FIRST 5 LA | HEALTHY KIDS RECRUITMENT AND · PDF fileThe Healthy Kids Recruitment and...

HEALTHY KIDS RECRUITMENT AND ENROLLMENT

EVALUATION STUDY

Prepared for:

Prepared by:

Research & Evaluation Team

Special Service for Groups

January 2013

ACKNOWLEDGEMENTS

The Healthy Kids Recruitment and Enrollment evaluation study involve many individuals and

organizations contributing their time, ideas, perspectives, and talents to the information-

gathering process. Special Service for Groups would like to thank the following individuals for

providing program and other secondary data, connecting us with focus group participants and

interview subjects, hosting focus groups, and reviewing and providing feedback to earlier drafts

of this report:

Melinda Leidy and Hayley Roper, Research & Evaluation Department, First 5 LA

Tara Ficek, Grants Management Department, First 5 LA

Suzanne Bostwick and Christine Villaseñor, Children’s Health Outreach Initiative,

L.A. County Department of Public Health

Shawnalynn Smith, Program Administration Department, L.A. Care Health Plan

Raheleh Barznia, Product Management Department, L.A. Care Health Plan

Penny Chen, Enrollment Services Unit, Asian Pacific Health Care Venture

Marilyn Lawrence, Children’s Health and Wellness, Crystal Stairs

Maria Peacock, Get Enrollment Moving (GEM) Project, Citrus Valley Health Partners

Liz Ramirez, Training Department, Maternal Child Health Access

Dale Reinert, Children’s Health Access and Medi-Cal Program (CHAMP), Los Angeles

Unified School District (LAUSD)

Martha Rivera, Community Services, Glendale Adventist Medical Centers

Oscar Placencia, Medi-Cal and IHSS Division, Department of Public Social Services

We would also like to express gratitude to the numerous Certified Application Assistors (CAAs)

who have participated in this evaluation study.

ABOUT SSG RESEARCH & EVALUATION TEAM

Incorporated in 1952, Special Service for Groups (SSG) is a nonprofit

multi‐service agency that serves some of the hardest‐to‐reach populations

across Los Angeles County. Our Research and Evaluation Team works

with hospitals/clinics, philanthropic sectors, nonprofit organizations and

community members to collect and analyze information they need for

planning and action. We believe that information is power, and we invest in developing these

research skills within our communities. Please visit us at: www.ssgresearch.org.

For questions or more information about this report, please contact SSG Research & Evaluation

Team at (213) 553-1820 or [email protected].

http://www.ssgresearch.org/

mailto:[email protected]

Table of Contents

TABLE OF CONTENTS ................................................................................................................... 1

EXECUTIVE SUMMARY .................................................................................................................. 2

INTRODUCTION ............................................................................................................................ 5

CHAPTER 1: METHODOLOGY ........................................................................................................ 7

CHAPTER 2: ENROLLMENT TRENDS .............................................................................................11

CHAPTER 3: CURRENT RECRUITMENT STRATEGIES ......................................................................14

CHAPTER 4: REASONS FOR ENROLLMENT DECLINE ......................................................................17

A. Discontinued enrollment for children ages 6-18 ................................................................17

B. Decline in undocumented immigration ..............................................................................18

C. Fear and discouragement among undocumented immigrants in program participation ....20

D. Lack of community awareness about Healthy Kids ..........................................................22

E. Limited number of providers who accept Healthy Kids .....................................................23

F. Decreased number of Certified Application Assistors (CAAs) ...........................................23

CHAPTER 5: OPPORTUNITIES FOR INCREASING ENROLLMENT - RECOMMENDATIONS .......................25

A. Expansion of Healthy Kids to children ages 6-18 ..............................................................25

B. Outreach to eligible higher-income families (250%-400% FPL) ........................................25

C. Outreach materials and advertising specific to Healthy Kids ............................................28

D. Better coordination with County agencies ........................................................................29

CONCLUSION: RELEVANCE OF HEALTHY KIDS – NOW AND BEYOND ...............................................30

A. Contributions of Healthy Kids coverage ............................................................................30

B. Contributions of Healthy Kids outreach ............................................................................31

C. Health care reform and the implementation of the Affordable Care Act ............................32

REFERENCES .............................................................................................................................34

APPENDICES ..............................................................................................................................36

2 FIRST 5 LA | HEALTHY KIDS RECRUITMENT AND ENROLLMENT EVALUATION STUDY

EXECUTIVE SUMMARY

The First 5 LA Commission approved the Healthy Kids program in Los Angeles in July 2003 to

expand health insurance coverage to children ages 0-5 living at or below 300% Federal Poverty

Level (FPL). As a “last resort” health insurance option, the Healthy Kids program mainly covers

young children who are not eligible for Medi-Cal and Healthy Families, primarily undocumented

children and children in families with household income between 251% and 300% of the FPL.

In 2012, The Commission raised the upper income limit for eligibility from 300% FPL to 400%

FPL. First 5 LA is the primary financial contributor to outreach and enrollment for the Healthy

Kids program.

Healthy Kids enrollment for children ages 0-5 suffered significant decline although coverage has

been continuous for this age group. Total enrollment for children ages 0-5 peaked at 7,965 in

October 2005, and has steadily dwindled to 1,492 by August 2012. Attrition (through age out

and other reasons) has far outpaced new enrollment.

This report is an evaluation of Healthy Kids outreach and enrollment, which is designed to

provide feedback to stakeholders on how to address the decline in program enrollment. The

evaluation addressed three key questions: (1) reasons for enrollment decrease; (2) barriers and

challenges in the outreach and recruitment process within Los Angeles County, and (3)

opportunities for outreach and recruitment strategies. Methods used included key stakeholder

interviews, focus groups, literature reviews, and review of existing documents and program

data.

Key findings from the Healthy Kids recruitment and enrollment evaluation study include the

following:

There was a similar pattern of decline in total enrollment for children ages 0-5 for all

Service Planning Areas (SPAs) and in Healthy Kids programs in other counties in

California. Enrollment patterns for similar low-cost health insurance programs, such as

California Kids, and Kaiser Permanente Child Health Plan, also experienced declines,

except for Medi-Cal.

The Los Angeles County Department of Public Health (DPH) contracted more than a

dozen, of school districts, community clinics, and community-based organizations to

conduct outreach and enrollment for children’s health insurance programs. Certified

Application Assistants (CAAs) in all DPH-contracted agencies conducted outreach

aimed at the broader community such as local health fairs or existing community events.

“In-reach” activities that target clients in clinics, schools, and organizations were more

common. Many agencies also conduct outreach at churches, parks, WIC offices, and/or

other public agencies while at least one agency uses the promotora model.


Parents who have been outreached to enroll their children into Healthy Kids are

predominantly Spanish-speaking. However, many study participants reported seeing an

increase in non-Latino immigrant families interested in Healthy Kids, including Korean,

Armenian, Iranian, and Chinese, as well as indigenous populations from Latin America .

Many outreach agencies do not have the language capacity to serve these populations.

Because Healthy Kids is a “last resort” low-cost health insurance program, CAAs’

primary focus is on Medi-Cal and Healthy Families. CAAs only refer community

members to Healthy Kids after determining that they are not eligible for Medi-Cal or

Healthy Families, mostly due to undocumented status or household income above 250%

FPL. CAAs also use an “umbrella strategy” to build holistic relationships with families

and link them to other programs, such as CalFresh, housing, legal, and immigration

assistance.

Study participants believed that the discontinued enrollment for children ages 6-18 that

was implemented in June 2005 had a negative effect on recruitment and enrollment of

younger children as well. Parents often prefer to keep all their children with the same

provider in the same health plan. The knowledge that children would age out when they

turn age five also discourages parents from enrolling their children into Healthy Kids,

especially from undocumented families who do not want to risk exposing their children’s

immigration status.

All CAAs and other study participants reported seeing fewer undocumented children in

the 0-5 age range, at least in the last three years. This is consistent with national trends

showing a decline in undocumented immigration due to a lack of employment

opportunities in the U.S. Children ages 0-5 in immigrant families were also more likely to

be born in the U.S. and, therefore, eligible for other programs, such as Medi-Cal and

Healthy Families.

Fear of exposure, concerns about “public charge,” and discouragement based on

negative experiences in this country in general are major barriers for undocumented

immigrants’ access to services including Healthy Kids. A lack of community awareness

about Healthy Kids, a decrease in the number of CAAs, and a lack of providers who

accept Healthy Kids were also cited as reasons for enrollment decline.

Opportunities for increasing enrollment for Healthy Kids include expansion of the

program to children ages 6-18, outreach to higher-income families (250-400% FPL),

outreach materials and advertising specific to Healthy Kids, and better coordination with

county agencies, especially the Department of Public Social Services (DPSS).

All study participants cited the significant contributions of Healthy Kids to children’s

health insurance coverage, to increase in utilization of medical and dental services, and

to the improvement of overall health outcomes of underserved families in Los Angeles

County.


Study participants also stressed the importance of relationship building with hard-to-

reach communities as a key function of the Healthy Kids outreach partnership, especially

in a health insurance landscape that is constantly changing. These relationships also

support underserved families in access other vital services for which they are eligible.

The Healthy Kids program has begun to adjust in anticipation of the Affordable Care Act

(ACA) implementation in 2014. In November 2012, the First 5 LA Commission approved

raising the income eligibility for Healthy Kids from 300% FPL to 400% FPL, the income

population that will be affected by the ACA implementation. This will allow higher-income

families who are currently uninsured to become accustomed to being part of an

insurance program until the Exchange comes online in 2014.

Findings in this report suggest that the decline in Healthy Kids enrollment is primarily due to

policy change (enrollment hold for children ages 6-18) as a result of lack of funding and to

structural change in immigration patterns as a result of the economic downturn.

Recommendations that emerged can address current challenges in outreach and enrollment

as well as strengthen the outreach network to meet the demands of ACA implementation in

Los Angeles County.


