public plan is an important player, expansions are underway or being considered in FFS counties that do not have a public plan. 26 | CALIFORNIA HEALTHCARE FOUNDATION Table 14. Counties Where Coverage Is Underway and/or Being Considered CHILDREN’S INSURANCE PROGRAMS A D U LT I N S U R A N C E P R O G R A M S Underway (9) Being Considered (11) Underway (5) Being Considered (4) • Alameda (2) • Del Norte • Alameda • Lassen • Marin • El Dorado • El Dorado • Mendocino • Riverside • Kern • Sacramento • Sacramento • San Bernardino • Mendocino • San Francisco • San Francisco • San Francisco • Orange • Solano • San Mateo • Sacramento • Santa Clara • San Francisco • Solano • Santa Barbara • Tuolumne (Dental) • Santa Cruz* • Sonoma • Tuolumne * Since the 2004 survey findings were tabulated, Santa Cruz has implemented its insurance program for children. Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 27 IX. Follow-up Interviews TO BETTER UNDERSTAND WHY SOME COUNTIES continue to pursue coverage expansions under adverse financial conditions, we interviewed representatives from 6 counties that have maintained (or increased) their commitment to launching insurance programs for uninsured children and/or adults. Using the 2004 survey data, we identified 6 counties that met the following the criteria: ■ Had implemented or were proposing an insurance program; ■ Had experienced an increase in coverage activity during the last two years; and ■ Had indicated they were considering allocating resources on coverage in the future. We identified the following counties: Adults ■ El Dorado (proposing, FFS County) ■ San Francisco (implemented, Two-Plan County) Youth ■ El Dorado (proposing, FFS County) ■ Kern (proposing, Two-Plan County) ■ Marin (implemented, FFS County) ■ Riverside (implemented, Two-Plan County) ■ San Francisco (implemented, Two-Plan County) ■ Santa Cruz (proposed, COHS County) We conducted 30-minute phone interviews with representatives from the county health agency or First Five Commission (Kern County), specifically those individuals that completed the 2004 survey. All interviews were transcribed, coded, and analyzed for cross-cutting themes and commonalities/ differences. The following is a summary and discussion of these findings. Facilitating Factors in Last Two Years Respondents mentioned five factors that had facilitated their efforts: 1. Political support (5 counties); e.g., high Board of Super- visors commitment to increased access or universal coverage 28 | CALIFORNIA HEALTHCARE FOUNDATION 2. Availability of funding (5 counties); ■ The importance of addressing health issues e.g., First Five Commission, foundation, of younger generation, e.g., immunizations County General Funds ■ The importance of an early success in 3. Commitment more generally (3 counties); expanding coverage more broadly e.g., cross-organizational desire to address Other reasons for pursuing coverage expansions health needs of children early on more generally included: 4. Involvement of Medi-Cal managed ■ Availability of funding care plan (2 out of 4 counties); e.g., Santa Cruz and San Francisco5 ■ Primary care services in place 5. Alignment of Key Factors (2 counties); e.g., good alignment between First County Political Environment Five Commission and county desire All respondents indicated their county enjoyed to expand access policymaker (Board of Supervisor) support Additionally, all respondents spoke to a deep though this support varied from “no resistance” commitment to increased access to care for the to being a “trend-setter.” There were modest uninsured, with three counties indicating they differences in their commitment and involve- were committed to universal coverage (Marin, ment, with one respondent indicating that San Francisco, and Santa Cruz. While El Dorado coverage expansion was something a conservative may be in the “proposed” stages, it has not made Board could support because of the impetus a firm commitment to developing an insurance from constituents. product. Similarly, some counties like Kern and Other dimensions of the political environment Riverside are focusing primarily on children and noted by respondents included: have expressed a high commitment to maintain- ■ Agency involvement ing or expanding health care services. This could be an important distinction and may be useful ■ Recognition and support for addressing in determining the likelihood of coverage needs of the uninsured expansions for children and adults. ■ Policymaker willingness to allocate resources Why Pursue Coverage Expansions? Changes in County Ability to In addition to having a strong desire to address Finance Coverage Expansions the needs of the uninsured more generally, our We asked respondents to comment on whether respondents indicated they were very committed their county had experienced any changes in to reducing the barriers to health care for their ability to finance coverage expansions in children, citing the following reasons: the last two years, such as decreased funding or ■ Children are seen as a good investment appearance of new funding. Not surprisingly, 4 counties (Marin, Santa Cruz, Riverside, ■ High political willingness to “leave no and San Francisco) described their county as child behind” “stretched” or challenged financially. However, ■ “People can get behind youth” all counties indicated there was continued ■ Children were identified in a county commitment to finance coverage expansions. assessment study Only Riverside County reported that it had ■ Children are cheaper and easier to insure capped its Healthy Kids Program. Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 29 There were some differences across counties in ■ Availability of Federal funds; e.g., Healthy the number and type of funding sources being Communities Access Program (HCAP) dedicated to coverage expansions, with Kern and clinic Federally Qualified Health Center County indicating that Prop 10 funds are the 330 expansion grants (1 county). only funds available to them. Two counties mentioned leveraging funds; that is, Tobacco Impeding Factors Settlement funds, cobbling together funds from different sources, and grant-writing. Nearly all counties (5) mentioned state-level factors that have impeded their efforts to expand Interestingly, only one respondent, San Francisco, coverage, including: spoke to developing a sustainable model for ■ Proposed cuts to the Medi-Cal program funding its coverage expansions, relying on (3 counties) County General Fund Support and Prop 10 funding (not Realignment or Tobacco funds). ■ State budget; e.g., repeal of the Vehicle The county has increased funding for its Healthy License Fees increase and give back to Kids program in the face of significant budget the state (1 county) cutbacks, suggesting that the program may be ■ Limited state capacity; e.g., working on less vulnerable to cuts. However, San Francisco waivers submitted to the federal government may be unique because of its combined city/ (1 county) county structure and enjoys some structural and Only 1 county (Kern) indicated there were no political advantages. By comparison, Riverside factors stopping or impeding its progress and County has a similar funding stream approach — 1 county (Riverside) mentioned changing County General Fund Support, Local Initiative, demographics. and a local foundation — but it indicated its county funds are at risk. In summary, the findings from the interviews corroborate many of the 2004 survey findings, namely that there are fewer barriers to coverage Facilitating Factors expansions for children though the state budget Respondents identified a handful of external and county finances may impede these efforts. factors that had facilitated county-level coverage Interestingly, while most coverage programs for efforts: youth are modeled on the Santa Clara Healthy ■ Availability of funding/Prop 10 Commission Kids program, there are some significant (2 counties); differences in funding these programs, ranging ■ Presence/assistance from other counties from relying on two or three sources of funding like Santa Clara (2 counties); to assembling multiple sources of funding. However, they all share in common the use of ■ Role of technology (1 county); Prop 10/First Five funding. Similarly, there is no one sustainable funding approach though San Francisco’s model holds promise. Last, coverage expansions in general may enjoy a limited “immunity” to larger financial pressures — there are other available funding sources and at worst, the county response has been to cap the Healthy Kids program (Riverside and Santa Clara). 30 | CALIFORNIA HEALTHCARE FOUNDATION X. Conclusion: Future Expansions LAST, WE WERE INTERESTED IN ASSESSING THE likelihood of future expansions, particularly coverage program. In 2002, the study findings suggested that counties that had assets that directly contribute to coverage and/or service expansion such as a local plan or public hospital were likely to proceed with these expansions. However, the 2004 data on “proposed” programs suggest that counties that don’t have these assets ARE also willing to expand coverage for children and adults. We cross-tabulated the access program types with the key factors to see whether some counties were more predisposed than others to expand specific types of programs. As indicated in Table 15, 8 Fee-for-Service counties are proposing to launch an insurance program for children and 4 FFS counties are considering coverage expansions for adults. Having a Medi-Cal public plan may be less important as other insurance models are considered such as piggybacking on CalKids to expand coverage for children. Having a county-run hospital and being an urban/rural county may be less important to proposing a coverage program for children and adults than the availability of funding like Prop 10 funding. Also, having an access coalition may be moderately important in those counties proposing to expand coverage. Similarly, service expansions are being considered by FFS and non- provider counties. Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 31 Table 15. Key Factors in Determining Access Approaches – Proposed Programs, 2004 Medi-Cal Model Provider Access Coalition Location FFS Two-Plan COHS GMC Yes No Yes No Urban Rural PROPOSED PROGRAM (22) (12) (8) (2) (13) (31) (17) (7) (18) (26) Insurance coverage for children 8 1 2 1 2 10 8 3 5 7 (not incl. S-CHIP or Medi-Cal) Insurance coverage for adults 4 1 1 0 2 4 4 1 2 4 (e.g., IHSS Workers) Managed care for the county 4 2 0 1 1 6 4 2 3 4 indigent Premium subsidies for small 2 0 0 0 0 2 2 0 0 2 employers Information on coverage options 0 2 0 0 1 1 1 1 1 1 Outreach/enrollment/retention 1 0 1 0 0 2 2 0 1 1 in public insurance programs Consumer education 3 2 2 1 3 5 6 1 6 2 (e.g., use of prevention services) Facilities expansions 6 3 2 2 1 12 9 3 4 9 (e.g., clinics) Increase in providers 5 2 3 1 1 10 8 2 3 8 (e.g., specialists) Increase in clinic hours 4 1 2 1 1 7 7 1 3 5 (e.g., weekends) Assistance with transportation 2 1 0 1 1 3 1 2 2 2 (e.g., mini-vans) Appointment system changes 5 2 0 1 1 7 4 3 2 6 “Insurance-like” programs 2 1 0 1 1 3 4 0 2 2 (e.g., bundling of county health services, lower out-of-pocket fees) Additionally, we asked respondents in the 2004 Interestingly, some counties experienced a survey to indicate whether their county had decrease in outreach/enrollment/retention experienced a change in the amount of activity activities, which could be due to significant since 2002 in the four major types of access success and decreased need for these programs or programs. As described in Table 16, while some difficulty in securing funding for these activities. counties experienced “decreased” activity in the four program types, many counties experienced “increased” or “no change” in activity in all areas. Coverage for adults saw the least amount of change compared to the other three areas. 32 | CALIFORNIA HEALTHCARE FOUNDATION Table 16. County Perception of Change in Access Activities Since 2002 PROGRAM Decreased Activity Increased Activity No Change Unsure Insurance coverage for children 11% 45% 36% 7% (5) (20) (16) (3) Insurance coverage for adults 16% 14% 57% 14% (7) (6) (25) (6) Outreach/enrollment/retention 20% 52% 18% 9% (9) (23) (8) (4) Service expansions 16% 50% 30% 5% (e.g., clinics, providers) (7) (22) (13) (2) More broadly, the data suggest that we can anticipate continued growth in insurance coverage for children and modest growth in insurance coverage for adults. Also, while having a Medi-Cal managed care plan may facilitate coverage expansions in these counties, an increasing number of FFS counties are offering coverage and are restructuring their programs for the Medically Indigent. Also, most counties have established systems or programs to connect people to existing public insurance programs. Last, the continued emphasis on service expansions in all county types suggests growing demand and a willingness to meet this demand in most areas. Significant public support for expanding access to care using coverage approaches and new funding sources may be expanding the possibility for coverage expansions beyond what was anticipated in 2002. Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 33 Appendix A: Responding Counties Alameda San Bernardino Butte San Diego Contra Costa San Francisco Del Norte San Joaquin El Dorado San Luis Obispo Fresno San Mateo Glenn Santa Barbara Humboldt Santa Clara Kern* Santa Cruz Kings Shasta* Lassen Siskiyou* Los Angeles Solano Marin Sonoma Mendocino Stanislaus* Merced Sutter Mono* Tehama Monterey Tulare Napa Tuolumne Orange Ventura Plumas Yolo Riverside Yuba* Sacramento San Benito* *Responded to 2004 survey only. 34 | CALIFORNIA HEALTHCARE FOUNDATION Appendix B: Funding Stream Definitions Business Community Contributions Private Foundations Some counties like Santa Clara are Foundations such as Packard, The California approaching the business community and are Endowment, and the California HealthCare securing contributions. Foundation have provided funds to launch coverage expansions for children and adults. CHIP/CMSP (Medically Indigent) In some cases, funding for premium subsidies “CHIP” refers to the California Healthcare has been provided. for the Indigents Program. It is funded with Prop 99 funds (tobacco funds) and includes Prop 10 — Children and Families First 24 participating counties — typically the more Commission populated, urban counties. “CMSP” refers to Enacted in 1998, Prop 10 uses revenues the County Medical Services Program. It is generated by increases in the state