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					PREPARED FOR
ORANGE COUNTY UNINSURED
INITIATIVES PROJECT




EVALUATION OF


  O r a n g e C o u n t y ’s
Community Access Program
                      FIRST YEAR ACTIVITIES
About the USC Division of
Community Health
The Division of Community Health is a multi-disciplinary team based in the
Department of Family Medicine at USC Keck School of Medicine. The Division is
devoted to promoting the health and well being of communities, particularly for
underserved populations, and is involved with community-based planning and evaluation
efforts state-wide as well as community program development, needs assessment, policy
analysis and research. The Division pools the extensive expertise of USC faculty and
researchers with backgrounds in evaluation, health education, public policy, health
services administration, survey research, epidemiology, international health, biostatistics
and demography. The Division also contributes to the education and training of future
researchers by providing opportunities to undergraduate and graduate students. The
Division consults with other research faculty and centers, local governments, foundations
and community based organizations.


Acknowledgments
The authors acknowledge the invaluable assistance of numerous individuals who
generously provided their time and serious attention to this project.
At CalOptima, we wish to thank Hilary Frazer, Manager, New Insurance Initiatives, for
providing us with comprehensive background information, clear direction in the design
of the evaluation and continued assistance and patience throughout the evaluation
process. Hilary Frazer and Pete Nakahata, Director of Strategic Development, reviewed
drafts of the report and provided extensive comments.
We are particularly grateful to the individuals we interviewed for this evaluation,
including members of the Uninsured Initiatives Project, collaborators, and stakeholders.
Despite the demands of their daily work, everyone’s responsiveness in speaking with us
and providing background documents and follow-up information was exemplary.
Without their cooperation, this report could not have been completed. The professional
commitment to addressing the issue of the uninsured in Orange County was apparent in
all the individuals with whom we spoke.
We would like to thank Peter Long, M.H.S., UCLA School of Public Health, who worked
as a consultant on this project and provided background information on federal, state and
local issues, as they relate to Orange County’s Community Access Program (CAP) grant.
Alysia Kwon, USC Division of Community Health, edited earlier drafts of this report.
The authors remain responsible for any errors or misinterpretation of information.


Division of Community Health • USC Keck School of Medicine, Dept. of Family Medicine
3375 South Hoover St., Suite H201b, Los Angeles, CA 90007
Tel: 213.821.0701 • E-mail: cousinea@usc.edu • Web: abbc3.hsc.usc.edu/familymed/dch
PREPARED FOR
ORANGE COUNTY UNINSURED
INITIATIVES PROJECT




EVALUATION OF


  O r a n g e C o u n t y ’s
Community Access Program
                       FIRST YEAR ACTIVITIES




                      University of Southern California
                      Keck School of Medicine
                      Department of Family Medicine
                      Division of Community Health


                      Michael R. Cousineau, Dr.PH.,
                      and Alicia Kokkinis, M.A.



                      june 2003
EVALUATION OF ORANGE COUNT Y ’ S COMMUNIT Y ACCESS PROGRAM ( CAP ): FIRST YEAR ACTIVITIES




Table of Contents

1. Background                                                                               5
      The Orange County Community Access Program (CAP) Grant                                 6
      The Goals of the Orange County CAP Grant                                               7

2. Evaluation Purpose and Methods                                                           8
      Environmental Scan                                                                     8
      Review of Program Documents                                                            8
      Key Informant Interviews                                                               9

3. The Environment for Reform in California and Orange County                               10
      Fiscal Environment in California                                                      10
      Understanding the Orange County Environment                                           11
      The Uninsured in Orange County                                                        12
      Health Care Financing of Care for Uninsured                                           13
      Efforts to Improve Access to Health Care for Uninsured                                17

4. Progress of the Orange County CAP Project                                                20
      Accomplishments                                                                       20
      Challenges                                                                            23

5. Recommendations for Next Steps                                                           26


6. Appendices                                                                               28
      Appendix A: Key Informant Biographical Sketches                                       28
      Appendix B: Summary of County Efforts to Expand Health
         Insurance Coverage to Children in California                                       33

7. Notes & References                                                                       35



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1. Background
Since 1996, California has implemented the Healthy Families Program, California’s
State Children’s Health Insurance Program (S-CHIP), a federal matching program for
uninsured children ineligible for Medi-Cal. Because many children are still left out of
public programs in California, several counties in California have implemented or are
in the process of implementing ambitious initiatives to extend health coverage to all
uninsured children (Appendix B). With few exceptions, these programs build on the
Healthy Families and Medi-Cal programs but offer coverage to children living in
families with incomes up to 300 percent of the Federal Poverty Level (FPL)1 who do
not qualify for publicly sponsored programs. These initiatives often cover low-income,
undocumented children (ineligible for Healthy Families and only eligible for
Emergency Medi-Cal) and children living in families with incomes above 250 percent
of FPL, the Healthy Families upper limit. Counties that have successfully launched
initiatives generally share certain environmental characteristics 2:

                 ■        Health care access moved from being a concern to being an issue
                          requiring county intervention;
                 ■        Data on the uninsured existed to document needs;
                 ■        Input from grass roots organizations on the nature and the extent of the
                          problem;
                 ■        Board of Supervisors commitment;
                 ■        Championing of the issue by a long-time leader;
                 ■        Availability of Tobacco Settlement and Proposition 10 (California’s
                          Children & Families Act of 1998) funds;
                 ■        Presence of a Local Initiative.3
There are also several counties where new programs have been launched aimed at
expanding health coverage among employees of small businesses. These counties
include San Diego, Sacramento and Riverside.




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         The Orange County Community Access Program (CAP) Grant
In 1998, a number of health care organizations in Orange County began to meet to
discuss health care access issues facing residents of the county. In 2000, this group
officially formed the Uninsured Initiatives Project Steering Committee, which
included the following organizations:

            ■     CalOptima
            ■     Children’s Hospital of Orange County
            ■     Coalition of Orange County Community Clinics
            ■     Orange County Medical Association
            ■     County of Orange Health Care Agency
            ■     Hospital Association of Southern California
            ■     Children and Families Commission of Orange County
            ■     Health Care Council of Orange County
In 2001, on behalf of the Uninsured Initiatives Project Steering Committee,
CalOptima4 submitted a county-based proposal to the federal Health Resources
Services Administration (HRSA) under its Community Access Program (CAP). The
project Steering Committee initially envisioned Orange County’s CAP project as an
opportunity to identify opportunities for developing a health insurance premium
assistance program for low-wage workers and their dependents. It was believed that
this goal fit well with Orange County’s strong private business base and with the
county’s traditional focus and interest in developing local solutions to social problems.
The CAP project focus was further expanded, however, to include a distinct yet
complementary initiative addressing uninsured, low-income children who were not
eligible for existing public programs. The focus on uninsured children was driven by a
desire to parallel efforts in other counties throughout California to implement or
develop initiatives for uninsured children, by the strong interest that local private
foundations had in projects aimed at uninsured children, and by local uncertainty
regarding the future of Orange County’s existing private health insurance program for
low-income uninsured children, California Kids.




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            The Goals of the Orange County CAP Grant
Orange County’s CAP grant has two very ambitious objectives: (1) to expand
insurance coverage for low-income children currently ineligible for public health
insurance programs, and (2) to explore the potential for expanding insurance
coverage for low-wage employees in non-offering small businesses. Following the
receipt of the CAP grant in fall 2001, the Uninsured Initiatives Project collectively
agreed to start by focusing on the issue of uninsured children. An Advisory Board was
formed to provide community insight into the project’s goal of increasing health
insurance coverage for Orange County children. The Advisory Board included
representatives from hospitals caring for a large number of uninsured patients, from
community-based health education and health care access organizations, faith-based
organizations, and minority coalitions. A separate entity that would focus more
exclusively on the needs of the working uninsured, composed primarily of business
interests in Orange County, was also planned.