INTRODUCTION

In July 2003, the First 5 LA Commission approved a new program called Healthy Kids, which

was designed to expand eligibility for existing health insurance programs by covering all children

ages 0-5 living at or below 300% of the Federal Poverty Level (FPL) in Los Angeles County.1

The vision for Healthy Kids is: 1) to achieve health insurance coverage for all children ages 0-5

living at or below 300% FPL; 2) to optimize children’s health and development by increasing

access to coordinated and quality health care; and 3) to support the health care safety net by

increasing the pool of insured children. The First 5 LA Commission also approved a strategic

partnership with the Los Angeles County Department of Public Health (DPH) to administer the

outreach, enrollment, retention and utilization efforts countywide to ensure universal coverage

for the 0 to 5 population. Healthy Kids is the “program of last resort” for children ages 0-5 not

eligible for Medi-Cal or Healthy Families. Most of these children are eligible for Healthy Kids

because of their undocumented status, and far fewer of them qualify based on their families’

incomes being above the limit for Medi-Cal or Healthy Families. At its peak in October 2005,

Healthy Kids had the enrollment of 7,965 children. Over the years, its enrollment has declined

to 1,492 in August 2012. The latest change in enrollment eligibility occurred during this

evaluation study. In November 2012, the Commission approved a policy that raises the upper

income limit for children eligible for Healthy Kids from 300% FPL to 400% FPL. Currently, due

to funding cuts by the State of California and other funding sources, First 5 LA remains the

primary financial contributor to outreach and enrollment for low-cost children’s health insurance

programs, including but not limited to Healthy Kids.

First 5 LA has contracted Special Service for Groups (SSG) to conduct the Healthy Kids

Recruitment and Enrollment Evaluation Study to address the following study aims about the

declining enrollment of the program:

1. Why is enrollment decreasing in the Healthy Kids program? Is this issue particular to the

Healthy Kids program compared to other low or no-cost insurance programs within and

outside of LA County?

2. What barriers and challenges are encountered in the outreach and recruitment process

within LA County? Are these challenges related to the program characteristic or

recruitment strategies? Are there larger system issues contributing to these barriers?

3. What outreach and recruitment strategies are being used? What strategies have been

used and are available to be used? Are these outreach and recruitment strategies

targeting the right population?

This report addresses the three study aims in the following five chapters. Chapter 1 describes

the methodology used in framing the research study and collecting and analyzing the data.

1 The Federal Poverty Level varies according to family size and is adjusted for inflation. In 2012, for a

family of four, 300% of the FPL is $69,150. For 400% FPL, it is $92,200. This amount increases with each additional person. A pregnant woman is counted as two persons.


Chapter 2 describes the enrollment trend of Healthy Kids program in Los Angeles County and

compares it to other low-cost health insurance programs for children. Chapter 3 describes

current outreach strategies, which provide important contextual information about the enrollment

decline. Chapter 4 discusses the various reasons for the enrollment decline according to study

participants, with support from secondary data. Chapter 5 includes recommendations to

increase enrollment for Healthy Kids. The Conclusion of the report discusses the relevance of

Healthy Kids, especially in the context of the Affordable Care Act (ACA).2

2 The Affordable Care Act (ACA), more popularly known as health care reform, was initiated by the

Obama administration and passed by the U.S. Congress in 2010 and upheld by the U.S. Supreme Court in 2012. ACA would expand health insurance coverage to many who are currently uninsured by expanding Medicaid as well as providing the federal tax credits to subsidize health insurance cost through a health benefits exchange in each state. Families with income at or below 400% FPL will be eligible to participate. Many states, including California, have already begun taking steps to build infrastructure to meet the demands anticipated from the ACA.


CHAPTER 1: METHODOLOGY

Evaluation Approach: The methodology of the Healthy Kids Recruitment and Enrollment

Evaluation Study is based on the concepts of empowerment evaluation and grounded theory.

Empowerment evaluation “is an evaluation approach that aims to increase the likelihood that

programs will achieve results by increasing the capacity of program stakeholders to plan,

implement, and evaluate their own programs" (Wandersman, et al., 2005). This is

accomplished usually by involving multiple stakeholders as much as possible in the

implementation of the evaluation. For this project, we involved multiple stakeholders throughout

the various phases of the evaluation, from design to interpretation, to ensure we produce data

and findings that are meaningful and useful in improving Healthy Kids recruitments and

enrollment in particular, and the work of contracted outreach agencies in general. During the

planning stage, the SSG Research & Evaluation Team met separately with staff from our three

study partners, First 5 LA, L.A. County Department of Public Health, and L.A. Care Health Plan,

to review the three study aims and develop specific evaluation questions to be addressed in the

study. We presented these evaluation questions and approach to the DPH-contracted outreach

agencies at their monthly meetings for feedback. To implement the evaluation, we solicited help

from these agencies in recruiting their outreach staff for our focus groups. After data were

analyzed, we presented our findings to our study partners and to the contracted agencies at

their monthly meeting for validation and recommendations for next steps.

Grounded theory is a research approach that begins with data collection before determining a

hypothesis. It is mostly practiced with qualitative methods in social sciences, where a theory is

developed based on knowledge of the research subjects who are directly impacted by the

phenomenon being studied, rather than by an existing theoretical framework. Our analysis was

informed by previous evaluation studies on similar topics. The SSG Team conducted literature

review, focusing on evaluation of similar programs in other counties in California, current

immigration and demographic trends, and shifting health insurance landscape as a result of the

Affordable Care Act. However, the framework of analysis of primary data is guided and

developed through a preliminary reading (“coding”) of the qualitative data from focus groups,

key stakeholder interviews and document review (including previous Healthy Kids evaluation

reports and Healthy Kids outreach partnership’s quarterly progress reports).

Primary Data Collection Methods and Participants: Based on discussion with our study

partners and document review, the SSG Team decided on conducting a series of focus groups

with Certified Application Assistors (CAAs) in the Healthy Kids outreach partnership as well as

interviews with key stakeholders with one of the following expertise: data experts, policy

experts, outreach experts, and experts from similar low-cost programs in California, including

Healthy Kids programs in other counties. A focus group and interview guide was developed to

cover five broad research areas, including:

1. Enrollment trends

2. Current recruitment strategies


3. Reasons for decline in enrollment

4. Opportunities for improving enrollment

5. Relevance of Healthy Kids: now and beyond

For the key stakeholder interview method, study partners provided candidates for interviews.

To achieve the right mix of expertise and diversity of experience, the SSG Team selected and

conducted 14 interviews involving 18 stakeholders between August 29 and October 22, 2012

(some interviews have more than one participant). Depending on interview participant’s

knowledge and experience, certain research areas are emphasized more than others, and

additional questions were developed to tailor their expertise. All interviews were conducted in-

person, at the offices of the interview participants, except for those who do not reside or work in

Los Angeles County. In those cases, interviews were conducted over the phone. Participating

agencies included:

California Coverage and Health Initiatives

California Kids

Children’s Health Initiative of Orange County

Health Plan of San Mateo

Insure the Uninsured Project

L.A. Care Health Plan

Los Angeles County Office of Education

Santa Clara Family Health Foundation

UCLA Center for Health Policy Research

Universal Care

USC Population Dynamics Research Group

Venice Family Clinic

Worksite Wellness

For the focus group method, the SSG Team presented the research design to the DPH-

contracted agencies in the Healthy Kids outreach partnership at their monthly meeting in

September. The presentation aimed to create buy-in among the outreach partners for the

evaluation study, seek feedback on how to engage their CAAs, and ask for assistance in

hosting focus groups and recruiting participants. After the meeting, we shared the focus group

guide with all the contracted agencies and asked each of them to recruit 2-3 CAAs who have

the most knowledge in addressing the questions on the guide, including questions about trends.

Outreach partners recommended organizing six focus groups using a combination of regions

and population focus, including at least one Spanish-language focus group. Outreach partners

also recommended inviting non-DPH-contracted agencies that also have CAA staff, which the

SSG Team incorporated in the research design. All focus groups were hosted by one of the


outreach partners. Between September 12 and October 11, 2012, the SSG conducted six focus

groups with a total of 41 CAAs3, representing the following 17 participating agencies:

LAUSD

SPA 1 & 2: Child & Family Guidance Center, Glendale Adventist Medical Center,

Northeast Valley Health Corporation, and Tarzana Treatment Centers

SPA 3: AltaMed Health Services, Citrus Valley Health Partners, and Pasadena Public

Health Department

SPA 4 & 6 (Spanish): California Hospital Medical Center, Community Health Councils,

Crystal Stairs, and Maternal Child Health Access

SPA 7 & 8: Community Health Councils, Crystal Stairs, and Long Beach Department of

Health and Human Services

Asian Pacific Islander-serving outreach partners: Asian Pacific Health Care Venture,

Chinatown Service Center, Korean Health Education, Information, and Research Center,

and South Asian Network

SPA 5 was not represented in the focus groups because there is only one outreach partner in

that service planning area, Venice Family Clinic. The SSG Team interviewed staff from the

Clinic separately. Over 80% of the CAAs who participated had worked in this capacity for five

years or more, and a majority had more than eight years of experience. At the recommendation

of the contracted agencies, the SSG Team provided incentive (movie vouchers) to focus group

participants.

Coding and Analysis: With permission from the participants, all focus groups and interviews

were audio-recorded and then transcribed. To maintain the confidentiality of the participants,

audio recording did not begin until after participants introduced themselves, and the transcripts

did not contain any names. Focus groups and interviews are assigned unique numbers

(including in their file names) for references and storage. In some cases, because interview

participants have unique expertise and experience, it is possible that their identities can be

inferred from the transcripts even without identifying information. For focus groups, we

encouraged participants to be accountable to each other’s confidentiality and privacy by not

sharing any information that might harm any of the participants with anyone outside of the focus

group. Participants were notified of these risks before any data were collected.

The transcripts became the basis of the content analysis for this report. The SSG Team met to

discuss common responses from the data collection and categorized them into a set of key

themes according to each research area. The key themes became the preliminary codes with

which the SSG Team analyzed the transcripts. Deeper analysis during the coding process

revealed relationships among some key themes and their relative significance. In the process

of coding each transcript, these key themes were sometimes added, combined, or separated, or

the order of importance was re-arranged. Based on this analysis, the SSG Team drafted a

3 Among DPH-contracted agencies, there are about 107 CAAs, 47 of whom are full-time. According to a

2010 report by the Community Health Councils about CAAs, there were about 1,500 CAAs in Los Angeles County working for close to 850 enrollment entities.


memo detailing the key themes and data sources that support them, often using actual quotes

from data collection to substantiate the analysis. The memo was reviewed by First 5 LA and

DPH staff and presented verbally to DPH-contracted agencies at their monthly meeting in

December 2012, for data validation and interpretation, including relative significance of key

findings. Almost all of their feedback was incorporated into this final report.