excise funded primarily with Realignment funds taxes on tobacco products to fund childhood and county general funds, and includes 34 development programs that are carried out rural counties. Both programs reimburse by state and county commissions. Many providers for uncompensated services for counties are using these funds to launch medically indigent patients — individuals health care insurance programs for uninsured who cannot afford care and for whom no children up to 18 years of age. other source of payment is available. Realignment Funds Federal Funds Enacted in 1991, “Realignment” refers to Federal funds like the Bureau of Primary a funding mechanism that gives counties Health Care’s Healthy Communities Access greater flexibility and responsibility for fund- Program (HCAP) are being used by counties ing health, mental health, and social services. to plan and develop a variety of access This funding source is a combination of programs, including coverage expansions. vehicle license fees (VLF), sales tax revenues and county matching health and mental Hospital or Hospital District Funds health dollars. It is used to fund county Some access programs are receiving funding programs targeted to the medically indigent. from hospitals or hospital districts. Tobacco Settlement Funds Local Initiative or COHS Savings Under the 1998 Master Tobacco Settlement, Medi-Cal managed care plans are also a tobacco companies are required to make source of funding, with some savings being payments to the states through 2025. In re-allocated to coverage expansions for California, the counties receive half of the children and adults. funds, having significant discretion in the Other County General Funds types of programs and services they can fund. Some counties such as San Francisco have Some counties like Santa Clara have allocated earmarked county general funds for coverage these funds for coverage expansions for expansions for children and adults. These are uninsured children. non-Realignment, local funds. United Way A new player, United Way has recently contributed coverage expansion funding in the Sacramento area. Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 35 Appendix C: Funding Used to Finance Access Programs In Place Coverage Medi-Cal Model Access Coalition Provider FUNDING STREAM Youth Adult FFS Two-Plan COHS GMC Yes No Yes No (RESPONSES) (13) (11) (22) (12) (8) (2) (26) (14) (13) (31) Business Community 3 4 1 3 2 1 5 1 2 5 Contributions (7) CHIP /CMSP (29) 8 8 17 6 4 2 18 8 8 21 (Medically Indigent) Federal Funds (29) 10 9 13 7 7 2 21 6 10 19 (e.g., HRSA Cap Grants) Hospital/Hospital District Funds (14) 4 6 2 2 4 2 10 2 3 11 Local Initiative/COHS Savings (6) 6 0 6 6 0 0 6 0 6 0 Other County General Funds (19) 9 7 10 6 3 0 14 4 8 11 Private Foundation Funds (27) 11 10 11 7 7 2 20 5 9 18 Prop 10 — Children & Families 12 9 18 10 5 2 22 9 11 24 First Commission (35) Realignment Funds (29) 6 6 18 6 5 0 19 8 7 22 Tobacco Settlement Funds (24) 11 9 10 7 5 2 18 4 9 15 United Way (10) 2 5 1 1 3 1 7 0 3 7 36 | CALIFORNIA HEALTHCARE FOUNDATION Appendix D: Survey Instrument In 2002, the California HealthCare Foundation administered a 58-county survey on existing and proposed programs to increase access to health care for the uninsured, as well as county needs in designing and implementing these programs. The findings from this survey contributed to the design and launch of the Foundation’s Step by Step Initiative, providing technical assistance to counties in planning and implementing insurance coverage programs for uninsured children and adults. The Foundation is interested in updating its understanding of county efforts to increase access to health care for the uninsured, including current and proposed access and coverage programs and barriers to launching these programs. Please take 15 minutes to complete the following survey. The results of the survey will assist the Foundation in developing services and assistance to support local expansion efforts. All responses will be reported anonymously. Your completion of the survey implies you are providing your consent to participate in this study. The deadline for completing the survey is March 19, 2004. If you have questions regarding the survey, please contact Annette Gardner, PhD, MPH, Study Director, Institute for Health Policy Studies, University of California, San Francisco at 415.514.1543 or algard@itsa.UCSF.edu. Section A: Access Programs 1. Please indicate the types of county-level programs that are currently underway or are being considered to increase access to health care for the uninsured. Check one box per program type that best describes your county’s situation: In Place Proposed No Activity Don’t Know a. Insurance coverage for children (children not eligible for Healthy Families, Medi-Cal, e.g., CalKids, Healthy Kids) b. Insurance coverage for adults (e.g., IHSS workers) c. Managed care for the county indigent d. Premium subsidies for small employers e. Information on coverage options f. Outreach/enrollment/retention in public insurance programs g. Consumer education (e.g., use of prevention services) h. Facilities expansions (e.g., new clinics) i. Increase in providers (e.g., specialists) j. Increase in clinic hours (e.g., weekends) k. Assistance with transportation (e.g., mini-vans) l. Appointment system changes (e.g., same-day appointments) m.