During the first year of the CAP grant, the Uninsured Initiatives Project held six
Steering Committee meetings and two Advisory Board meetings. In the first year, the
Uninsured Initiatives Project designed a pilot health insurance plan, OC Kids, that
would provide low-cost health insurance to uninsured children in the county with
family incomes below 250 percent FPL who do not qualify for Medi-Cal or Healthy
Families. For Year 2, the Uninsured Initiatives Project has turned their attention to the
development of a premium subsidy program for small businesses and their low-wage
workers. During the first year of the grant, the Uninsured Initiatives Project had
already begun research activities, specifically a series of focus groups with small business
owners, to inform the development of project’s small business insurance initiative.




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2. Evaluation Purpose and Methods
In August 2002, at the conclusion of Orange County’s CAP project first year, the
Uninsured Initiatives Project commissioned University of Southern California’s
(USC) Division of Community Health to conduct a retrospective process evaluation5
of the project’s first-year grant activities. The evaluation timeline was three months,
between August and November, 2002. The purpose of the evaluation was to
document the process, including successes and challenges, of establishing the CAP-
funded initiatives in Orange County. In this regard, we describe the political context
for this project, the background both statewide and in Orange County, the delivery
system and the interactions between major providers and other stakeholders. Finally,
we offer recommendations for next steps. The USC evaluation team’s evaluation
methodology included:

            (1) Environmental scanning of local, state and national climate.
            (2) Review of project’s operational documents.
            (3) Key Informant interviews with project staff, consultants, partners,
                stakeholders.

         Environmental Scan
Environmental scanning is a review of important trends in the environment (e.g.,
political, economic, institutional) and how these trends affect a program. For the
purposes of this evaluation, the USC evaluation team reviewed current federal, state,
and local health insurance programs that serve low- and moderate-income children in
California and Orange County; the current financing and delivery of health care for
uninsured children in the state and the county; similar projects undertaken in other
counties; and, the political and historical circumstances related to the financing and
delivery of health care unique to Orange County.


         Review of Program Documents
The evaluation team reviewed the agendas and meeting notes, when available, from
meetings of the Uninsured Initiatives Project Steering Committee and Advisory
Board. We also reviewed project documents outlining grant goals, timelines, activities
and scope of work. In addition, we obtained supplemental documents from project
partners regarding related activities in the county.




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            Key Informant Interviews
The evaluators developed an interview guide based on a review of existing interview
instruments used by other researchers who had conducted evaluations of insurance
expansion efforts in Santa Clara County and San Joaquin County. After one round of
review by CalOptima, the interview guide was pilot-tested on three interviewees in the
interview pool. The interview guide was then revised based on results from the pilot-
test and adapted for each of the four interview groups: 1) project staff, 2) consultants,
3) partners, 4) stakeholders. The interview guide covered three main topic areas:
health policymaking in Orange County; perceptions of CAP project first-year
activities and outcomes; and, recommendations for upcoming grant year.

We conducted 21 interviews between late August and late October 2002. Of the 21
total interviews, four interviews were with project staff, one with a consultant hired by
the project, ten with project partners [project Steering Committee or Advisory Board
members], and six with stakeholders not directly involved with the project. All 21
interviews were conducted individually with each of the key informants (one interview
was conducted with two individuals from the same organization) and confidentiality
was ensured; seven interviews took place in-person and fourteen by telephone.




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3. The Environment for Reform in
   California and Orange County

         Fiscal Environment in California
Most children’s health insurance expansion initiatives in California began during a
period of economic prosperity. Officials in counties that have already implemented
expansion programs remain committed to maintaining these programs during
difficult economic times, but acknowledge that their long-term sustainability is
uncertain and new enrollments may be curtailed.

Since spring 2002, efforts to increase enrollment in public programs have been
overshadowed by massive shortfalls in the state ’s budget. The Governor currently
estimates a budget deficit of approximately $34. 6 billion by the end of FY 2003-
2004. In January 2003, the Governor proposed $3. 1 billion in Medi-Cal
reductions to close the budget gap. The 15% reduction in Medi-Cal provider
payment rates, essentially rescinded Medi-Cal provider rate increases included in
the 2000 Budget Act. The Governor has also proposed a series of administrative
measures, eligibility reductions, and benefit cuts to reduce enrollment and
spending under Medi-Cal for adults. For example, these reductions rollback the
1931(b) Medi-Cal eligibility expansions from March 2000, reducing Medi-Cal
income eligibility limits to 61%of the Federal Poverty level for parents who apply
for the program. The Governor’s budget also proposes to require adult Medi-Cal
beneficiaries to recertify their eligibility each quarter rather than annually. The
cumulative effect of these proposals will be to reduce Medi-Cal enrollment by 1.0
million individuals over the next year. Although the Centers for Medicare &
Medicaid Services (CMS) approved the state’s waiver to expand Healthy Families
coverage to parents of children enrolled in Medi-Cal or Healthy Families,
implementation of the expansion has been delayed until 2006. The Governor has
proposed eliminating state outreach funding beginning in July 2003. In addition,
he has floated a proposal to transfer funding and responsibility for administering
certain state programs to counties. The state budget will not be finalized until July
2003 at the earliest so it is difficult to assess the final impact of these proposals.
However, given the magnitude of the state’s budget crisis, the likelihood of deep
cuts to Medi-Cal and other health programs serving low-income residents is very
high. Orange County, like many counties, is concerned about its ability to continue
to provide essential services during this period.


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            Understanding the Orange County Environment
Over the past three years, many counties throughout California have begun efforts
to increase enrollment and to expand coverage options through new insurance
products. These experiences provide valuable lessons about which elements have
been critical to success. However, it is not realistic to evaluate the success of one
county’s initiative against efforts in other counties because of differences in health
care delivery systems, political climate, and economic environments. In order to
evaluate the success of the ambitious agenda generated by Orange County’s CAP
grant, it is important to understand the project’s efforts within the context of
existing public and private programs that cover the target populations, as well as
the political and social environment in which the activities were conducted. It is
equally important to understand the existing system of financing and delivery of
care to uninsured populations in Orange County.

Orange County has a political and fiscal history that is unique among California
counties. It has a reputation for being politically conservative, and many leaders and
residents have traditionally favored a more limited role of government in addressing
social problems. Planning efforts have been affected by legal, political, and cultural
constraints related to extending programs to low-income children and their families.
In Orange County, more so than in other large counties in California, a politically
conservative electorate with strong libertarian roots and opposition to public
support of services for undocumented immigrants underlies a general preference for
a limited government role in addressing local issues.

On December 6, 1994, Orange County became the largest municipality in United
States history to declare bankruptcy. The county treasurer had lost $1.7 billion of
taxpayers’ money through investments in risky Wall Street securities. This large
suburban area, with a reputation for both affluence and conservatism, had amassed
a huge public debt through speculation in the financial markets and then refused to
honor its debts.6 Researchers have since identified three factors as the principle
causes of the bankruptcy: 1) political fragmentation, 2) voter distrust, and 3) fiscal
austerity. Some observers believe that the bankruptcy continued to jeopardize
Orange County’s financial outlook even as the state’s economy recovered and the
county experienced unprecedented growth and voter optimism.7

A 2001 survey of Orange County residents by the Public Policy Institute of
California (PPIC) and University of California, Irvine, found that only 43 percent
of Orange County residents think the county government does an excellent or
good job in solving problems in Orange County. Nevertheless, only about one in
10 residents believe that county officials pay a lot of attention to what the people
think when making policy decisions. About four in 10 residents believe that the


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EVALUATION OF ORANGE COUNT Y ’ S COMMUNIT Y ACCESS PROGRAM ( CAP ): FIRST YEAR ACTIVITIES




people who run county government waste a lot of the money paid in taxes. This
perception has changed very little since PPIC began asking this question in the
1996 Orange County Annual Survey.8

Over the past decade, the county has experienced rapid demographic shifts due to
an influx of Asian and Latino immigrant populations. Sixty-five percent of residents
believe that population increases will make the county a less desirable place to live
in the future. Non-Hispanic whites are more likely (73%) than Latinos and Asians
(48% each) to feel this way.9 The racial and ethnic change underway is having
profound effects on the ability to reach consensus on crucial state issues. Divisions
over racial and immigration policies have already surfaced in voter initiatives-
Propositions 187 (elimination of social services to undocumented immigrants),
Prop 209 (elimination of public affirmative action programs), and Prop 227 (ending
public support for bilingual education)-creating social tension and conflicts.10
Barbara Coe, founder of the Huntington Beach-based California Coalition for
Immigration Reform (CCIR), co-authored Proposition 187, the 1994 anti-
immigration law that was never implemented due to a series of legal challenges. As
a result, open discussion of immigration issues and the development of programs
explicitly benefiting undocumented individuals is extremely difficult.