CHAPTER 2: ENROLLMENT TRENDS

The First 5 LA Commission approved the Healthy Kids program in Los Angeles in July 2003 to

expand health insurance coverage to children ages 0-5 living at or below 300% Federal Poverty

Level (FPL). As a “last resort” health insurance option, the Healthy Kids program covers young

children who are not eligible for Medi-Cal and Healthy Families, primarily undocumented

children and children in families with household income between 251% and 300% of the FPL

(referred to as “eligible higher-income families” throughout this report). In May 2004, other

funders, through the Children’s Health Initiative Coalition of Greater Los Angeles, contributed to

expand coverage to children ages 6-18. In June 2005, when State legislation to provide health

insurance coverage for undocumented children of all ages became unlikely, the Coalition’s

support to Healthy Kids stopped, and there was an enrollment hold placed on children ages 6-

18 that continues to this day. L.A. Care Health Plan continues to support children in that age

population who were already enrolled before June 2005 through a low-premium plan, while First

5 LA has maintained coverage for children ages 0-5 since the inception of the program. Not

surprisingly, Healthy Kids enrollment overall has declined over the years as a result of children

aging out and premium non-payment for various reasons.

However, Healthy Kids enrollment for children ages 0-5, even though coverage has been

continuous, also suffered significant decline. Enrollment for this age group hovered around

7,800 since June 2005 (when enrollment hold was placed for older children), peaked at 7,965 in

October 2005, and has steadily dwindled to 1,492 in August 2012. Attrition has far outpaced

new enrollment. Chart A in the Appendix shows the enrollment trend based on the data

available during the data collection for this study. Some study participants suggested that Los

Angeles County was reaching close to saturation in health insurance coverage for children.

One data expert who participated in the study stated, “The fact is that the undocumented

population of kids in California as a whole and in Los Angeles County is pretty small. We’re

down to 8% or so of uninsured kids. So it ends up being harder and harder [to identify children

who are still uninsured] because honestly they’ve done a pretty good job of enrolling eligible

kids in some program.”

Decline across SPAs: Program data shows that a similar pattern of decline in total enrollment

for children ages 0-5 occurred for all Service Planning Areas (SPAs), both in actual numbers

(Chart B) and proportionally (Chart C). In actual numbers, those SPAs with significant

enrollment saw a steady decline around the same time. Each SPA also maintained similar

proportion of total Healthy Kids enrollment from 2004 to 2012. The lack of fluctuation suggests

that the causes for the decline are not specific to any one SPA and more likely to be system-

wide.

Decline in Similar Programs: This evaluation study also examines enrollment patterns for

similar low-cost health insurance programs by engaging stakeholders who are familiar with

Healthy Kids programs in Orange, San Mateo and Santa Clara Counties, as well as California

Kids, Kaiser Permanente Child Health Plan, Medi-Cal, and Healthy Families. San Mateo and

Santa Clara Counties were selected because their Healthy Kids programs have conducted


independent evaluation. Orange County was one of two other counties identified because of

their geographic proximity to Los Angeles County and their relative similarity in terms of racial

and immigrant compositions. (Representative from the other county did not respond to request

for interview.)

Previous research has found that enrollment in all Healthy Kids programs in California have

declined since 2006, from 90,094 in the fourth quarter that year to 84,803 a year later in 2007,

“as more and more counties closed enrollments to children 6-18 years of age due to lack of

funding for children in this age group” (Cousineau, Stevens, and Farias, 2009). According to a

stakeholder, the Santa Clara Healthy Kids program closed its enrollment to children ages 6-18

in 2006 and saw the enrollment of younger children also drop significantly afterwards. This

program has re-opened enrollment for children ages 6-18 in 2010 and is considering raising

income eligibility to 400% FPL. No data is available yet to determine the impact of these

program changes. In Orange County, because of lack of funding, which results in the

inconsistency of program availability, enrollment for its Healthy Kids program was discontinued

simultaneously both for children ages 0-5 and 6-18 in 2009, with the last member exiting the

program in February 2010 after one full year of coverage.

In comparison, the San Mateo County Healthy Kids program continues to maintain coverage for

children both ages 0-5 and 6-18 at 400% FPL. While the program saw a decrease of 8% in

enrollment in the past year, the decline was less steep than Los Angeles, Orange and Santa

Clara Counties. In fact, San Mateo saw a slight increase in enrollment (2%) from households

with 300%-400% FPL in the same period. One stakeholder added, “We are very fortunate to

have incredible financial support from the County, the health care district, and First 5. We’ve

never had a waitlist for the 0-5 or 6-18.”

Established in 1992, California Kids provides low-cost medical and dental insurance for children

under 18. At its peak, enrollment reached about 7,000 in Los Angeles County. As more low-

cost insurance programs became available since its inception, including Healthy Families,

Healthy Kids, and Kaiser Permanente Child Health Plan, California Kids membership has

declined to about 400 children and currently focuses on children ages 6-18 who are ineligible for

other programs. Its premium ($75 per month) is higher than those of other low-cost insurance

programs, primarily because of the small pool of membership. With a lower premium, they

would have to open and close the program depending on funding availability. The leadership of

California Kids believed that this inconsistency of program availability would be detrimental to

outreach efforts. Beyond the availability of other programs, California Kids also attributes its

membership decline to population trends: “[California Kids] started looking at demographic and

immigration information and we saw a decrease. And we said, no matter what strategy we use,

we aren’t going to see great numbers. This is across the state, not just L.A.”4

4 According to the U.S. Census, the proportion of children under 5 years of age in California decreased

from 7.3% to 6.8% between 2000 and 2010, even though this population increased slightly (+1.8%) in real number during that decade. In Los Angeles County, the population of young children decreased both in proportion (from 7.7% to 6.6%) and in real number (-12.5%) between 2000 and 2010.


Kaiser Permanente Child Health Plan is another low-cost health insurance option, but it opens

enrollment occasionally. The Plan was closed at the beginning of the study but became open

during data collection. Many study participants expressed excitement about this program

because it fills the gap in the children’s insurance landscape by covering all children from low-

income households regardless of immigration status, including those who are ages 6-18 no

longer eligible for Healthy Kids, at a low cost (between $8 and $15 per child per month).

However, unlike previous times when the Plan had to close shortly after it opened enrollment

because of demands, this health plan is having difficulties with meeting their enrollment goal as

well. There is no study examining the current trend for this health plan. Study participants put

forth several theories, including the inconsistency of program availability (which has made it

difficult to build trust and momentum for outreach), changing demographics both in age and

immigration, and the Deferred Action competing for the attention of undocumented young

people who are more focused on their path to citizenship than obtaining health insurance.

One program that has experienced a surge in applications and enrollment since 2006 is Medi-

Cal. Study participants reported witnessing more families in their service populations becoming

eligible for Medi-Cal because of loss of income during the Great Recession. According to

program data maintained by the Department of Public Health, the Healthy Kids outreach

partnership, despite enrollment decline in Healthy Kids, has continued to submit about 30,000

applications a year; typically more than two-thirds are Medi-Cal applications. The DPH-

contracted agencies have submitted increasing number of Medi-Cal applications since FY 2006-

2007 (the beginning of the Recession) until FY 2009-2010. During FY 2006-2007, for children

ages 0-5, DPH-contracted agencies submitted 1,061 applications for Healthy Kids, 2,623 for

Healthy Families, and 6,647 for Medi-Cal. During FY 2009-2010, DPH-contracted agencies

submitted 370 applications for Healthy Kids, 1,619 for Healthy Families, and 8,813 for Medi-Cal.

Study participants suggested that the increase in Medi-Cal applications reflected the increase in

number of families who became eligible to this program as a result of loss of income due to the

Recession. The number of submitted applications for Medi-Cal has decreased in the past two

years, as the economy slowly improved (Chart D and Table A in the appendices).


CHAPTER 3: CURRENT RECRUITMENT STRATEGIES

To understand fully the reasons for enrollment decline for Healthy Kids, it is important to know

how outreach and recruitment are being conducted currently. The Los Angeles County

Department of Public Health contracts 11 community clinics or community-based organizations,

two local public health departments (Pasadena and Long Beach), and two educational agencies

(Los Angeles Unified School District and Los Angeles County Office of Education) to conduct

outreach and enrollment for children’s health insurance programs, including Healthy Kids. One

of the clinics (Asian Pacific Health Care Venture) subcontracted three additional organizations

specialized in outreaching to ethnic-specific communities in the diverse Asian American

population. Together, these contractors cover all eight SPAs in Los Angeles County. (For a list

of contracted agencies and the SPAs each serves, please see Table B in the appendices.) Los

Angeles Unified School District is responsible for outreach and enrollment through all the public

schools in its district, while Los Angeles County Office of Education works with all other school

districts in the county.

According to a monitoring report in 2007 by the Healthy Kids Evaluator at the time, DPH-

contracted agencies generated about 1 in 5 completed applications to Healthy Kids; only clinics

submitted more applications during that year. Applications submitted by these contractors also

had among the lowest denial rates, compared to other enrollment sources (Urban Institute,

2007). The role of these DPH-contracted agencies have become more significant, as other

funding sources for CAAs have slowly disappeared since the State’s budget cut during the

Schwarzenegger administration in 2007. First 5 LA is essentially the sole funder for CAA’s

outreach, enrollment, retention, and utilization (OERU) activities.

There are other community-based organizations and community clinics that conduct outreach

and enrollment activities for Healthy Kids and other low-cost insurance programs but are not

part of the DPH contractor network. Three of these organizations participated in focus groups

and interviews for this study. Their outreach strategies do not differ from those used by the

DPH-contracted agencies.

Outreach Activities: CAAs in all DPH-contracted agencies conducted outreach aimed at the

broader community, at venues such as local health fairs or existing community events. This

type of outreach provides visibility for the organization, but success in actually identifying

children who are eligible for Healthy Kids is uneven. Many agencies limit this type of outreach

activities to more strategic sites and events that attract families with young children. More

common are “in-reach” activities that target clients and program participants in places such as

clinics, schools, and their own organizations as well as community partners. All focus groups

identified schools and clinics as the most important places to promote Healthy Kids and enroll

children. Many agencies also conduct outreach at churches, parks, WIC offices and/or other

public agencies. At least one agency uses the promotora model, going door-to-door, focusing

on low-income or Section 8 housing. Some CAAs working in the Asian communities also found

outreaching at Asian supermarkets to be effective. Because of the importance of ethnic media

in this community, at least one agency includes local advertising in ethnic media in their budget.


Only one key stakeholder (non-DPH contractor) mentioned conducting outreach and recruitment

at workplaces.

Another key activity that CAAs engage in to support outreach and enrollment is networking,

particularly with organizations that have access to the target populations, such as clinics,

schools, and WIC offices. Part of the networking includes community education to providers

and staff at these organizations about eligibility and requirements of Healthy Kids and other

programs, especially when there are changes that affect the families they work with. This may

include presentations at staff meetings, participation in community networks, one-on-one

relationship building, and reciprocal involvement in each other’s events.