“Insurance-like” programs (e.g., bundling of county health services, lower out-of-pocket fees, no premiums) Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 37 2. Please list other programs to increase access 5. Which agency or organizations are responsi- to care that are not listed above. ble for spearheading access initiatives in your county? Please list the top three in 3. Has your county experienced a decrease/ order of importance: increase/no change in activity since 2002 in any of the following areas? a. a. Insurance coverage for children b. (not incl. Healthy Families, Medi-Cal) c. b. Insurance coverage for adults 6. Does your county have a coalition that c. Outreach/enrollment/retention in specifically focuses on access issues (not public insurance programs including the county Prop 10 Commission)? d. Service expansions Yes No Don’t Know (e.g., clinics, providers) 7. We are interested in knowing the type of 4. We are interested in knowing what organiza- funding your county has used to finance the tions or stakeholders have played a key role access programs checked off above. Please in mobilizing, launching, and supporting check the funding streams that your county access initiatives, be coverage and/or services has used or is intending to use. Check all expansions, in your county. Please rate each that apply. participant on a scale of 1 to 4 (1=no role, a. Prop 10 — 4=very important role, N/A=does not apply to our Children and Families First Commission county, e.g., county public plan). b. CMSP/CHIP — a. Board of Supervisors 1 2 3 4 Medically Indigent funds b. County health agency 1 2 3 4 c. Tobacco Settlement funds c. County human services agency 1 2 3 4 d. Realignment funds d. County Medi-Cal Plan 1 2 3 4 e. Other county general funds (e.g., LI, COHS) f. Private foundation funds e. Non-county community g. Business community contributions health centers 1 2 3 4 h. Federal funds f. Community-based (e.g., CAP Grants, MAA, AB 495) organizations 1 2 3 4 i. Local initiative or COHS savings g. Local coalition 1 2 3 4 j. Hospital or hospital district funds h. Prop 10 Commission 1 2 3 4 k. United Way i. Private insurers 1 2 3 4 l. Other, please specify: (e.g., KP Cares for Kids) j. Private providers 1 2 3 4 k. Private funders 1 2 3 4 (e.g., foundations) l. The business community 1 2 3 4 m.Community-at-large 1 2 3 4 38 | CALIFORNIA HEALTHCARE FOUNDATION Section B: Barriers to Access 9. Is your county considering using any of the Initiatives strategies and resources listed in Question 8 Since this survey was administered in 2002, there to fund the following types of access have been many economic changes at the state programs? and local level, such as the repeal of the Vehicle Yes No Don’t Know License Fee tax increase, that may challenge a. Insurance coverage counties. The California HealthCare Foundation for children (not incl. Healthy Families, Medi-Cal) is interested in knowing about the opportunities b. Insurance coverage and barriers to increasing access to care for the for adults uninsured that exist in your county. c. Outreach/enrollment 8. Please check the following resources and /retention in public insurance programs strategies to which your county has access: d. Service expansions a. Tapping existing county funds that (e.g., clinics, providers) haven’t been used in the past 10. There are some barriers to access initiatives b. Approaching the business community that can not be readily addressed using c. Securing federal funds like resources. Please check off any barriers that HRSA Cap Grants exist in your county: d. Leveraging existing funds like a. Political barriers Prop 10 funds to attract new funding (e.g., low political commitment) e. Increased grant-writing b. Cultural/social barriers (e.g., local foundations) (e.g., language barriers) f. Applying savings from other areas c. Limited technical expertise (e.g., from the Local Initiative) (e.g., difficulty in developing coverage contracts) g. Using Healthy Families S-CHIP d. Health care delivery system unused funds to leverage federal funds (e.g., high unmet need) h. Recommending allocation of e. Rural issues Tobacco Settlement funds (e.g., poor transportation between areas) i. Other, please specify: f. Low stakeholder engagement (e.g., lack of coalition focused on access) g. Competing priorities (e.g., transportation, security) h. Other, please