         The Uninsured in Orange County
In 2001, 1 million of California’s 10 million children lacked health insurance. Analysis
of their demographic characteristics indicates that two out of every three uninsured
children in California may qualify for Medi-Cal or Healthy Families. Thirty-six
percent or 355,000 children may qualify for Medi-Cal. Another 301,000 children may
qualify for the Healthy Families program.11 The remaining one-third of uninsured
children in California live in families that earn more than the maximum annual
income to qualify for Healthy Families (161,000) or are undocumented immigrant
children (180,000). This latter group may be eligible to receive emergency medical
services under Medi-Cal if their families have low incomes.12

Orange County is the second most populous county in the state with more than 2.9
million residents including 765,000 children under age 18.13 Nearly two-thirds of
children receive health insurance through their parent’s employer and one quarter
(23.6%) are enrolled in either Medi-Cal or Healthy Families. All of the 163,000
children who participate in Medi-Cal are enrolled in CalOptima, the county
organized health system. As of October 2002, nearly 60,000 children in Orange
County were enrolled in Healthy Families.14 Enrollment for Healthy Families is
split among five health plans. CalOptima has the largest market share at 42 percent
followed by Blue Cross at 33 percent. HealthNet, Universal Care and Kaiser also
participate in the program, and, combined, comprise the remaining quarter.

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An additional 3,500 infants under age 2 were enrolled in the AIM program as of
March 2002.15 California Kids, a private program that provides preventive and
primary care services to low-income, uninsured children between the age of 2 and
18 who do not qualify for Medi-Cal or Healthy Families, provided coverage to
4,300 children in Orange County in 2001.16 The Kaiser Permanente Cares for Kids
(KPCK) I program offers subsidized health insurance to uninsured children
between 2 and 19 with family incomes that exceed the Medi-Cal and Healthy
Families income requirements yet are still below 300 percent FPL in those
counties where Kaiser Permanente offers coverage. Only 160 children from
Orange County were enrolled in KPCK as of February 2002.17


            f i g u r e 1 . Insurance Coverage for Children in Orange County, 2002

                                                   Uninsured Eligible 6%                                  Uninsured Ineligible
                                                                                                          2%
                                             Privately Subsidized 1%
                                                          AIM <1%
                                                                                                                                    Private 62%
                                            Healthy Families 8%




                                                          Medi-Cal 21%


In 2001, approximately 10 percent or 75,000 children in Orange County lacked health
insurance coverage.18,19 Of these children, approximately 51,000 were eligible to
participate in either Medi-Cal or Healthy Families and 24,000 were not eligible.
Within this group, CalOptima estimates that between 9,000 and 20,000 children live
in families earning less than 250 percent of FPL.


            Health Care Financing of Care for Uninsured
California counties can be divided into three broad categories in terms of their
financing and delivery of health service to uninsured individuals: rural counties (e.g.,
Imperial), urban counties that pay non-county facilities to provide indigent health
services (e.g., Orange and San Diego), and urban provider counties that provide
health services through publicly funded hospitals and clinics (e.g., Los Angeles).
Urban provider counties typically operate under an open door policy, providing
health care to all uninsured adults and children regardless of their ability to pay.
They also receive a disproportionate share of state funds earmarked for the
uninsured. The bulk of financial support for indigent medical services for children
and adults in the 24 largest counties is provided through realignment and the


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California Healthcare for Indigents Program (CHIP). Revenues from Proposition
99 provide the bulk of funds for CHIP. Overall, state payments to counties under
CHIP declined significantly from $164 million in 1997-98 to $67.6 million in 2002-
03. (Table 2) In FY 1999-2000, the state and all counties spent a total of $1.36
billion to provide services to 1.3 million patients.20 (Table 1) Although Orange
County provided services to 103,000 uninsured patients, its total expenditures were
only $48 million, or $465 per uninsured patient served. In contrast, Kern County
spent more than $3,500 per indigent patient served, nearly eight times more than
that spent per uninsured resident in Orange County. Orange County receives a
disproportionately small CHIP allotment, given that it is the second most populous
county in the state.

In California, the health care safety net is comprised of public hospitals, county
clinics, certain private hospitals, community clinics, and physician groups who serve
large numbers of Medi-Cal and uninsured patients. As mentioned above, Orange
County does not have a county hospital system but instead pays private facilities and
the public academic medical center to provide services for its indigent population.
Uninsured patients rely on the narrowly-targeted county indigent care program,
free and community clinics; non-profit, academic, and private hospitals emergency
departments and outpatient departments for their health care. This reflects both
Orange County’s historic legacy as a politically and fiscally conservative county with
a strong reliance on private sector charity care, and the considerable differential the
number of uninsured in need of services and the resources and infrastructure
available to serve them.

free and community clinics Orange County is home to eighteen free and
community clinics. Community clinics have a stronger presence in the Central and
Western regions of the county than in either North or South County. The two
largest clinics are the University of California Irvine (UCI) Family Health Center in
Santa Ana and the Huntington Beach Community Clinic. Only two of the county’s
free and community clinics are Federally Qualified Health Centers (FQHCs). In
2000, the eighteen free and community clinics provided 363,713 visits to 133,669
unduplicated patients, with an average of 2.3 annual visits per patient. In total, 50,
635 of the clinics’ patients were children under age 19, representing 38 percent of
all their patients.21 The majority of community clinic patients (80%) are uninsured.
The uninsured also comprised the majority of all visits (78%) and revenues (72%).
Of the $9 million received by clinics in patient revenues from uninsured patients,
nearly half (49%) came from state-sponsored programs, one-third (32%) from
patients, and 17% from county programs.

Using funds from the National Tobacco Settlement, the Coalition of Orange
County Community Clinics (COCCC) is completing a needs assessment of current

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services and remaining gaps. They have established a goal of serving 50 percent of
the uninsured population in the County, which they estimate to be between 459,000
and 600,000.22 (Note that these estimates are dramatically higher than California
Health Interview Survey (CHIS) estimates of 389,000 uninsured individuals.)
Achieving the target “market share” would require increasing the capacity of
community clinics by between 170 and 245 percent. Currently, all community
clinics in the county provided only 0.6 visits per uninsured county resident. Unlike
San Diego or Los Angeles counties, Orange County clinics do not have strong
negotiating leverage because of their variable capacity and affiliation with hospitals.

hospitals Private hospitals and the public academic medical center are also a
crucial part of Orange County’s safety net as these facilities also provide measurable
amounts of indigent and charity care. In FY 1999-2000, 34 acute care hospitals in
the county collectively provided 354,024 outpatient visits and 11,712 emergency
department visits to uninsured patients.23 In addition, they provided almost 28,000
days for inpatient care to this population. Orange County paid $48 million to
hospitals for these services. The county received $80 million in state realignment
funds and $3 million in Proposition 99 funds to help finance care for the uninsured
in return for the county’s $16 million in matching funds.24 In total, the 34 non-
public hospitals in Orange County received $78 million in Disproportionate Share
Hospital (DSH) Funds in state fiscal year 2001.25 University of California Irvine
(UCI) Medical Center provided the greatest proportion of bed days to county
indigent (29%), followed by Anaheim Memorial Medical Center (9%).26




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 t a b l e 1 . County Indigent Health Care Clients and Expenditures, in Selected
                             Counties, FY 1999-2000.