Language Capacity in Outreach: In 2005, the ethnic background of children served by Healthy

Kids was predominantly Latino (88%), with another 11% identified as Asians (primarily Korean)

(Howell, et al., 2006). According to a key stakeholder, parents who enroll their children into

Healthy Kids are predominantly Spanish-speaking. That percentage has consistently hovered

just below 90% since the program’s inception. Many study participants (including but not limited

to DPH-contracted agencies) reported seeing an increase in non-Latino immigrant families

interested in Healthy Kids, including Korean, Armenian, Iranian, and Chinese, as well as

indigenous populations from Mexico and Central America who are not proficient in Spanish.

Many of these agencies may not have the language capacity to work with limited-English-

efficient (LEP) and non-Spanish-speaking families. If the parent speaks an Asian language, the

agency may refer her to Asian Pacific Health Care Venture or one of its subcontractors.

Sometimes the agencies rely on their children to interpret for their parents. While study

participants admitted this is not an ideal solution, they were concerned that a referral to another

agency would delay, or worse, discourage these immigrant parents in already hard-to-reach

communities from following through with the application.

Beyond Healthy Kids: Study partners and participants consistently stressed the significance of

Healthy Kids outreach not only in terms of enrollment in Healthy Kids, but also in terms of its

impact in the overall quality of life for families, regardless of their eligibility for Healthy Kids. The

CAAs do this by linking families to a plethora of programs available to them. Healthy Kids is just

one of the programs the CAAs try to introduce and link families to in their outreach. Because

Healthy Kids is a “last resort” low-cost health insurance program, the primary focus is on Medi-

Cal and Healthy Families. In other words, CAAs refer Healthy Kids to community members only

after it is determined they are not eligible for Medi-Cal or Healthy Families, mostly because the

children are undocumented or sometimes because their household income is between 250%

and 300% of the FPL. Having a portfolio of health insurance options that offer something to

almost everyone is also critical to relationship-building and eventual enrollment of the families in

the most appropriate program. This approach was reinforced by a 2011 report by the California

Coverage & Health Initiatives, which states, “Outreach using an ‘umbrella strategy’ that offers

something for everyone, as opposed to addressing only specific programs, is critical to

enrollment success.”


CAAs also link families to other programs, such as CalFresh, housing, legal, and immigration

assistance. CAAs will attempt to build relationships and learn more about the families they

outreach to, instead of focusing only on their health insurance status. This holistic relationship-

building approach is necessary because initially CAAs would need to learn the family’s income

and immigration status before deciding which programs they are eligible for. Both types of

information are sensitive especially to low-income and immigrant populations, and community

members may not share this information unless some trust is built and they know CAAs are

trying to be helpful. For some community members, health insurance may not be their priority

for their children, especially in communities where there are a plethora of needs and lack in

resources. Other times, health insurance may be a foreign concept, especially to immigrants

who do not have a similar system in their countries of origin. CAAs often have to educate these

community members on the importance of health insurance while addressing their other needs

that they may find more “immediate.” This could be something as simple as reading a letter or

utilities bill for them, or something as complicated as legal issues that may be beyond the

expertise of the CAAs, and for which they have to find additional resources for the community

members.

Another function of the CAAs beyond outreach is advocacy. Often, the application process for

Healthy Kids and other public programs can be an arduous one for populations who are not

familiar with navigating the system. CAAs support families in completing the application,

explaining requirements (like eligibility and required documents), and sometimes advocating on

their behalf to agencies that oversee the respective programs. Successful applications may

take multiple encounters. In focus groups, CAAs shared how their persistence led to severely ill

children finally getting treatment, or parents being relieved that they were able to get a diagnosis

for their children. As time-consuming as this advocacy is, it is critical to making sure

applications are successful, to improving health outcomes in underserved communities, and to

building relationships with community members that may have other needs in the near future.

Many study participants, especially CAAs, believed that, while not directly related to Healthy

Kids enrollment, these activities are necessary to identify the harder-to-reach Healthy Kids-

eligible populations and achieve the program goal of filling the health insurance gaps for young

children.


CHAPTER 4: REASONS FOR ENROLLMENT DECLINE

Focus group and interview participants identified the following reasons for enrollment decline:

A. Discontinued enrollment for children ages 6-18

B. Decline in undocumented immigration, especially children ages 0-5

C. Fear and discouragement among undocumented immigrants in program participation

D. Lack of community awareness about Healthy Kids

E. Limited number of providers who accept Healthy Kids

F. Decreased number of Certified Application Assistors (CAAs)

A. Discontinued enrollment for children ages 6-18

Although the hold on Healthy Kids enrollment in 2005 only applied to children ages 6-18, study

participants believed that the policy had a negative effect on recruiting and enrolling younger

children that continues to this day. Since as early as 2007, evaluation of the program has

attributed a decline in completed Healthy Kids applications from children ages 0-5 to “the

enrollment hold for children 6-18 that was implemented in June 2005” (The Urban Institute,

2007). Study participants gave several explanations for this “carryover” effect.

The lack of insurance options for older children (especially undocumented) creates a gap in the

overall package of health insurance programs that makes outreach and relationship-building

challenging to CAAs. For some families with multiple children, the fact that their older children

would not be eligible for Healthy Kids (or any other insurance programs because of their

immigration status) “just stops the conversation.” Previous research has also shown that

“families who have the option of covering all children versus covering only children ages 0-5

may be more inclined to enroll their child if the older child remain eligible” (Farias, Cousineau &

E-Nunu, 2009).

Parents want to keep all their children with the same provider in the same health plan, where

possible. It is more convenient to be able to take all of one’s children to the same doctor,

especially if the family trusts that doctor and if the doctor already has a good understanding of

the family’s medical history. Some families would prioritize insuring the older child because of

school requirements; for instance, a child who wants to participate in school athletics would

require a physical exam. As one study participant stated, “Many parents who don’t have

familiarity with health insurance don’t start really caring about it until they have to put their kids

in sports, which will be after 6 years old.” Parents may also reason that younger children tend to

be healthier and less at risk. Often, they would wait until their younger children get sick before

they seek help. Parents who “know how the system works” would also rely on Emergency

Medi-Cal when that happens or the Child Health and Disability Prevention (CHDP) program for

periodic immunizations and health check-ups.


Finally, the fact that younger children would age out when they turn five also discourages

parents from enrolling their children into Healthy Kids. This is especially true with the

undocumented population, who may consider that the risk of exposure outweighs the benefits of

health coverage for a couple years. For this reason, many families prefer the Kaiser

Permanente Child Health Plan, which allows them to keep all their children in one plan and will

insure their children until they become 18. Even though this plan does not have a consistent

open enrollment period, these families are willing to wait. As one participant stated, “Honestly, if

Kaiser opens, they don’t even want to know about Healthy Kids, especially because Healthy

Kids is only until the age of 5.” Some study participants observed the migration of some families

enrolled in Healthy Kids to Kaiser Permanente Child Health Plan when it becomes available,

even though they have to pay a premium for the Kaiser plan. One study participant, stated,

“Some families choose [Kaiser] because they don’t feel secure with Healthy Kids. They don’t

know if it’s going to be there in the future or their children will age out.” However, some parents

prefer to keep their children in Healthy Kids because they have developed a trusting relationship

with their existing providers or because there is no Kaiser facility near their homes. Especially

for families that rely on public transportation, having access to a clinic close to home is of

paramount concern. Familiarity with the providers and transportation are important

considerations for parents when choosing a plan.

Many study participants also noted that L.A. Care has kept coverage for children ages 6-18 who

enrolled prior to the enrollment hold. However, if a child is dropped because of missed payment

(for even a month) or another reason, he or she cannot get back into the program. While this

does not affect the enrollment of children ages 0-5, it does contribute to the decline in overall

enrollment for the program.

B. Decline in undocumented immigration

All the CAAs and other study participants reported seeing fewer undocumented children in the

0-5 age range, in at least the last three years. This is consistent with research examining

national trends in unauthorized immigration in the last decade. According to one report, the

number of undocumented immigrants in the U.S. grew rapidly at the beginning of the millennium

but “had essentially stopped growing” since 2007. States with the largest unauthorized

immigrant populations, including California, experienced at or below zero growth (Warren, 2011;

Johnson & Hill, 2011). One study participant, a data expert, explained,

[Undocumented immigration in Los Angeles] is now back to about 1975

level…What you have now is long-settled immigrants. When we think about

immigrants, we think of them as being in a sea of newcomers. Everybody has an

image that is 20 years out of date.

A 2012 report by the Migration Policy Institute also reports a significant change in the immigrant

population in the U.S. According to the report, “The shift that has been taking place over time

has been the increasing proportion of second-generation immigrants who are born in the United


States and are US citizens: in 2009 second-generation children outnumbered first-generation

children by more than six to one” (Jones-Correa, 2012).

The explanation cited by study participants most for this decline has to do with lack of

employment opportunities in Los Angeles County, as compared to before the Recession. The

economic downturn hit harder those industries that have a high concentration of undocumented

labor, including construction, restaurant, and garment industries. As one participant stated,

“They don’t risk it [coming to the U.S.] because for them it’s not worth it anymore. They’re

struggling over here just as they are over there.” One study participant who specializes in

outreach in workplaces stated that, because of the shrinkage of the garment industry, older and

more experienced workers are retained at the expense of younger workers. There are just

fewer opportunities for newly arrived immigrants. Many study participants shared stories of

immigrants moving from California to other states, including North Carolina, Alabama, Arkansas,

Iowa, Nebraska, Georgia, and Mississippi. These are also states that have experienced an

exceptional proportional surge in immigrant population, according to national studies.

As the immigration “pull” weakens, study participants also observed the diminishing of the

“push” factors. The relative economic stability of Mexico and countries in Central America also

reduces the likelihood of emigration. Some study participants even reported an increase in

families moving back to the countries of their origin. The employment opportunities in Latin

American may have even improved recently. According to a study participant who is a policy

expert, the decrease in the birth rate in Mexico the past decade demands a larger labor force in

that country.

