Published Online: January 29, 1997

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HMO Targeting School Clinics For Pupil Care

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One of the nation's largest HMOs has begun selling low-cost insurance to cover 1,300 poor children in the Denver area who attend school districts that have health clinics.

The pilot program is an effort by Colorado administrators of Kaiser Permanente to provide medical services to children who badly need them, and also to show school clinics how to survive in the evolving health-care environment.

The program launched this month by the nonprofit health maintenance organization comes at a time of heightened interest in the estimated 10.5 million children nationwide who do not have health insurance. In Washington, Democratic legislators have vowed to make the issue a priority this congressional session.

Two Democratic senators have unveiled proposals that would provide coverage to uninsured children, saying it is the logical next step in incremental health-care reform. Republicans, meanwhile, are considering proposals that would require less government involvement.

$3 a Month

Officials at Kaiser Permanente estimate there are between 45,000 and 50,000 uninsured children in Colorado. Most of these children fall between the cracks of the system: Their parents cannot afford insurance but earn too much to qualify for Medicaid, the federal-state program for the poor and disabled.

Experts say the Denver program may be the first in which a private insurer has chosen school clinics as the exclusive entry point for care.

"The beauty of the Kaiser program is they've taken a step to provide youngsters with both access and coverage," said John Schlitt, the deputy director of Making the Grade, a Washington-based group that supports school health clinics.

Children who are eligible for the federal free- and reduced-price lunch program can sign up for the Kaiser program.

For $3 a month per child, or a maximum of $9 a family, participants will receive full Kaiser Permanente benefits. "Everything from immunization to transplants," said Bruce Guernsey, the director of an effort by the Colorado health department to promote school health clinics.

The eligible students in the three districts--Denver, Adams County District 14, and Sheridan--have access to a school-based clinic. The clinics will serve as the children's source for primary care.

Gain for Clinics

The program is expected to cost the managed-care organization about $1 million a year.

Even so, Kaiser officials say they believe the insurance is a good deal for both the children and Oakland, Calif.-based Kaiser, which channels a portion of its dues into charitable work.

Using the school health clinics and targeting school-age children makes for economical care without a trade-off in quality, said Maureen Hanrahan, the director of community and preventive care for Kaiser's Colorado region.

In fact, Kaiser found in a two-year study of Denver students that school clinics apparently encouraged children to seek more preventive and early-stage care.

The study involved 600 Kaiser-insured students; half attended schools with health clinics, and half were in schools without. It found that students in the clinic schools made more visits each year to a primary-care doctor and fewer visits to more costly after-hours care.

The students with access to school clinics also received more preventive care and made significantly more visits for mental-health and chemical-dependency concerns. "For not very many more visits and close to the same cost, the health centers had achieved some things we hadn't," Ms. Hanrahan said.

In addition, the Denver pilot program highlights a potential new source of revenue for school clinics, which in Colorado and elsewhere are funded from a grab bag of public and private sources.

"Frankly, school-based health centers have been struggling with who pays," said Mr. Guernsey of the Colorado health department. "Health clinics are at risk of being shut out in the current health environment."

But, he added, if clinics can receive payments from managed-care organizations, their prospects for survival will improve.

On Capitol Hill

In Washington, leaders of both parties say that participation from private insurers like Kaiser will be important in efforts to improve access to health care for uninsured children.

President Clinton is likely to include in his upcoming budget a $750 million proposal for states to expand coverage of uninsured children through vouchers, tax credits, or other means.

In the Senate, Democratic plans call for spending an estimated $3 billion to $4 billion a year to increase the numbers of insured children, while Republicans are toying with the idea of redirecting money from the federal earned-income tax credit, which subsidizes the working poor.

A bill introduced late last year by Sens. Edward M. Kennedy and John Kerry, both Massachusetts Democrats, would offer federal vouchers to low- and moderate-income families for the purchase of insurance.

A separate bill, unveiled by Sen. Tom Daschle, D-S.D., would provide families with a refundable tax credit for the purchase of insurance. The amount of the credit would decrease on a sliding scale of annual family income.

But Republicans are leery of creating an expensive new federal program. An alternative approach favored by some Republicans would require families who receive an earned-income tax credit to spend a portion of it on health coverage for their children.

In a recent television interview, the Senate majority leader, Trent Lott of Mississippi, said "health affordability and accessibility" are high priorities for the GOP. But, in a reference to the massive health-care overhaul President Clinton proposed in his first term, Mr. Lott promised to battle efforts by Democrats to do piece by piece what they "couldn't get with one big government takeover of health care."

With Republicans controlling both houses of Congress, the fate of any bill aimed at expanding federal spending on health coverage is at best uncertain.

"A lot of people are saying it is not going anywhere, but there's a lot of talk around the issue," said Anne Rossier Markus, a research associate at George Washington University's Center for Health Policy Research in Washington.

Many states, meanwhile, have taken steps to expand coverage of uninsured children. Several have created publicly funded insurance programs targeted at children from low-income families.

State Initiatives

Others have built on existing programs, including Medicaid, to bring coverage to more children. At least 15 states, according to the Center for Health Policy Research, have expanded eligibility for Medicaid. Fourteen states offer subsidies to families for the purchase of health insurance, an approach similar to the one Senate Democrats are pushing. Last year, Florida, Massachusetts, and New York expanded their children-only insurance programs.

Also, 24 states have encouraged private organizations like Kaiser Permanente to offer children-only insurance policies to needy families, mostly at private expense.

Betty Pepin, the director of school health clinics for the 8,000-student Adams County District 14, hailed the Colorado experiment.

"It's great for the kids to get a comprehensive package many of the families couldn't dream about having," she said. "We've been taking care of the children of the working poor for many years. Now we're getting paid for it."

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