         County           Unduplicated Cost                  Cost            Cost            Cost Per        Total
                            Patients   Per                    Per             Per           Emergency        Cost
                                      Patient              Inpatient       Outpatient         Patient

         All Counties* 1,281,700             $1,061         $10,032            $160           $290      $1,361,000,000

         Fresno                17,900         $927           $4,888            $461           $207        $17,000,000

         Kern                   5,700        $3,512         $10,938           $1,669          $677        $20,000,000

         Los Angeles          699,900        $1,063         $11,619            $500           $368      $744,000,000

         Orange               103,300         $465           $4,744            $246           $443        $48,000,000

         San Diego             52,000         $886           $7,889            $451           $514        $46,000,000

         San Francisco         67,300        $1,131          $9,827            $568           $350        $76,000,000

         Santa Clara           72,500        $1,040         $10,574            $426           $740        $75,000,000

         Tulare                 4,200        $1,581          $4,731            $848           $387        $6,600,000

                    * Does not include data from Sacramento County, because data are not available.
    SOURCE: Medically Indigent Care Reporting System, Office of County Health Services, Department of Health Services.



 t a b l e 2 . California Health Care for Indigent Program (CHIP) Allotments to
              Selected Counties, FY 1997-8 to 2002-03 (In Thousands)


         State                 Total         Alameda              Los              Orange         San           Tulare
         Fiscal Year                                            Angeles                        Bernardino

         1997-98            $163,592           $7,897           $72,932             $7,918       $6,358         $2,122

         1998-99            $148,730           $7,185           $66,320             $7,181       $5,782         $1,924

         1999-00             $74,621           $3,719           $34,578             $3,085       $3,013         $827

         2000-01             $84,819           $4,101           $39,033             $3,618       $3,438         $969

         2001-02             $71,947           $3,550           $33,714             $2,902       $2,861         $777

         2002-03             $67,596           $3,298           $31,593             $2,704       $2,780         $725

                           SOURCE: Office of County Health Services, Department of Health Services.




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            Efforts to Improve Access to Health Care for Uninsured
Efforts to expand health insurance coverage in Orange County have been conducted
within the larger political and fiscal constraints. Despite these political and financial
realities, multiple organizations have been working within the county to address health
care access issues for low-income uninsured residents.

m e a s u r e h ( n at i o n a l t o b a c c o s e t t l e m e n t f u n d s )
In 1998, California participated in the national tobacco settlement with 41 other states
and several cities. The Legislative Analysts’ Office estimates that between $369
million and $446 million will be paid to California annually as a result of the
settlement. Counties and cities throughout the state receive additional revenue
directly as a condition of the settlement. Orange County expects to receive between
$30 and $38 million annually for the next 25 years.

Initially, the Board of Supervisors proposed allocating these extraordinary funds to
retire Orange County’s debt—unlike Santa Clara, Alameda, and San Francisco
counties, which earmarked all of these funds to pay for health care services. However,
given that the funds were the result of lawsuits to recover the cost to taxpayers of
smoking-related medical care, advocates primarily from the provider community
authored Measure H, which stated that these funds must be used to promote health.
Measure H specified the following annual allocation of funds:

                 ■        19 percent for health care services for seniors and disabled persons;
                 ■        23 percent for emergency medical services provided to non-paying
                          patients;
                 ■        12 percent for tobacco prevention, addiction programs, and mental health
                          programs and facilities;
                 ■        6 percent for hospitals in Orange County, which maintain emergency
                          services and trauma centers; and,
                 ■        20 percent for the Sheriff’s Department for public safety programs and
                          services.
All new allocations must be used to supplement and supplant existing funds. After a
contentious campaign, Measure H was passed by voters in Orange County in
November 2000. According to the proposition, a 2/3 majority vote by the Board of
Supervisors is required to reallocate Tobacco Settlement funds to any other purpose
unless county general funds revenues are predicted to decline by more than 10 percent
in the succeeding fiscal year. The extraordinary measures needed to ensure that
tobacco funds were dedicated to health programs highlight the fiscal priorities of the
Board of Supervisor in the wake of the County’s bankruptcy.



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orange county children and families commission
( p r o p o s i t i o n 1 0 c o m m i s s i o n ) i n i t i a t i v e s Proposition 10, the
California Children and Families Act of 1998, was approved by California voters in
November 1998. The proposition added a 50-cent tax per pack of cigarettes sold in
California, and earmarked the additional revenue to be used to support education,
health, and child care programs that promote health and early childhood development,
from 0 to 5 years. The Orange County Children and Families Commission is an
independent nine-member panel that oversees the allocation of funds received as a
result of Proposition 10, which are estimated to be $48 million annually.

After a consultation process, the Commission established its seven core missions:
services for at-risk children, family counseling and parental resources, health access
opportunities, medical services, injury prevention education, early care and education,
and school readiness. In September 2002, the Commission approved $28.5 million
over the next three years to fund a new initiative between Children’s Hospital of
Orange County (CHOC) and the University of California Irvine (UCI) Medical
Center to improve pediatric healthcare throughout the county. The three-year
allocation represents the first installment of $81 million over the next ten years.
Specific programs funded under the initiative include:

            ■     ADHD/Learning Disorders
            ■     Asthma and Chronic Lung Disease
            ■     Metabolic Disorders
            ■     Pediatric Community Clinics
            ■     Autism Clinics
            ■     Healthy Infant and Toddler Network Program
c h i l d r e n ’ s h e a l t h c a r e a c c e s s i n i t i at i v e ( c h a i )
The Children’s Healthcare Access Initiative (CHAI) was established in 2000 to ensure
that all children in Orange County have access to health care and a medical home.27 It
is co-chaired by staff from the Orange County Health Care Agency and Orange
County Social Services Agency. The Steering Committee includes representatives
from other public and private organizations, including CalOptima. The Initiative has
been executed solely with in-kind financial support of the sponsoring organizations
and committee members.

CHAI conducted an extensive strategic planning process during 2001, soliciting input
from community members through a number of mechanisms. As a result of the
planning process, CHAI identified the following strategic directions: 1) develop a
web-based central clearinghouse for all services and programs, 2) develop and fund a
health insurance program for children who are ineligible for publicly-funded


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insurance, 3) educate parents about health insurance and use of the health care system,
4) strengthen community clinics and other sources of non-urgent care, 5) track and
advocate on behalf of uninsured children and their families, and 6) use schools to
conduct community-linked pilot projects. The CHAI Steering Committee is currently
developing action plans to implement each of these strategic directions.




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4. Progress of the Orange County
   CAP Project

         Accomplishments
s u m m a r y Many project partners seemed frustrated that more was not
accomplished during the first year, and that a larger health insurance product for
low-income uninsured children is not yet available in Orange County while other
counties in California have implemented insurance expansion initiatives. In the
context of the environment in which the project was operating, however, the
Uninsured Initiatives Project has taken important and meaningful steps towards
accomplishing its expansion goal. The CAP project provides a new but critical focal
point for a dialogue in Orange County and an infrastructure for launching new
coverage programs. Indeed, given the fiscal and political context (local political
history, the absence of some key environmental characteristics, such as a strong labor
union presence and strong poverty advocacy infrastructure) and the soft economy,
evaluators were struck that the project participants have remained cohesive and kept
options open for expanding coverage in the future. If anything, the project
crystallized for the community the need for such an initiative and provided the initial
draft of a road map of how to reach its expansion goal. The importance of this first
step cannot be overstated given the fiscal and political obstacles present in Orange
County. The process activities during the first year of the grant were critical steps in
the development of a sustainable program in any locality. Each local area, including
Orange County, must develop an initiative consistent with its own culture and
environment, using the resources available. Accomplishments during the first year of
the grant fall within several important areas:

s t r e n g t h e n i n g p a r t n e r s h i p s The Uninsured Initiatives Project’s
Steering Committee successfully brought together representation from key health
organizations in the county. The partnership represents a cohesive group of health
organizations. Many of the Project Steering Committee members that we interviewed
during the evaluation described a “relatively small group” who “travel in the same
circles” surrounding health policymaking. Some interviewees felt that the county’s
decentralized health system has encouraged public/private partnerships and solidarity
across organizations representing various contingencies. The Uninsured Initiatives
Project partners have a successful history of meeting together across a range of health
projects. Interviewees repeatedly told us of the strong, unified collaboration behind
collecting and disseminating data for the county’s health needs assessments.