Particularly for children ages 0-5 in immigrant families, study participants stated that they were

more likely to be born in the U.S. and are therefore eligible for other programs, such as Medi-

Cal and Healthy Families. Many participants also believed that it has become more dangerous

to cross the border, so not as many families risk bringing their young children with them as there

used to be. They cited increasing border patrol (by the federal government as well as civilians)

as well as the escalating drug trafficking between U.S. and Mexico as major risks that deter

migration as a family unit. In addition, recent media coverage reported that “Mexican smugglers

have been increasingly turning to the sea to skirt border security and get illegal immigrants into

California” (KPCC, 2011). The Los Angeles Times reported that in 2010 “867 illegal immigrants

and smugglers were arrested at sea or along the California coast, more than double the number

in 2009.” Because the boats used in these instances are often small fishing vessels without

lights and safety equipment in order to evade detection, they “are not designed for deep-water

trips and are unsafe.” Overcrowding also makes capsizing more likely, and passengers are

easily ejected when these boats crash against waves or come through surf, resulting in

significant injuries or even death (Quinones & Blankstein, 2001). Because of the dangers

associated with smuggling, by sea or by land, study participants stated that undocumented

immigrants are not likely to bring young children with them to the U.S.

These local observations about the decline in undocumented immigration are consistent with

national data trends. As the 2012 Migration Policy Institute states, “Recent trends indicate a


sharp drop in border apprehensions, the result of a combination of increased policing at the US-

Mexico border, a slowing economy in the United States, and growing opportunities in Mexico”

(Jones-Correa, 2012).

However, one study participant, data expert, discussed the possibility of an upward trend for

immigration in the near future. He stated, “If the economy improves and the housing market

picks up steam, there is not a ready pool of domestic labor to go out and work construction

cranes and move concrete around. My guess would be that immigration from somewhere

would pick up. If it’s not from Mexico, it will be from Nicaragua or El Salvador. When there is a

demand for labor in the United Stated, for the last 200 years, we have found a way to bring it in.”

C. Fear and discouragement among undocumented immigrants in program

participation

Study participants consistently emphasized the fear of exposure among undocumented

immigrants as a major barrier for that population’s access to services, including Healthy Kids.

The national political climate has contributed to this fear, since the passage of SB1070 in

Arizona in 2010, which spurred passage of similar legislation in five other states. The

ramifications are felt locally. As one study participant stated,

I think the political situation has more to do with the stress that people face, their

worry over engaging with public services, their reticence to take their kids in for

health care…For children who are undocumented, that becomes an even higher

bar…You don’t have to be in Arizona to be in that situation.

Both mainstream and ethnic media have reported on the historic number of deportations by the

Obama administration, which was only recently tempered by the recent Deferred Action

executive order by the President.5 Undocumented immigrants not only read about them in the

papers, but they also experienced family separations personally or through someone they know.

Study participants emphasized that personal experiences of discrimination, such as immigration

check points in their neighborhoods and ICE raids in the workplace, discourage civic

engagement and public participation by undocumented immigrants. As one study participant

stated, “A lot more people are getting deported, so now they’re thinking that maybe by applying

for this [Healthy Kids] they’re doing to be identified as being undocumented.”

These personal experiences also include negative interactions with the very system that could

help them. Sometimes, it is their lawyers who perpetrate the myth of “public charge”6 and

5 In 2010, detentions and returns of undocumented immigrants at the border declined from over 1.6

million in 2000 to about 476,000, the lowest number of apprehensions since 1972. Immigration enforcement by the Obama administration shifted the focus to undocumented immigrants who were already living in the U.S. According to a 2012 Migration Policy Institute report, “Over 387,000 noncitizens were deported in 2010 alone – almost double the number in 2000” (Jones-Correa, 2012). 6 According to U.S. Citizenship and Immigration Services, “For purposes of determining inadmissibility,

‘public charge’ means an individual who is likely to become primarily dependent on the government for


misinform them that participation in Healthy Kids and other non-cash-aid programs would

jeopardize their chances of naturalization. Other times, it was reinforced by previous negative

experience in the U.S. when they were cheated by people who sold them fraudulent insurance

products. This is why CAAs focused on building relationships with their target population by

learning about their whole lives, rather than honing in only on their health insurance status and

giving the appearance of “selling them something.” As one study participant noted,

Because they had already had previous experience with people that have

charged them…They fear that they will receive some bills that could hurt them

when they go and start making the arrangements for their immigration

paperwork.

When parents find out about Healthy Kids, they are sometimes incredulous because it “sounds

too good to be true,” as one study participant put it. Another study participant stated, “I do think

there is some feeling about [Healthy Kids] being a scam because they look at what Healthy Kids

gives in terms of benefits and the premium that they charge. They can seem like they’re not

real because it’s a very good deal.” This sense of disbelief underscores the wariness

undocumented immigrants feel as a result of their negative experiences or expectations from

living in the United States.

Community members who may be eligible for Healthy Kids often feel discouraged to apply by

their own eligibility workers and social workers within County agencies. Several study

participants who are CAAs observed that some public agency staff have been hostile to some

applicants because of their immigration status. Or if the applicant was denied other programs,

such as Medi-Cal, they were not referred to Healthy Kids, which they are most likely eligible to.

One study participant explained, “Once they get that letter saying you don’t qualify, they’re

convinced that they can’t get anything.” Many study participants who are CAAs stated they

often had to advocate on the behalf of these immigrant applicants to their social workers or

eligibility workers. This advocacy is an important function of their work, without which

enrollment into Healthy Kids and other programs would certainly be much lower. Although the

Healthy Kids application process is more streamlined and requires fewer documents and

information than other programs, many study participants who are CAAs reported that eligibility

workers who are not familiar with Healthy Kids would demand documents and information that is

not required for families to disclose. As one study participant who is a CAA stated, “That’s why

we are advocates. We need to educate the [eligibility workers] that they’re not supposed to ask

for certain information [that food stamps or Medi-Cal require]. As advocates, we can say,

‘You’re wrong. You cannot do that. You have to bring up the form and look at the page.’ We

do that a lot.”

subsistence, as demonstrated by either the receipt of public cash assistance for income maintenance or institutionalization for long-term care at government expense.” See http://www.uscis.gov. Many in immigrant communities believe mistakenly that any utilization of public programs would constitute dependence on the government, or “public charge,” and therefore make them less likely to be eligible for citizenship.

http://www.uscis.gov/


Because of the culmination of these negative personal experiences, parents “just don’t feel

comfortable disclosing their information.” The overwhelming majority of children enrolled in

Healthy Kids as a “last resort” because their immigration status has made them ineligible for

Medi-Cal or Healthy Families. Given that enrollment is capped at the age of 5, many parents do

not find it worth the risk of exposure to have their children only insured for a few years or less

(or they wait until their children get sick before risking exposure).

D. Lack of community awareness about Healthy Kids

Many study participants attributed early success in Healthy Kids enrollment to a highly visible

marketing campaign promoting the program. According to a research report, “Early on in the

[Healthy Kids] program, there was an emphasis on identifying uninsured children and enrolling

those eligible into public insurance programs. In recent years, attention has shifted towards

addressing discontinuity in care, retention in public insurance programs and reducing lapses in

continuous enrollment” (Farias, Cousineau & E-Nunu, 2009). There is currently no concerted

publicity effort in the media on behalf of Healthy Kids, especially when compared to advertising

about Medi-Cal and Healthy Families. As a result, the general public may know about the Medi-

Cal and Healthy Families, but they are not likely to be familiar with Healthy Kids. When asked

whether eligible higher-income families (251%-300% FPL) would be discouraged from applying

for Healthy Kids because most of enrollees are undocumented, one study participant responded

that it is not an issue because they would not know about Healthy Kids in the first place. A

focus group participant added, “Healthy Kids is seen as the ugly duckling because they don’t

promote it.”

Furthermore, study participants who are CAAs reported that there is no collateral material

specific to Healthy Kids. First 5 LA used to produce Healthy Kids flyers, but they are no longer

available. Individual agencies have to develop these materials themselves, with limited graphic

design. Because of their holistic approach to health insurance coverage, handouts and

curriculum produced by individual agency combine Healthy Kids with other health insurance

programs. Since much fewer children enrolled in Healthy Kids than Medi-Cal or Healthy

Families, sometimes written materials do not even have information on Healthy Kids. All study

participants who are CAAs recognized the usefulness of Healthy Kids-specific materials. As

one study participant stated, “If you have something more specific [to Healthy Kids] with playful

graphics, if you can put it together in a user-friendly and simple language, I think it will really

help.” Other participants noted the importance of having these materials in languages in

addition to English and Spanish.

These materials are also important in educating social workers or eligibility workers who are not

familiar with Healthy Kids eligibility requirements and application procedures, which are often

less stringent or complicated than other programs low-income families may apply for. Study

participants complained that these workers often demand more documents that Healthy Kids

required because they are used to other programs, such as Medi-Cal. One participant called

the streamlined application procedures of Healthy Kids as “antithetical to the way DPSS does


enrollment.” These unnecessary requests often discourage people from going through the

process or make them feel they are not eligible.

E. Limited number of providers who accept Healthy Kids

Another reason given by study participants about the decline in Healthy Kids enrollment has to

do with the limited number of doctors and providers who accept Healthy Kids. They reported

that some families have difficulty especially finding pediatricians and dentists. This is not

common in all regions of Los Angeles County. Typically, provider network is more sparse in

remote areas of the County (such as Antelope Valley) where there are not many providers to

begin with, as well as in more affluent areas throughout the County where there is a smaller

concentration of community clinics. Also, many providers in more affluent areas who can “pick

and choose” the type of patients they want often decide not to accept Healthy Kids, which has a

lower reimbursement rate than most other public insurance programs. Conversely, SPA 4 and

SPA 6 are perceived to have a wider network of Healthy Kids providers. Study participants who

are CAAs also heard from families enrolled in Healthy Kids visiting their doctor’s office only to

find out the doctor is no longer part of the network or does not realize she or he is part of the

network. Evidently, the lack of awareness about Healthy Kids extends beyond community

members to include some providers as well.

F. Decreased number of Certified Application Assistors (CAAs)

When Healthy Kids covered children ages 6-18, other funders, such as the California

Endowment, provided funding for outreach and enrollment assistance, which stopped by the

end of 2006. State funding was also eliminated in August 2008 under the Schwarzenegger

administration. Since then, First 5 LA became the primary funder for outreach, enrollment,

retention, and utilization (OERU) activities in Los Angeles, with very limited funding coming from

LAUSD and CHIPRA (the federal Children’s Health Insurance Program Reauthorization Act).