specify: 11. We understand counties may be confronted with very different health issues. Please indicate your county’s top health issue: Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 39 12. From the perspective of a county official, g. Key stakeholders important in program please rate the importance of access to design and launch: health care services for the uninsured in your county relative to other health issues h. If applicable, did the Local Initiative or on a scale of 1 to 4 (1=not at all and 4=very COHS play a key role? important). Yes No Don’t Know 1 2 3 4 Program 2: (repeat above) 13. From the perspective of a county official, has the issue of access to health care for the Insurance Programs for Uninsured Adults: uninsured decreased/increased/not sure in Program 1: importance since 2002? Decreased Increased Not Sure a. Program name: b. Program launch date: Section C: Local Health Insurance c. Program target populations (e.g., adults up Coverage Expansions to 300% FPL): 14. The California HealthCare Foundation is d. Number of people enrolled in program interested in knowing more about your as of January 2004: county’s efforts to expand insurance coverage e. If available, program funding source(s): for uninsured youth and/or adults. Please complete the following information for each f. If available, amount of funding secured: program that is currently underway. Please indicate “Don’t Know” for any program g. Key stakeholders important in program characteristics that you are not aware of. design and launch: Insurance Programs for Uninsured Children (children not eligible for Healthy Families, h. If applicable, did the Local Initiative or Medi-Cal) COHS play a key role? Yes No Don’t Know Program 1: a. Program name: Program 2: (repeat above) b. Program launch date: c. Program target populations (e.g., undocumented children up to 300% FPL): d. Number of people enrolled in program as of January 2004: e. If available, program funding source(s): f. If available, amount of funding secured: 40 | CALIFORNIA HEALTHCARE FOUNDATION 15. The California HealthCare Foundation is d. Number of people enrolled in program interested in knowing more about programs as of January 2004: being considered by your county to expand e. If available, program funding source(s): insurance coverage for uninsured youth and/or adults. Please complete the following f. If available, amount of funding secured: information for each program that is being considered. Please indicate “Don’t Know” for any program characteristics that you are not g. Key stakeholders important in program aware of. design and launch: Insurance Programs for Uninsured Children h. If applicable, did the Local Initiative or (children not eligible for Healthy Families, COHS play a key role? Medi-Cal) Yes No Don’t Know Program 1: Program 2: (repeat above) a. Program name: b. Program launch date: Respondent Information c. Program target populations (e.g., 16. First name undocumented children up to 300% FPL): 17. Last name 18. Position d. Number of people enrolled in program as of January 2004: 19. Organization e. If available, program funding source(s): 20. Address 21. City f. If available, amount of funding secured: 22. State 23. Zip code g. Key stakeholders important in program 24. County design and launch: 25. Phone 26. Fax h. If applicable, did the Local Initiative or COHS play a key role? 27. Email Yes No Don’t Know 28. County type: Check one Program 2: (repeat above) Rural Urban 29. County Medi-Cal Program Type: Check one Insurance Programs for Uninsured Adults: Fee-for-Service COHS Program 1: Two-Plan GMC a. Program name: 30. Does your county have a county-run b. Program launch date: hospital? Yes No c. Program target populations (e.g., adults up to 300% FPL): Assessing County Capacity to Meet the Needs of California’s Uninsured: 2004 Survey Findings | 41 Endnotes 1. In 2002, respondents were asked to identify coverage programs from a list of 10 program types. In 2004, we expanded this list to 13 program types. 2. CaliforniaKids (CalKids) offers coverage for uninsured children in 39 counties. Enrollment is capped in all counties except for Orange, Marin, and Solano — 3 counties that counted these programs as “in place” coverage programs for children in their surveys. 3. The data are very sensitive to modest changes in the number of responses and could understate the importance of some stakeholders. 4. For a more detailed analysis of recent cut-backs in county services, see the study by Baldassare et al., The State Budget and Local Health Services in California: Survey of County Officials, at: www.ppic.org/content/pubs/OP_504MBOP.pdf. 5. Having a Medi-Cal managed care plan may not necessarily suggest that the plan will be involved with coverage expansions, as appears to be the case in Kern County. 42 | CALIFORNIA HEALTHCARE FOUNDATION