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Additionally, the recent joint advocacy during the Measure H campaign was viewed as
a “major collaborative success” that involved broad participation and “brought
together the health care community.”

CalOptima had agreed to serve as the lead agency for the CAP grant, taking on the day-
to-day administration of the grant. There was strong agreement and confidence across
project partners that CalOptima was the best organization to administer the grant
project. The Uninsured Initiatives Project partners felt that CalOptima had the general
support and trust of the health community, which allowed CalOptima to act unbiased
when coordinating the project. Interviewees described CalOptima as being “community-
minded” and they noted that there was a “gravitation in the [health] community toward
CalOptima.” At the same time, the partners recognized that the initiative was only viable
so long as it had the support of the partner organizations.

s u c c e s s f u l p r o j e c t p l a n n i n g & d e s i g n In the first year of the
CAP grant, the Uninsured Initiatives Project made significant progress in the planning
and design of a pilot health insurance plan. The pilot health insurance plan, OC Kids,
would provide low-cost health insurance to uninsured children with family incomes
below 250 percent FPL and who do not qualify for Medi-Cal or Healthy Families.
The Uninsured Initiatives Project developed the plan’s cost models, scope of benefits,
provider network and secured some funding. During interviews, the Uninsured
Initiatives Project partners expressed a great deal of confidence that CalOptima has the
administrative capacity to develop and implement a new health plan. Partners indicated
that CalOptima already provides health coverage to Medi-Cal and Healthy Families
beneficiaries, and therefore have: experience with the target populations, appropriate
provider networks in place, and sufficient administrative capacity.

The Uninsured Initiatives Project strove to design a health plan that could be integrated
seamlessly into the existing system of public and private programs that serve low-income
children in Orange County. The OC Kids proposed benefit set and provider network
were intended to be comparable with existing programs so that families could have a
single point of entry. The Uninsured Initiatives Project also sought to create a
comprehensive health plan: proposed services included inpatient, outpatient, vision,
dental, physical and mental health, and a dedicated Care Management Program.

e x p a n d i n g awa r e n e s s a n d b u i l d i n g c o n s e n s u s
Participants in the Uninsured Initiatives Project understood the importance of precise
cost projections prior to launching a new health insurance plan. In Year 1, the
Uninsured Initiatives Project obtained actuarial estimates for the OC Kids insurance
product. During the process of reviewing actuarial estimates, the Uninsured Initiatives
Project Steering Committee learned of an evaluation of the Los Angeles County
CalKids program. The CalKids evaluation found that only one-third of CalKids


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members in Los Angeles County used any physician services in the first six months of
enrollment.28 The Los Angeles County CalKids evaluation spurred concern about the
accuracy of the OC Kids actuarial analysis, mainly regarding whether or not the
utilization estimates, and therefore cost estimates, would accurately reflect the level of
resources needed for the OC Kids target population.

The Children and Families Commission, a member of the Uninsured Initiatives
Project Steering Committee, urged Orange County’s CalKids program to convert from
a capitated plan to a fee-for-service plan, a change that was implemented in July 2002.
The Uninsured Initiatives Project also proposed a year-long data collection effort to
examine utilization and cost data for CalKids members, in order to provide the
Uninsured Initiatives Project more reliable utilization and cost estimates. Although the
Uninsured Initiatives Project’s decision to collect utilization data on CalKids members
will delay OC Kids implementation, the data collection effort will provide a strong
foundation to evaluate the impact and effectiveness of OC Kids once it is implemented.

b u i l d i n g i n f r a s t r u c t u r e f o r e x p a n s i o n The Uninsured
Initiatives Project recognized the importance of building the infrastructure of free and
community clinics, in order for them to fully participate in the OC Kids provider
network. In developing this network, CalOptima made concerted efforts to include the
free and community clinic system. However, the great variability in capacity and services
across Orange County’s free and community clinics, made it difficult to fully include
them in the provider network. Many clinics do not currently meet the criteria for
provider selection, such as 24/7 access and a full complement of primary care services.

increased funding for existing insurance programs
Although the project was unable to secure enough funding to launch OC Kids,
$710,000 in new funding has been directed to an Orange County Children & Families
Commission-directed Initiative to expand access to care for children. The Project was
only able to secure a one-year commitment of $250,000 from CalOptima and
$250,000 from the Orange County Health Care Agency to subsidize OC Kids
premiums. Later, the Orange County Children & Families Commission, earmarked
$210,000 for a care management component.

In October 2002, after the OC Kids pilot project was put on hold, the $710,000 in
funding that had been earmarked for OC Kids was redirected towards supporting the
CalKids program. These funds subsidize new CalKids enrollment, fund a care
management program for new CalKids enrollees, and fund a pilot project not directly
related to CalKids, to increase access to health services for uninsured children.




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c o o r d i n a t i o n o f e f f o r t s Most of the organizations participating in the
Uninsured Initiatives Project also participate in a related Orange County initiative, the
Children’s Healthcare Access Initiative (CHAI). The two initiatives shared
complimentary agendas of improving healthcare access, however, the Uninsured
Initiatives Project Steering Committee focuses more globally on insurance needs of all
uninsured residents, adults and children, while CHAI focused exclusively on the needs
of uninsured children.

wider audience for issue of uninsured in orange county
Even though the OC Kids health plan was not launched in the first year of the grant,
the project partners have maintained enthusiasm about developing the small business
health insurance initiative in Year 2. During the key informant interviews, the partners
expressed excitement about building new partnerships with the business community
and engaging new stakeholders outside of the health community around the issue of
insurance coverage.


            Challenges
s u m m a r y Orange County’s CAP project, with two large-scale initiatives, may
have been overly ambitious. In retrospect, the Uninsured Initiatives Project may have
made more progress had it begun with the initiative addressing uninsured, low-wage
workers since this initiative most closely matches the local environmental climate.
The County faced financial and political constraints that created enormous barriers
to progressing on the children’s insurance initiative, but may not have impeded as
greatly the small business insurance project. Challenges during the first year of the
grant fall within several important areas:

p r o j e c t p a r t n e r r e l a t i o n s h i p s While the Uninsured Initiatives
Project was inclusive of key stakeholders, ownership of OC Kids was not very broad.
CalOptima took the day-to-day lead on the administration of the grant. But while
CalOptima has the technical ability to implement an insurance coverage program, it
does not seem to have, by itself, the ability to act as a political champion to rally
political support and shore up local funding for the program. Collectively, all of the
project’s partners struggled in some ways to bring this idea to life. Based on interviews
during the evaluation, it appears that the partners’ hesitance to spearhead the project
may have been a result of partners’ concern about being asked to contribute to the
funding of the initiative either directly or by redirecting funds they receive from
Measure H, or about being out in front of a politically charged issue directly
addressing undocumented county residents.




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p r o j e c t p l a n n i n g a n d d e s i g n The competing interests of the
Uninsured Initiatives Project partners may have hampered progress on the project.
While general agreement seemed to exist among the Steering Committee members
regarding the design of the OC Kids health plan, areas of disagreement appeared to
stem from competing organizational interests among the partners. Based on a
review of project documents and key informant interviews, there were two main
areas of contention in the development of OC Kids: (1) scope of benefits and (2)
relationship between OC Kids and the existing program, CalKids.