As a result, the number of CAAs declined significantly. Outside of the contractor network under

the Department of Public Health, many community clinics have maintained a small CAA staff to

help their uninsured patients find coverage that would pay for clinical services. Although OERU

activities are such a critical component of Healthy Kids and other public health insurance

programs, the number of CAAs is not likely to increase anytime soon. According to a report

commissioned by the California Endowment, published shortly after the State’s budget cut in

2008, “The future of the outreach and enrollment activities are also highly in doubt… The CHIs

[Children’s Health Initiatives] now rely on local funding (First 5, health plan, small grants) for

OERU activities and small fees paid by the state to Certified Application Assistors for successful

applications. CHIs are continually challenged to find OERU funding” (Diringer and Wunsch,

2008).

Concurrent with the decrease in the CAAs is the reduction of the workforce that often

collaborates with and makes referrals to them, particularly the school nurses. In some cases,


study participants reported that, in the absence of these nurses, they are relying on principals

and teachers, who are overwhelmed with their regular responsibilities, to refer students who

may need their services. In light of this staff shortage, the Department of Public Health and its

contracted agencies have made strategic partnership with LAUSD and other school districts

through the Los Angeles County Office of Education. Nevertheless, the lack of investment in

OERU activities is another important factor in maintaining the enrollment level of previous years.


CHAPTER 5: OPPORTUNITIES FOR INCREASING ENROLLMENT -

RECOMMENDATIONS

Based on the reasons for enrollment decline provided by the study participants, they also

identified opportunities for increasing enrollment, including the following:

A. Expansion of Healthy Kids to children ages 6-18

B. Outreach to eligible higher-income families (251%-400% FPL)

C. Outreach materials and advertising specific to Healthy Kids

D. Better coordination with County agencies

A. Expansion of Healthy Kids to children ages 6-18

All study participants emphasized that currently there is no viable health insurance option for

undocumented children ages 6-18. They remain the largest uninsured population among

children. Study participants were observing a trend that has been occurring statewide.

According to the 2008 California Endowment report, “Healthy Kids total enrollment [in California]

declined between May 2006 and April 2008 from a peak of approximately 89,000. At least 18 of

the 22 CHIs with Healthy Kids programs maintain active wait lists, totaling 21,000 children, due

to funding limitations. Nearly all waitlisted children are between 6 and 18 years of age” (Diringer

and Wunsch, 2008). Interviews with managers of Healthy Kids programs in other Counties also

suggested that counties that maintain enrollment for children ages 6-18 tend to experience a

smaller decline in enrollment than other counties who exclusively cover young children.

Similarly, CAAs who are part of this study also believed that including the older age group would

also increase enrollment for younger children. In fact, out of all the opportunities identified,

study participants believed that this is the key recommendation that would truly make a

difference in increasing Healthy Kids enrollment.

The legislation governing Children and Families Commissions prevents First 5 LA from

dedicating its funding to the older age group, and the philanthropic sector is not likely to invest

additional dollars in this kind of efforts as they have done before 2006. Counties where there is

continuous coverage are able to do so only with investment from the County government.

Study participants urged First 5 LA to explore funding and policy opportunities to expand

Healthy Kids coverage to children ages 6 to 18 in order to fill the last significant gap in children’s

health insurance coverage in Los Angeles County.

B. Outreach to eligible higher-income families (250%-400% FPL)

The rising unemployment rate after the Recession in 2007 allowed for many families to become

eligible for low-income programs, which many attributed to the increase in Medi-Cal applications

in that time period. However, the Recession also affects other families who still make too much


to qualify for Medi-Cal and Healthy Families. In fact, some CAAs who are part of the study

reported seeing slightly more higher-income families than they typically serve coming through

their door and seeking services, despite not being the primary focus of their outreach. Some

are multiple-earner families where one earner is laid off or reduced to part-time, but because of

other earners, the families still have too much income to qualify for Medi-Cal or Healthy

Families. Others are working parents with employers who offer employer-paid insurance but

have to increase their contribution to a health plan to cover dependent children. Healthy Kids

could be a less expensive alternative for these families. As the Commission increases the

income eligibility for Healthy Kids from 300% FPL to 400% FPL, small business owners, their

employees, and people who are self-employed are also likely target populations. Study

participants observed that these groups would be more diverse in both race/ethnicity as well as

preferred spoken language.

Study participants also admitted that the eligible higher-income families (250%-400% FPL) have

been relatively unexplored as a target population for Healthy Kids, as lack of legal status

remains the overwhelming reason why children are enrolled into the program. Some of the

challenges in outreaching to families with relatively higher-income have to do with stigma of

needing help and lack of experience navigating the system that discourages these families from

applying to Healthy Kids and other programs they are now eligible for. Stigma is not an

insurmountable barrier; some study participants explained that this population has responded

positively despite any stigma, once they make the decision to seek help and build trusting

relationships with providers. Also, during the Recession, as one study participant explained,

“You have a perfect excuse because there are many others who are in the same boat.” Besides

stigma, the few CAAs who have had some experience working with this population observed

that they are also less patient with inefficiencies and bureaucracy; they have not accepted the

complicated procedures, required documents of eligibility, and inordinate amount of paperwork

as “normal” in a way that someone who is familiar with using the system has.

Yet, despite potential stigma and frustration with the system, study participants believed that

struggling families with higher but eligible incomes are receptive to receiving help. A lot of

times, they are just not aware that help is available to them. According to study participants,

these families may think having a job or other assets (like a house) would make them ineligible.

These CAAs are beginning to craft messages that address these assumptions in their outreach

materials.

Eligible higher-income families (250%-400% FPL) are diverse, in terms of geography,

occupation, race/ethnicity, immigration status, language of preference, and attitude towards and

experience with program participation. Outreaching to them effectively will require a better

understanding of who they are and different outreach strategies than the ones traditionally used

in Healthy Kids. One study participant noted,

The challenge is going to be how to outreach to them in a way that makes them

feel comfortable with the program that they’re eligible for and that it’s not a

government handout. It’s helping to help them be able to afford what would


otherwise be an unaffordable insurance product for them. We need to develop

new strategies and new partnerships to outreach to those communities.

Meaningful outreach to this population would require more than crafting new messages.

Unfortunately, most of the outreach has been focused on the low-income populations. For

many contracted agencies, the eligible higher-income families are not part of their target

populations or organization’s mission, which is to serve low-income or indigent populations. It

would not serve these agencies or the communities they work with to dilute their mission and

focus. Rather, study participants believed that it is necessary to expand the current outreach

network (with additional financial support) to include places where the uninsured but eligible

higher-income families could be found, such as community colleges and small businesses,

especially those that do not offer a health plan to their employees.

Among the potential outreach partners suggested by study participants, small businesses are

perhaps the most crucial but potentially the most challenging to penetrate. Some business

owners are skeptical about someone “selling them a product” or “agitating their staff.” In

addition to this resistance, most small businesses work through insurance brokers and agents

who work on commissions and have a different bottom line and self-interests. There are also a

plethora of small businesses, ranging in number of employees, industry types, profit margins,

and ownership models (e.g. self-employed, mom-and-pop, franchise, etc.). In approaching

small businesses, participants believed that it would be more strategic to work with entities that

work with them, instead of approaching small businesses directly. Some of these entities are

chambers of commerce, business and professional associations, and labor groups (especially in

non-unionized sectors).7 Some study participants cited some successes with targeted

campaigns, including more receptive businesses or business associations, such as the Hispanic

Chamber of Commerce. Furthermore, study participants believed that a coordinated campaign

backed by both First 5 LA and other trusted official entities would make any appeal to the

business community more credible.

A few study participants also suggested that, to be effective, there needs to be more research

into the eligible higher-income families, including their racial/ethnic, linguistic, geographic, family

composition, employment and other diversity and concentration in Los Angeles County. A few

others cautioned that while the increase to 400% FPL would make more families more eligible

for Healthy Kids, the need of the uninsured children still largely remains with older children who

are undocumented and have essentially no alternatives.

7 A 2011 report by the California Coverage & Health Initiatives also states that “the recession has given

California outreach workers increased experience with higher-income populations, as the recession has affected families and individuals who have never before sought to enroll in public insurance programs…[These] individuals are more likely to be English speakers and are more wary of government programs, expressing both privacy concerns and frustration with the inefficiencies of the application process. New strategies and approaches will be essential to reaching individuals eligible for Exchange subsidies…In addition to CBOs and the CAA network, potential partners to assist in reaching this population are tax preparers, retail outlets, faith organizations, colleges and trade schools, insurance agents and brokers, and sports and entertainment outlets.”


C. Outreach materials and advertising specific to Healthy Kids

Ethnic media have been identified as important channels, including radio and TV, to stress the

importance of health insurance for children, especially for immigrant populations. Study

participants realized that these advertising campaigns cannot be piecemeal but need to be

“massive, permanent, and constant” to reinforce the message. One study participant, who is a

policy expert, also questioned the wisdom of an expensive media campaign at this point. By the

time a media campaign is developed, the evolution of the insurance landscape leading up to the

implementation of the Affordable Care Act (ACA) in 2014 may make some messages less

relevant.

A more cost-efficient method, as employed by some contracted agencies occasionally when

opportunities arose, may be working with public affairs program on these radio and TV stations.

Many study participants believed that it would be more effective if trusted community leaders

speak on behalf of Healthy Kids to “vouch for the safety” of the program to allay fears among

undocumented families. Study participants also suggested leveraging relationships First 5 LA

has with various media outlets to increase such opportunities.

Another First 5 LA asset, according to many study participants, is its public affairs department

and its ability to produce social marketing materials that have “playful” and colorful graphics and

simple language. Some study participants referred to previous materials First 5 LA developed

specifically for the Healthy Kids program but are no longer available. These materials are useful

tools in their outreach efforts. They believed branding Healthy Kids consistently with other First

5 LA marketing campaigns would give the program more visibility and community awareness.

Study participants could not agree on the usefulness of other collateral materials, such as pens,

magnets, and other “giveaways,” that bear the branding of Healthy Kids. It seems that on their

own, these giveaways have little added value and are not likely to be effective in getting families

interested in enrolling into Healthy Kids (or addressing their concerns or fears). However,

according to other study participants, “eye-catching giveaways” can entice potential families to

come and hear about Healthy Kids and other insurance programs; they are a “conversation

starter.” As one study participant stated, “Most people at festivals are in a festive mood and

won’t stop by our booth unless there are freebies.”

For eligible higher-income families that qualify for Healthy Kids (251%-400% FPL), websites

tend to be a viable medium for promoting the program, even if the website is only in English.

Outreach materials should be clear that young children could still be eligible for Healthy Kids

even if their parents have a job or own a house. Study participants also qualified that so far

efforts to appeal to this population have been limited, and any outreach strategy could only be

preliminarily deemed as successful without deeper commitment to engage this population.


