摘要：Objectives. Many county coalitions throughout California have created local health insurance programs known as Healthy Kids to cover uninsured children ineligible for public programs as a result of family income level or undocumented immigrant status. We sought to gain an understanding of the experiences of these coalitions as they pursue the goal of universal coverage for children. Methods. We conducted semistructured telephone-based or in-person interviews with coalition leaders from 28 counties or regions engaged in expansion activities. Results. Children’s Health Initiative coalitions have emerged in 31 counties (17 are operational and 14 are planned) and have enrolled more than 85000 children in their health insurance program, Healthy Kids. Respondents attributed the success of these programs to strong leadership, diverse coalitions of stakeholders, and the generosity of local and statewide contributors. Because Healthy Kids programs face major sustainability challenges and difficulties with provider capacity, most are cautiously looking toward statewide legislative solutions. Conclusions. The expansion of Healthy Kids programs demonstrates the ability of local coalitions to reduce the number of uninsured children through local health reform. Such local programs may become important models as other states struggle with declines in employer-based coverage and increasing immigration and poverty rates. Over the past decade, California has experienced major changes in the financing of health insurance coverage for families. Increasing national poverty rates, downturns in employer-based coverage, and rising immigration rates have influenced the proportion of state residents who have health insurance as well as how they obtain coverage. 1 , 2 The most salient changes have occurred among children, for whom public program expansions have more than offset major decreases in employer-based coverage, resulting in an estimated net decrease of 117000 uninsured children between 2001 and 2003. 3 Whereas approximately 8% of California children aged 0 to 18 years (a total of 782000 children) remain uninsured, an estimated two thirds are already eligible for but not yet enrolled in existing programs such as Medi-Cal and Healthy Families (California’s Medicaid and State Children’s Health Insurance Program, respectively). 3 In the case of these children, the challenge is not changing policy but expanding outreach and enrollment, simplifying application processes, and increasing retention among those already covered. The remaining one third of uninsured children do not qualify for existing programs as a result of their family’s income level or, more commonly, undocumented immigration status. 4 Because Medi-Cal and Healthy Families have restrictions on providing assistance to undocumented families, child health advocates have sought alternatives to ensure that the estimated 200000 or so ineligible children without coverage can obtain care. One approach that is unique to California is the formation of county-based coalitions known as Children’s Health Initiatives (CHIs). CHIs have been convened by a range of community-based organizations not only to expand outreach and enrollment for existing programs but to design new insurance programs (i.e., Healthy Kids programs) entirely separate from other public programs in an effort to cover otherwise ineligible children. The first CHI (and the first Healthy Kids program) was initiated in Santa Clara County in 2001 by a group of community-based organizations. 5 These organizations convinced the county’s supervisors to allocate funds to children’s health insurance, assembled a coalition, and began working to design a comprehensive insurance program for uninsured children. Obtaining a mix of public and private funding and contracting with the Santa Clara Family Health Plan to administer the plan, the Santa Clara CHI launched its Healthy Kids program in a period of only about 6 months. The large response to the program that followed provided the impetus for advocates elsewhere to develop similar programs. Currently, 17 counties offer Healthy Kids programs and 14 are developing such programs. Given this major county-based movement toward universal coverage for children (including those in families of undocumented immigration status), understanding the experiences of CHIs may provide important guidance for California, as well as other states such as Illinois and Massachusetts that are aiming to expand coverage for children. We examined the progress of CHIs toward enrolling all eligible children; variations in program design, financing, and sustainability; the leadership and composition of CHI coalitions; outreach strategies; provider capacity (the availability and willingness of providers to serve Healthy Kids enrollees); and experiences with a statewide Healthy Kids legislative initiative.