While some partners argued for a comprehensive benefits package, others felt that
inpatient services were not necessary given that public programs would cover
inpatient care for OC Kids members. Ironically, the hospital partners, the group
most likely to be benefit from the inclusion of inpatient benefits, were the partners
mainly opposed to including inpatient coverage. Hospital partners, who had
historically funded CalKids, and were looked to for contributing substantial funding
to the new health plan, argued that inpatient coverage increased the cost of the
product, which impacted the amount of funding needed and the number of children
who could be covered by the plan.

Project partners disagreed about the proposed relationship between the new plan,
OC Kids, and the existing plan, CalKids. Some partners wanted OC Kids to
supplant CalKids, in the hopes that new funding sources would be identified for OC
Kids and existing funding commitments to CalKids could end. Others envisioned
that OC Kids would replace CalKids but that current funding of CalKids would be
redirected to OC Kids, with additional funding secured from new sources. Others
hoped that OC Kids would augment CalKids, either for a short-term period, of 2-5
years, or indefinitely maintaining existing funding for CalKids and securing new
funding sources for OC Kids.

f u n d i n g Although project partners agree that OC Kids implementation was
stalled due to inadequate funding, the project partners had neither a unified
approach nor a strategy to secure funding for OC Kids. Not surprisingly, given the
broad range of organizations represented on the Uninsured Initiatives Project
Steering Committee, the project partners disagreed on potential funding sources
and funding responsibility for OC Kids.

Although OC Kids received modest funding commitments for the first year, there
are related healthcare access expansion efforts in Orange County that have received
significant funding. For example, the Coalition of Orange County Community
Clinics (COCCC) received $8.5 million from the Tobacco Settlement Outcomes
Program in FY 2001-2 to enhance the level of services provided to the uninsured
population in the county. In September 2002, the Children and Families


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Commission approved $28.5 million in funding over three years for a new initiative
between Children’s Hospital of Orange County (CHOC) and the University of
California Irvine (UCI) Medical Center to improve pediatric healthcare throughout
the county. The funding of these independent yet related activities has not been
linked to the Uninsured Initiatives Project.




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5. Recommendations For Next Steps
BUILD PROJECT SUPPORT

            ■     Reconvene key partners for the purpose of reviewing progress on both
                  initiatives, and identifying a common and unifying vision for the project
                  as a whole.
            ■     Identify a few key leaders currently working within the Uninsured
                  Initiative Project who could act as advocates for the project. In other
                  counties, the combination of strong leadership and community buy-in was
                  necessary for the creation and implementation of initiatives.
            ■     Identify others -especially within the business community- who could be
                  brought into the planning process and have both financial and political
                  resources to bring to the project.
            ■     With new leaders and vision in place, develop a five-year strategic plan for
                  a single or unified children’s health initiative in the county, one that
                  consolidates CHAI and CAP grant activities to avoid confusion and
                  fragmentation, and will avoid competing requests for resources.
            ■     Develop a short-term objective by accelerating the development of the
                  small business pilot project to include a strong educational component,
                  and a public insurance piece for dependents.
            ■     Embrace a long-range goal of merging the small business and children’s
                  health projects into a single enterprise.




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BUILD FUNDING SUPPORT

                 ■        Review all existing commitments that can be mobilized or restructured
                          to support project goals but reengineered to capture federal
                          participation. For example Measure H funding for community clinics
                          could be preserved in an insurance product by designating clinics as an
                          exclusive or preferred provider.
                 ■        Seek corporate sponsorship, to subsidize insurance premiums for example.
                 ■        Identify foundation support for start-up and planning, and
                          one-time activities.
                 ■        Consider public funding options such as AB 495 or other local options,
                          such as property tax levy.
                 ■        Consider a Medicaid Section 1115 Demonstration Project for
                          consolidating all funding for children.
SHORT TERM OR INCREMENTAL STEPS

                 ■        Consider phasing-in OC Kids health plan benefits and/or
                          enrollment over time.
                 ■        Continue expansion of enrollment in CalKids.
                 ■        Continue to fund enrollment, retention and utilization activities for
                          existing public and private programs.




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6. Appendices

         Appendix A: Key Informant Biographical Sketches
Michele Blair Revelle is the Principal of Blair Revelle Communications, Inc. Ms.
Blair Revelle specializes in government relations, grass roots coalition building,
communications and fundraising. She is on the Board of Directors of the Orange
County Coalition of Comprehensive Mental Health Services and represents Orange
County Emergency Physicians and State Senator Joseph Dunn among others.

Marika Bonner is a member of the Uninsured Initiatives Project Steering
Committee. Ms. Bonner is the Executive Director/CEO of the Orange County
Medical Association (OCMA). She also serves as the Executive Director of OCMA
Services, Inc. a subsidiary of the OCMA and ex-officio on the Orange County
Foundation for Medical Care, an affiliate organization of the OCMA. Ms. Bonner is
on the Board of Directors of the Healthcare Council of Orange County and various
local and state level committees dealing with healthcare issues.

Dennis K. Clark is a member of the Uninsured Initiatives Project Steering
Committee and chairperson of CalOptima’s Member Advisory Committee. Mr. Clark
is the retired Director of Ambulatory Care Services at the University of California,
Irvine (UCI) Medical Center and a founding Board member of the Coalition of
Orange County Community Clinics. He now serves on the Board of Directors of the
Health Care Council of Orange County, the Share Our Selves (SOS) Free Medical &
Dental Clinic and the UCI Retirees Association.

Mary Dewane is the Chief Executive Officer for CalOptima. Prior to launching
CalOptima, she served as Director of the Medicaid Managed Care Offices for the
Centers for Medicare and Medicaid Services (CMS), formerly Health Care Financing
Administration (HCFA), where she was responsible for administration of the Medicaid
program nationally.

Ronald R. DiLuigi is a member of the Uninsured Initiatives Project Advisory Board.
Mr. DiLuigi is Regional Vice President of Advocacy and Community Benefits for the
Southern California Region of St. Joseph Health System, where he provides
leadership in the planning and implementation of annual advocacy priorities, including
all public policy issues of financial and programmatic significance being addressed at
the local, state and federal levels. Mr. DiLuigi also serves on the state Healthy
Families Program Advisory Panel and on the Board of Directors for Maternal
Outreach Management System.

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Marty Earlabaugh-Gordon is a member of the Uninsured Initiatives Project Steering
Committee. Ms. Earlabaugh-Gordon is Chief Executive Officer for the Coalition of
Orange County Community Clinics. Ms. Earlabaugh-Gordon represents the
Coalition’s members on the Orange County Health Needs Assessment, Health Care
Council of Orange County, and Children’s Healthcare Access Initiative. She is also
chair of CalOptima’s Provider Advisory Committee.

Jean Forbath is a member of CalOptima’s Board of Directors. Ms. Forbath is founder
of Share Our Selves (SOS), a non-profit organization that provides food, financial aid,
and free medical and dental care to the working poor and indigent of Orange County.
She is currently on the Board of Directors of CalOptima, Orange Coast Interfaith
Shelter, Health Care Council of Orange County, Save our Youth, Families Costa
Mesa, and the SOS Free Medical and Dental Clinic.

Hilary Frazer is Manager of New Insurance Initiatives at CalOptima. Prior to joining
CalOptima, Ms. Frazer was a health analyst at Mathematica Policy Research’s
Washington, DC office where her research focus was managed care and vulnerable
populations.

Jon D. Gilwee is a member of the Uninsured Initiatives Project Steering Committee.
Mr. Gilwee is Vice President of the Orange County Office for the Hospital
Association of Southern California (HASC). He directs HASC public policy
development on health issues in Orange County and also participates in the
management of HASC’s state and federal advocacy and political action activities in
cooperation with the California Hospital Association and the American Hospital
Association. He is a diplomate of the American College of Healthcare Executives and
also currently serves as a member of the Health Care Council of Orange County
Board of Directors, the Orange County Tobacco Settlement Advisory Group and the
Orange County Terrorism Working Group.