D. Better coordination with County agencies

The group that CAAs in this study has to work most closely with in order to increase the number

of successful applications is eligibility workers at the Department of Public Social Services

(DPSS). Applications to any programs can be an arduous process, especially for immigrants

who do not speak, read, or write English proficiently. CAAs often intervene on behalf of these

applicants when there is incorrect information on the form or missing documents. The DPSS

eligibility workers are responsible for processing and approving applications for a plethora of

programs, including Medi-Cal, Healthy Families, CalWORKS, CalFresh (formerly known as food

stamps), General Relief, In-Home Supportive Services, CAPI (Cash Assistance Program for

Immigrants), among others. Each program has its set of eligibility requirements and

procedures. Medical assistance is the most common aid offered to DPSS clients. As of June

2012, Medi-Cal assistance alone already accounts for 725,736 cases in Los Angeles County,

involving almost 1.7 million people. DPSS staff are so overwhelmed by different regulations and

increasing caseloads (as a result of budget cuts and more people becoming unemployed and

eligible for services) that study participants suspected that Healthy Kids is one of the programs

most eligibility workers know very little about, especially as an alternative for children who do

not qualify for Medi-Cal or Healthy Families. Many participants have noted the

complementariness of Medi-Cal and Healthy Kids – one participant called them “cousins” – that

is unexplored by DPSS staff. One study participant explained, “When the person is over income

for Medi-Cal or Healthy Families, they [the eligibility workers] don’t send them to Healthy Kids.

They send them a letter telling they don’t qualify.” The participant further added that this makes

it more difficult to convince the families later that they are eligible for other programs.

There used to be DPSS staff who coordinated with the CAAs to do troubleshooting with

applications that were not getting approved. These “ombudsmen” are no longer available due

to funding cuts, according to study participants. There has been staff transfer and turnover in

the department over the years that it is difficult for CAAs from all but a few contracted agencies

to build consistent working relationships with the eligibility workers. Given the impending

implementation of the ACA, it is even more crucial for these relationships to be in place to

address the confusion that is likely to result in the transition to ACA, including the merging of

Healthy Families into Medi-Cal in January 2013. For instance, one key stakeholder suggested

that DPSS needs to develop more friendly language when denying Medi-Cal approval to

applicants that encourages and provides options for them to seek other opportunities made

available by the ACA that they may qualify for.

Overall, study participants felt that they needed help in cultivating and coordinating relationships

with DPSS to integrate Healthy Kids as one of the options for their clients. Less frequently

mentioned were DHS-operated clinics and hospitals. This will require education of County

workers about Healthy Kids and its requirements and application process, Healthy Kids-specific

materials that are readily available to County workers and their clients, and establishment of

liaisons between eligibility workers and CAAs. Study participants also believed that First 5 LA

can play a leadership role in fostering effective partnerships between County agencies and

agencies contracted to conduct OERU activities.


CONCLUSION: RELEVANCE OF HEALTHY KIDS – NOW AND

BEYOND

Despite the enrollment decline over the years, all study participants believed that the Healthy

Kids program continues to make significant contributions to children’s health insurance

coverage and to the overall health outcomes of underserved communities in Los Angeles

County. Furthermore, study participants also believed that Healthy Kids, particularly its

outreach partnership, can help Los Angeles County meet the challenges anticipated from the

implementation of the Affordable Care Act (ACA), which was upheld by the U.S. Supreme Court

in 2012.

A. Contributions of Healthy Kids coverage

Many study participants emphasized that Healthy Kids is still an important, and often the only,

health insurance option for the undocumented population. Even though this population in Los

Angeles is no longer growing at the pace of the last decade, California remains by far the state

with the largest undocumented population in the U.S. It is also important to note that the ACA

implementation will exclude the undocumented population. As a result, the uninsured

documented population would be “crowded out” even more once ACA creates an influx of newly

insured families. Without Healthy Kids, study participants believed that there would be even

more burden on urgent care centers, emergency rooms, and community clinics, resulting in long

waitlists, delay in care, and higher healthcare costs. While the economic impact of Healthy Kids

is beyond the scope of this study, there is some evidence to support these assertions. For

instance, a USC study estimated that Healthy Kids programs, if available in every county in

California, could prevent 4,300 hospitalizations annually at a savings of $24.3 million to the state

(Cousineau, Stevens, Arpawong, and Rice, 2007).

Even more important than the strain on the health care delivery system, study participants cited

the stress and emotional costs on the families caused by delay in, or lack of, care. As one study

participant stated, “Any child that gets covered is helpful. Any child. Just the relief of stress on

these families is helpful. It’s a relief across the board.” Another participant, who is a CAA in the

Asian Pacific Islander community, stated, “Families with children enrolled in Healthy Kids are

very grateful, especially those without immigration status, because they can have quality care

and they will never forget that.” For some contracted agencies, Healthy Kids sends a rare

positive message to the immigrant communities that “Los Angeles County cares” enough to

“create a culture of coverage” for communities without many health insurance options.

Because children with Healthy Kids coverage are able to access care, study participants also

believed that Healthy Kids improved health outcomes for this population. The California

Endowment report compiled independent evaluation studies of Healthy Kids programs in Santa

Clara, San Mateo, and Los Angeles County and reported that these studies “have shown that

enrollment in Healthy Kids is associated with an increase in medical and dental care utilization,


an improvement in health status, and fewer school days missed.” The report further stated that

“Healthy Kids programs throughout California may have helped prevent as many as 1,000

hospitalizations a year by treating health conditions such as asthma earlier on an outpatient

basis before they escalated and required hospitalization” (Diringer and Wunsch, 2008).

B. Contributions of Healthy Kids outreach

For populations that are not familiar with how health care is delivered in this country, CAAs

perform a necessary function in supporting Healthy Kids enrollment and utilization. As one

study participant stated, “The average education level of a lot of the immigrants, especially the

undocumented, is less than high school. So what may seem easy to you or me is going to be

daunting to a lot of these folks. So I would say application assistance is important.”

Study participants and study partners also stressed the importance of relationship building with

hard-to-reach communities as a key function of the Healthy Kids outreach partnership. There is

a depth to this work that cannot be captured solely by the number of Healthy Kids applications

submitted and approved. Because Healthy Kids is a “last resort” program, CAAs uses a holistic

or “umbrella” approach in outreach and application assistance to refer to Medi-Cal, Healthy

Families, and other public programs. Therefore, the benefits of Healthy Kids outreach cannot

be measured by only enrollment trends in this program alone. Study participants believed that

their outreach has led to increase in applications to these programs, contributing to overall

children’s health insurance coverage. According to program data maintained by the Department

of Public Health, through the Healthy Kids outreach partnership, there was a surge in overall

applications in FY 2004-2005 (41,915) when Healthy Kids became open to children ages 6-18,

not all of which are for Healthy Kids. A 2008 research study on whether Children’s Health

Initiative outreach effort increased Medi-Cal enrollment substantiated this claim, especially in

the early years of Healthy Kids. That report concluded that:

New Medi-Cal enrollment increased after the launch of Healthy Kids, and

continued its steady growth after the program’s expansion. This upward trend

occurred during an economic recovery when we might otherwise expect new

enrollment to decline. This trend suggests that outreach efforts brought new

eligible children into Medi-Cal coverage at a time when the number of eligible

children may have actually been shrinking (Sommers, Klein, Hill, and McFeeters,

2008).

Furthermore, the population who needs Healthy Kids also faces challenges in other aspects of

their lives, including employment, education, legal concerns, etc. CAAs built trust with this

population through referrals and advocacy. For many families they come in contact with,

application assistance is only one part of this relationship building process. As the immigrant

community is discouraged by the fear of exposure and negative experiences in this country, the

relationships they build with the CAAs encourage them to seek other services and improve their

overall health and quality of life. These relationships have become more critical as the health


insurance landscape continues to shift and community members will experience a lot of

confusion, starting with the transition of Healthy Families into Medi-Cal in January 2013, to

beyond the full implementation of the Affordable Care Act in 2014.

C. Health care reform and the implementation of the Affordable Care Act

The Healthy Kids program has begun to adjust in anticipation of the ACA implementation in

2014. In November 2012, the First 5 LA Commission approved raising the income eligibility for

Healthy Kids from 300% FPL to 400% FPL, to be aligned with the income population that will be

affected by the ACA implementation. This alignment will allow these higher-income families who

are currently uninsured to become accustomed to being part of an insurance program until the

Exchange comes online the following year. As one study participant, a policy expert, explained,

The idea is, get them valuing something now, get them using it so when the time

comes, they’ll be much less likely to drop it. They will have to make a decision to

lose something rather than a decision to start something when that comes up.

Another study participant added, “There might be a place for Healthy Kids program to fill that

gap at least for children until the exchange comes online. If they do a very, very good job of it,

they might even be able to keep those people after the exchange and collect the federal

subsidies for them.”

In fact, the network of outreach agencies, especially if expanded according to the

recommendations of this report, can be a foundation for a strong infrastructure for outreach and

education for the ACA implementation. Because Healthy Kids outreach strategies are holistic

and do not focus on only children eligible for the Healthy Kids program, study participants

believed that the network of outreach agencies already has developed a lot of experience,

relationships, and credibility across communities in Los Angeles County that can benefit from

the Affordable Care Act. Another policy expert echoed this suggestion,

Given the infrastructure that has been created in LA to outreach to the Healthy

Kids population, one recommendation I’d make is, how do you use that outreach

and enrollment network to reach not just kids but the parents of those kids who’ll

be eligible for Exchange coverage or potentially eligible for some kind of health

insurance or subsidy, to really think about leveraging that outreach and

enrollment network. That’s what’s happening in a lot of other counties.

Finally, this report’s findings suggest that the decline in Healthy Kids enrollment is primarily due

to policy change (specifically, enrollment hold for children ages 6-18) as a result of lack of

funding support, and to structural change in immigration patterns as a result of the economic

downturn. While the decline has been steep, there is strong research and community evidence

that Healthy Kids (through both its coverage and outreach) continues to make significant

contributions to decreasing the uninsured population in Los Angeles County and improving the


overall health and well-being of its residents. Furthermore, recommendations that emerged

from data collection and analysis and vetted by study partners and participants can address

current challenges in outreach and enrollment as well as strengthen the outreach network to

meet the demands of ACA implementation in Los Angeles County.

Limitations to this report: There are different limitations in describing and analyzing the

enrollment patterns of the two primary populations that benefit from Healthy Kids: children who

are undocumented and children from families with income between 250% and 400% of the

federal poverty level (“eligible higher-income families”).