Mark B. Horton is Deputy Agency Director and Health Officer of the Orange
County Health Care Agency. Dr. Horton directs County of Orange Children
Healthcare Access Initiative (CHAI). Prior to joining the Orange County Health Care
Agency, he served as Director of the Nebraska Department of Health and as Vice
President for Community Programs for the Children’s Hospital and Health Center in
San Diego, where he directed the Center for Child Protection and the Center for
Healthier Communities for Children.




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S. Russell Inglish is a member of the Uninsured Initiatives Project Advisory Board. Mr.
Inglish is the Administrator for Community Benefit and Government Services for T    enet
Health System’s Coastal Communities Hospital, Fountain Valley Regional Hospital and
Medical Center, Garden Grove Hospital and Medical Center, Santa Ana Hospital and
Medical Center, Western Medical Center Santa Ana and Western Medical Center
Anaheim. Mr. Inglish is an active participant on CalOptima’s Provider Advisory
Committee, the Private Essential Community Hospitals, the County of Orange Children
Healthcare Access Initiative and the Orange County Health Needs Assessment.

Michael Koch is Executive Director of the CaliforniaKids Healthcare Foundation, a
non-profit organization that provides uninsured children access to preventive and
primary health care services. Prior to CaliforniaKids, he worked at Blue Cross of
California as a project manager and was involved with the company’s financial
turnaround, as well as its strategic long-term plan. Mr. Koch currently serves on many
advisory committees to expand access to healthcare services for uninsured children and
is involved in bi-national projects to establish and promote cross-boarder partnerships.

Estela Martinez is Director of CalOptima’s Healthy Families Program, CalOptima
Kids, as well as CalOptima’s Medi-Cal Outreach Programs. Ms. Martinez is one of
the founding staff members of CalOptima. She is responsible for developing a range
of initiatives including an innovative program to meet the health care and social
service needs of persons with disabilities.

Alyce Mastrianni is Director of Program Development and Evaluation for the
Children and Families Commission of Orange County, which is responsible for
allocating the Proposition 10 tobacco tax revenue for health, education and housing
programs for children and their families. As Director of Program Development and
Evaluation, she provides leadership in designing and implementing an outcome and
performance reporting system to measure and report improvements the Commission
is making in the lives of children and their families. Prior to her current position, Ms.
Mastrianni served as the Commission’s Strategic Plan Project Manager.

Peter Nakahata is the Director of Strategic Development for CalOptima. Mr.
Nakahata is responsible for planning and implementing new programs, managing
specific organization-wide initiatives, and assisting in the development of the agency’s
budget and strategic plan. He was one of CalOptima’s founding employees and has
played an integral role in the design of the CalOptima program, as well as in the
program’s implementation and ongoing development.




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Patricia Nunn is the Economic Development Manager for the City of Santa Ana’s
Economic Development Division. In this capacity, she is responsible for encouraging
economic growth and job generation for Santa Ana, California. Ms. Nunn is also
responsible for assisting new business growth and coordinating with the local
universities to institute programs that will promote entrepreneurship and business
development. Ms. Nunn also serves as the Executive Director of the Santa Ana
Workforce Investment Board and as Chairperson of the Southland Economic
Development Corporation and the California Workforce Association.

Juliette A. Poulson is a member of the Uninsured Initiatives Project Steering
Committee. Ms. Poulson is the Director of the Orange County Health Care Agency.
Poulson is responsible for four core agency service areas: Public Health, Regulatory
Health, Behavioral Health and Medical and Institutional Health Services. She also
serves on the CalOptima Board of Directors and on the Children and Families
Commission of Orange County Board of Directors.

Nancy Rimsha serves on the Member Advisory Committee of CalOptima. Ms.
Rimsha is Directing Attorney for the Health Consumer Action Center (HCAC) of the
Legal Aid Society of Orange County, a partner of the statewide Health Consumer
Alliance. She is involved with several community activities in relation to her work in
health law, serving for many years on the Board of Directors of the Orange County
Health Care Council, as well as on the boards for the Coordination of Resources to
Infants for Better Service, the Family Support Network, and the Steering Committee
for the Orange County Immigrants Rights Alliance.

Michael Ruane is a member of the Uninsured Initiatives Project Steering Committee.
Mr. Ruane is the Executive Director of the Children and Families Commission of
Orange County. He held the position of Orange County’s Assistant County Executive
Officer for Strategic and Intergovernmental Affairs between 1996 and 2000. Mr.
Ruane is also an Adjunct Lecturer in the Graduate Program in Urban and Regional
Planning at University of California, Irvine.

Corey Timpson is a member of the Uninsured Initiatives Project Steering Committee.
Mr. Timpson is Executive Director of the Orange County Congregation Community
Organization (OCCCO), an interfaith church based community organization
anchored in 14 congregations and representing over 34,000 families. He currently
serves on the Board of Directors of Families Costa Mesa, the Health Care Council of
Orange County and the Orange County Community Development Council.




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EVALUATION OF ORANGE COUNT Y ’ S COMMUNIT Y ACCESS PROGRAM ( CAP ): FIRST YEAR ACTIVITIES




Liane Wong serves as a consultant to the Uninsured Initiatives Project. Ms. Wong is
the Director of the Institute for Health Policy Solutions’ Child and Family Coverage
Technical Assistance Center (CFCTAC). Dr. Wong provides policy analysis, technical
assistance and consultation to states and localities on health insurance coverage
expansions and strategic initiatives. Her current work focuses on the development of
public-private initiatives to extend access and health insurance coverage to the
uninsured. Before joining the Institute, Ms. Wong was a lead evaluator on the
California HealthCare Foundation’s First Things First Initiative.

Lucien Wulsin Jr. is an attorney in Los Angeles specializing in health law and health
policy. He is the project director of Insure the Uninsured Project and is currently
working on approaches to expanding coverage for uninsured working Californians in
counties and regions throughout the state. He has represented numerous health care
organizations throughout California in efforts to increase funding, care and coverage
for the uninsured.




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            Appendix B: Summary of County Efforts to Expand Health
               Insurance Coverage to Children in California

   County:                                 Target                               Funding                          Benefits &                    Administering                     Provider
   Program &                             Population                                                             Cost-Sharing                     Agency                          Network
   Start Date
   Alameda:                       9,500 uninsured                      $14.6 million has                   Comprehensive          Alameda                                    AAH network
   Family Care                    children under 19                    been committed from                 health, dental, mental Alliance for                               and Delta Dental
   July 2000                      living in families with              Alameda Alliance                    health, vision, and    Health (AAH)                               Network
                                  incomes up to 300%                   reserve fund. The                   prescription drugs are
                                  of FPL who do not                    Board of Supervisors                covered with minimal
                                  qualify for Medi-Cal                 committed $1 million                premiums and cost-
                                  or Healthy Families.                 from the national                   sharing. Similar to
                                  Residents of Alameda                 tobacco settlement.                 Healthy Families
                                  County.                              The California                      benefits.
                                                                       Endowment gave a
                                                                       $400,000 grant to
                                                                       subsidize premiums
                                                                       for undocumented
                                                                       children.

   Contra Costa:     Uninsured children                                Uses existing state                 Comprehensive                        Contra Costa                 CCHP Network
   Basic Health Plan living in families with                           and county funds that               medical care services.               Health Plan                  of County
   May 2002          income up to 200                                  pay for care for the                Dental coverage                      (CCHP)                       Providers
                     percent of FPL and                                uninsured.                          depends on age.
                     ineligible for Medi-
                     Cal or Healthy
                     Families. Residents of
                     Contra Costa
                     County.


   Los Angeles:                   20,000 uninsured                     $20 million in annual               Comprehensive          LA Care                                    LA Care
   Healthy Kids                   children under age 6                 funding has been                    health, dental, mental                                            Provider
   Proposed:                      with families incomes                committed by                        health, vision, and                                               Network
   July 2003                      up to 300 percent of                 Children and                        prescription drugs are
                                  FPL and ineligible                   Families Commission                 covered with minimal
                                  for Medi-Cal and                     for next five years.                premiums and cost-
                                  Healthy Families.                                                        sharing. Similar to
                                  Residents of Los                                                         Healthy Families
                                  Angeles.                                                                 benefits.


   Riverside:                     Approximately 13,000                 The annual budget of                Comprehensive          Inland Empire                              IEHP Provider
   Healthy Kids                   uninsured children                   $5.8 million comes                  health, dental, mental Health Plan                                Network
   August 2002                    under age 19 in the                  from a variety of                   health, vision, and    (IEHP)
                                  county, who are not                  sources: $2.5 million               prescription drugs are
                                  eligible for Medi-Cal                from the Board of                   covered with minimal
                                  or Healthy Families.                 Supervisors, $2                     premiums and cost-
                                  This program will                    million from the                    sharing. Similar to
                                  cover 6,000 children.                Children and                        Healthy Families
                                                                       Families First                      benefits.
                                                                       Commission, $1
                                                                       million from the
                                                                       Inland Empire
                                                                       Health Plan (IEHP),
                                                                       and $300,000 from
                                                                       the Community
                                                                       Health Corporation.




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EVALUATION OF ORANGE COUNT Y ’ S COMMUNIT Y ACCESS PROGRAM ( CAP ): FIRST YEAR ACTIVITIES




   County:                    Target                    Funding               Benefits &         Administering       Provider
   Program &                Population                                       Cost-Sharing          Agency            Network
   Start Date
   San Francisco:       An estimated 5,000        $5.7 million annual      Benefits and cost-     San Francisco    SFHP Healthy
   Healthy Kids         uninsured children        budget. Received         sharing are slightly   Health Plan      Families
   January 2002         with incomes              county general funds     lower than Healthy     (SFHP)           Network
                        between 0% - 300%         and Proposition 10       Families program.
                        of FPL who do not         funds. Applied for       Medical, dental,
                        qualify for Medi-Cal      special sales tax, and   vision, mental health
                        or Healthy Families.      Local Prop D funds.      care, and prescription
                        Residents of San                                   drugs are covered.
                        Francisco.

   San Joaquin:         3,000 uninsured                                    Benefits and cost-     Health Plan      HPSJ Provider
   Healthy Kids         children under 19                                  sharing are similar to of San Joaquin   Network
   Proposed:            living in families with                            Healthy Families       (HPSJ)
   July 2003            incomes up to 300%                                 program. Medical,
                        FPL who do not                                     dental, vision, mental
                        qualify for Medi-Cal                               health care, and
                        or Healthy Families.                               prescription drugs are
                        Residents of San                                   covered.
                        Joaquin.


   San Mateo:           7,000 uninsured           $7.7 million annual      Benefits and cost-     Health Plan of   Health Plan of
   Healthy Kids         children under 19         budget. Received         sharing are similar to San Mateo        San Mateo
   Proposed:            living in families with   $2.3 million from the    Healthy Families                        Provider
   January 2003         incomes up to 400%        Children and             program. Medical,                       Network
                        FPL who do not            Families Commission      dental, vision, mental
                        qualify for Medi-Cal      for children under 6.    health care, and
                        or Healthy Families.      Proposal for county      prescription drugs are
                        Residents of San          to match private         covered.
                        Mateo.                    contributions up to
                                                  $2.7 million.
                                                  Peninsula
                                                  Community
                                                  Foundation has been
                                                  designated as fund
                                                  holder.


   Santa Clara:         Approximately 14,000      $14-$16 million          Benefits and cost-     Santa Clara      SCFHP Medi-
   Healthy Kids         uninsured children        budget has been set      sharing are similar to Family Health    Cal and Healthy
   January 2001         under 19 living in        to subsidize             Healthy Families       Plan (SCFHP)     Families
                        families with incomes     premiums. Program        program. Medical,                       Network
                        up to 300% FPL            has received             dental, vision, mental
                        ($54,300 for a family     commitments from         health care, and
                        of four) who are not      County and San Jose      prescription drugs are
                        eligible for Medi-Cal     national tobacco         covered.
                        or Healthy Families       settlement funds,
                                                  Proposition 10,
                                                  Packard Foundation,
                                                  and SCFHP
                                                  Foundation.


  Source: Adapted from information on 100% Campaign website at www.100percentcampaign.org, accessed December 3, 2002.




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7. Notes & References
1     $53,000 for a family of four.
2     Annette Gardner and James G. Kahn. County Innovations In Meeting The Needs Of The Uninsured:
      Preliminary Findings. Institute for Health Policy Studies, University of California, San Francisco.
      November 1, 2001.
3     A county-based managed care plan serving Medi-Cal and Healthy Families enrollees in the nine California
      counties with a “two-plan” model.
4     CalOptima is a County Organized Health System (COHS) that is authorized by federal law to administer Medi-
      Cal benefits in Orange County. More than 280,000 Medi-Cal beneficiaries are enrolled in the program. Although
      CalOptima is a public agency subject to federal and state regulations, it is governed by a board of directors
      comprised of patient advocates, providers, local businesses, and health agencies. CalOptima contracts with nine
      health networks, including eight physician hospital consortia and four HMOs. These nine networks include
      approximately 3,500 primary care physicians and specialists. CalOptima also offers coverage to Healthy Families
      and Medicare beneficiaries.
5     Process evaluation examines the procedures and tasks involved in developing and implementing a program. This
      type of evaluation collects information about the administrative and organizational aspects of the overall effort.
6     Public Policy Institute of California. Research Brief: Bankruptcy in Orange County: Who’s Next? Issue #11.
      April 1998.
7     PPIC, April 1998.
8     Mark Baldassare. PPIC Statewide Survey: Special Survey of Orange County. Public Policy Institute of California
      and University of California, Irvine. Sacramento, CA. September 2001.
9     Baldassare. September 2001.
10    Public Policy Institute of California. Research Brief: The Changing Social and Political Landscape of California.
      Issue #31. April 2000.
11    Brown ER, Ponce N, Rice T, and Lavaredda SA. The State of Health Insurance in California: Findings from the
      2001 California Health Interview Survey. UCLA Center for Health Policy Research. Los Angeles, CA. 2002.
12    Brown ER, Ponce N, Rice T, and Lavaredda SA. 2002.
13    Brown ER, Ponce N, Rice T, and Lavaredda SA. 2002.
14    MRMIB. Healthy Families Enrollment Report 10 found at www.mrmib.ca.gov accessed on December 5, 2002.
15    Orange County Health Needs Assessment. Report, May 2002.
16    Children’s Healthcare Access Initiative. Building Solutions for Orange County: Strategic Directions, 2002.
      Santa Ana, CA. 2002.
17    Orange County Health Needs Assessment. Report, May 2002.
18    These estimates of the number of uninsured children from California Health Interview Survey (CHIS) are slightly
      higher than those produced for the Orange County Health Needs Assessment by researchers at California State
      University, Fullerton. The authors chose to use CHIS data since CHIS also provides statewide estimates, which
      allows for direct comparisons with other counties.
19    Brown ER, Ponce N, Rice T, and Lavaredda SA. 2002.
20    Long P and Wulsin L. A Summary of Health Care Financing for Low-Income Individuals in California,
      1997 to 2002. Insure the Uninsured Project. Santa Monica, CA. 2002.
21    Orange County Health Needs Assessment. Report, May 2002.
22    Coalition of Orange County Community Clinics. “System of Care Needs Assessment Project.” February 2002.
23    Insure the Uninsured Project, Orange County Summary. Santa Monica, CA. 2002.
24    Insure the Uninsured Project, 2002.
25    Insure the Uninsured Project, 2002.
26    Insured the Uninsured Project. Regional Workgroup Summary: Orange County. 2002
27    Children’s Healthcare Access Initiative. 2002.
28    Melnick et al. 2002.




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EVALUATION OF ORANGE COUNT Y ’ S COMMUNIT Y ACCESS PROGRAM ( CAP ): FIRST YEAR ACTIVITIES




                    For more information about the USC Division of Community Health,
                          visit the web site at abbc3.hsc.usc.edu/familymed/dch

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