With the first primary population, the SSG Team was only able to solicit input from CAAs who

work closely with undocumented families. Some of the CAAs, such as the promotoras, are

community members themselves. While they have great knowledge of this population, we

recognize that it is not equivalent to getting direct input from undocumented community

members. More research projects that involve undocumented families as study participants

would contribute tremendously to programs serving this population such as Healthy Kids.

With the second primary population, much is still unknown about the diversity of those families

with household income between 250% and 400% FPL; e.g. who they are, where they live and

work, what challenges they encounter with health insurance for their families, how they access

information, etc. This type of data would have been helpful in assessing the viability of the

recommendations to outreach and enroll those families more effectively. More research

projects that focus on this population will benefit not only Healthy Kids, but also the changing

and expanded health insurance landscape as a result of the Affordable Care Act.


REFERENCES

California Coverage & Health Initiatives. 2011. A Trusted Voice: Leveraging the Local

Experience of Community Based Organizations in Implementing the Affordable Care Act.

http://cchi4families.org/pdf/uploads/CCHI_NEW_WPoutreach_print%20(1)050411.pdf

Cousineau, Michael R., Gregory D. Stevens, T. Em. Arpawong, and Kyoko Rice. 2007. The

Impact of Healthy Kids on Access, Health Status and Costs. Los Angeles, CA: Center for

Community Health Studies, University of Southern California (USC) Keck School of

Medicine. http://www.cchi4families.org/pdf/evaluations/USC_chi_impact.pdf

Cousineau, Michael R., Gregory D. Stevens, and Albert J. Farias. 2009. Trends in Child

Enrollment in California’s Public Health Insurance Programs. Alhambra, CA: USC

Department of Family Medicine.

Diringer, Joel and Bobbie Wunsch. 2008. The Future of Children’s Coverage in California. San

Luis Obispo, CA: Diringer & Associates, with Pacific Health Consulting Group.

Farias, Albert, Michael Cousineau, and Timiyin E-Nunu. 2009. Retention in the Los Angeles

Healthy Kids Program. Los Angeles, CA: Center for Community Health Studies, University

of Southern California (USC) Keck School of Medicine.

Hill, Ian, Brigette Courtot, and Eriko Wada. 2006. Los Angeles Healthy Kids Program Gets a

Healthy Start: Findings from the First Evaluation Case Study. Washington, DC: The Urban

Institute (Health Policy Briefs, No. 19).

Hill, Laura E. and Hans P. Johnson. 2011. Unauthorized Immigrants in California: Estimates

for Counties. San Francisco, CA: Public Policy Institute of California.

Howell, Embry, et al. 2006. A Profile of Young Children in the Los Angeles Healthy Kids

Program: Who Are They and What Are Their Experiences on the Program? Washington,

DC: The Urban Institute, with the University of California at Los Angeles and Mathematica

Policy Research.

Jones-Correa, Michael. 2012. Contested Ground: Immigration in the United States.

Washington, DC: Migration Policy Institute. http://www.migrationpolicy.org/pubs/TCM-

UScasestudy.pdf

KPCC. 2011. 2 Dead in Possible Immigrant Smuggling Racket, Officials Say. October 5, 2011.

http://www.scpr.org/news/2011/10/05/29270/border-officials-say-2-dead-in-possible-

immigrant-/

Paredes, Mark, and Lark Galloway-Gilliam. 2010. Bridging the Health Divide: California’s

Certified Application Assistants. Los Angeles, CA: Community Health Councils, Inc.

Quinones, Sam and Andrew Blankstein. 2011. Tightened Borders Force Immigrant Smugglers

to Take Risky Sea Routes. Los Angeles Times, July 13, 2011.

http://articles.latimes.com/2011/jul/13/local/la-me-0713-immigrant-boat-20110713

http://cchi4families.org/pdf/uploads/CCHI_NEW_WPoutreach_print%20(1)050411.pdf

http://www.cchi4families.org/pdf/evaluations/USC_chi_impact.pdf

http://www.migrationpolicy.org/pubs/TCM-UScasestudy.pdf

http://www.migrationpolicy.org/pubs/TCM-UScasestudy.pdf

http://www.scpr.org/news/2011/10/05/29270/border-officials-say-2-dead-in-possible-immigrant-/

http://www.scpr.org/news/2011/10/05/29270/border-officials-say-2-dead-in-possible-immigrant-/

http://articles.latimes.com/2011/jul/13/local/la-me-0713-immigrant-boat-20110713


Sommers, Anna, Ariel Klein, Ian Hill, and Joshua McFeeters. 2008. Did the Los Angeles

Children’s Health Initiative Outreach Effort Increase Enrollment in Medi-Cal? Washington,

DC: The Urban Institute.

The Urban Institute. 2007. Los Angele Healthy Kids Evaluation, Quarterly Monitoring Report (Third & Fourth Quarter, 2007).

US Census Bureau. 2000. Profile of General Population and Housing Characteristics.

_______________. 2010. Profile of General Population and Housing Characteristics.

Wandersman, Abraham, et al. 2005. The Principles of Empowerment Evaluation. In

Empowerment Evaluation Principles in Practice, ed. David Fetterman and Abraham

Wandersman. New York: Guilford Publications, pp. 27-41.

Warren, Robert. 2011. Annual Estimates of the Unauthorized Immigrant Population in the

United States, by State: 1990-2008. San Francisco, CA: Public Policy Institute of California.

APPENDICES

Chart A. Total Enrollment of Healthy Kids, Children ages 0-5, LA County, by month

Source: LA Care Health Plan

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Mar

-04

Jun

-04

Sep

-04

De

c-0

4

Mar

-05

Jun

-05

Sep

-05

De

c-0

5

Mar

-06

Jun

-06

Sep

-06

De

c-0

6

Mar

-07

Jun

-07

Sep

-07

De

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7

Mar

-08

Jun

-08

Sep

-08

De

c-0

8

Mar

-09

Jun

-09

Sep

-09

De

c-0

9

Mar

-10

Jun

-10

Sep

-10

De

c-1

0

Mar

-11

Jun

-11

Sep

-11

De

c-1

1

Mar

-12

Jun

-12


Chart B. Total Enrollment of Healthy Kids, Children Ages 0-5, by month, by Service Planning Areas


0

200

400

600

800

1000

1200

1400

1600

1800

2000

Mar

-04

Jun

-04

Sep

-04

De

c-0

4

Mar

-05

Jun

-05

Sep

-05

De

c-0

5

Mar

-06

Jun

-06

Sep

-06

De

c-0

6

Mar

-07

Jun

-07

Sep

-07

De

c-0

7

Mar

-08

Jun

-08

Sep

-08

De

c-0

8

Mar

-09

Jun

-09

Sep

-09

De

c-0

9

Mar

-10

Jun

-10

Sep

-10

De

c-1

0

Mar

-11

Jun

-11

Sep

-11

De

c-1

1

Mar

-12

Jun

-12

SPA 1

SPA 2

SPA 3

SPA 4

SPA 5

SPA 6

SPA 7

SPA 8


Chart C. Proportion of Total Enrollment for Healthy Kids, by Service Planning Areas, by Year


1%

1%

1%

2%

2%

2%

2%

2%

1%

23%

22%

21%

21%

22%

21%

21%

22%

23%

16%

15%

15%

14%

14%

15%

16%

17%

20%

17%

17%

16%

15%

16%

16%

16%

16%

14%

2%

2%

2%

2%

2%

2%

2%

3%

3%

16%

17%

17%

18%

18%

17%

17%

15%

13%

12%

13%

13%

13%

13%

14%

14%

15%

13%

12%

13%

15%

14%

13%

12%

13%

12%

12%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

June 2004

June 2005

June 2006

June 2007

June 2008

June 2009

April 2010*

May 2011**

June 2012

SPA 1

SPA 2

SPA 3

SPA 4

SPA 5

SPA 6

SPA 7

SPA 8


Chart D. Applications Submitted by DPH-Contracted Agencies, by Program and by Fiscal Year

Source: Children’s Health Outreach Initiative, LA County Department of Public Health

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12

Healthy Kids

Healthy Families

Medi-Cal

Other


Table A. Applications Submitted by DPH-Contracted Agencies, by Age, Program and by Fiscal Year


Program

FY 03-04 FY 04-05 FY 05-06 FY 06-07 FY 07-08

Children 0-5

All Ages Children

0-5 All Ages

Children 0-5

All Ages Children

0-5 All Ages

Children 0-5

All Ages

HK 1,959 5,275 2,430 11,967 1,308 3,216 1,061 1,484 1,011 1,064

HF 2,712 8,551 2,580 8,639 2,515 7,771 2,623 8,417 2,511 7,519

MC 5,294 19,876 6,077 20,298 7,073 21,014 6,647 19,502 8,102 21,940

Other 216 1,134 155 1,011 613 5,425 298 2,549 155 1,789

Total 10,181 34,836 11,242 41,915 11,509 37,426 10,629 31,952 11,779 32,312

Program

FY 08-09 FY 09-10 FY 10-11 FY 11-12 FY 12-13*

Children 0-5

All Ages Children

0-5 All Ages

Children 0-5

All Ages Children

0-5 All Ages

Children 0-5

All Ages

HK 325 325 370 371 221 222 290 299 91 93

HF 2,267 7,077 1,619 5,385 1,786 5,901 1,709 5,799 609 2,004

MC 8,694 23,263 8,813 23,961 8,529 24,302 7,776 22,132 2,587 7,514

Other 723 6,566 35 444 4 168 82 1,744 152 2,123

Total 12,009 37,231 10,837 30,161 10,540 30,593 9,857 29,974 3,439 11,734

HK = Healthy Kids

HF = Healthy Families

MC = Medi-Cal

*As of November 2012


Table B. DPH-Contracted Agencies by Service Planning Areas*


Contract Agency SPA

1 2 3 4 5 6 7 8 AltaMed Health Services

Asian Pacific Health Care Venture

California Hospital Medical Center

Chinatown Service Center (subcontractor)

Citrus Valley Health Partners

Community Health Councils

Crystal Stairs

Glendale Adventist Medical Center

Korean Health Education, Information and Research Center (KHEIR) (subcontractor)

Long Beach Department of Health & Human Services

Maternal & Child Health Access

Pasadena Public Health Department

South Asian Network (subcontractor)

Tarzana Treatment Center

Venice Family Clinic

*Not included are Los Angeles Unified School District (which serves schools within LAUSD) and Los Angeles County Office

of Education (LACOE), which coordinates schools in all other school districts in Los Angeles County.

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