1. California's Electronic Application Is Live! From California: We are pleased to announce Health-e-App, the first fully automated, Web-based application for enrolling low-income children in public health insurance programs. We are very excited about its potential to streamline the application process and to speed up the time it takes for eligible children to get access to care. In cooperation with the Department of Health Services (DHS) and the Managed Risk Medical Insurance Board (MRMIB), the Institute and the California HealthCare Foundation are preparing to pilot test the application. Our goal is to have Health-e-App ready for statewide implementation by the end of the year. 2. Reallocation of Unused State CHIP Funds Based on state estimates of their projected spending through FY 2000, it appears that about $1.9 billion will be unspent from the FY 1998 allotments. That is the amount of money that is available for redistribution. The statute sets forth that unspent money is taken from the states that have not spent all of their FY98 allotments and given to those states that have exhausted their FY 98 allotments. Based on current estimates of states projected spending through FY2000, it appears that 9 states will be eligible for redistribution funds. This number could change (higher or lower) if state estimates were off. The nine states are: AK, IN, KY, MA, ME, MO, NY, NC, and SC. The timing of the redistribution will take place in early FY 2001. We don't know exactly what date it will occur because there is a delay as states submit claims for the prior quarter and as adjustments for prior periods are made. All the accounting for FY98 money needs to be complete before we know exactly how much was unspent. It could be several months into FY 2001 before funds can be redistributed. 3. New Report Documents Racial Disparities in Health Care Coverage and Access to Care Working minority Americans are less likely than Whites to have job-based health coverage, according to research by the Kaiser Family Foundation and the UCLA Center for Health Policy Research. The report, entitled "Racial and Ethnic Disparities in Access to Health Insurance and Health Care," analyzes the relationship of ethnicity and other factors to health insurance coverage and access to health services for Latino, African American, Asian American/Pacific Islander and Native American/Alaska Native populations. It also provides information, for the first time, on health coverage and access to care for subgroups of Asian American/Pacific Islanders and Latinos. Estimates from the March 1998 Current Population Survey show that 73% of Non-Latino Whites, 64% of Asian American/Pacific Islanders, 53% of African Americans, 51% of American Indian/Alaska Natives, and 43% of Latinos have job-based health coverage. "The majority of the nation's 44 million uninsured are White, but minority groups are disproportionately affected by the lack of health insurance. Elected officials who represent (minority groups), advocates and minority communities themselves need to recognize the tremendous stake minority Americans have in this problem," said Drew Altman, PhD, President of the Kaiser Family Foundation. For example, Latinos represent 12% of the U.S. population but comprise nearly 25% of the nation's uninsured. Although a similar percentage of African American and White children lack a usual source of care (4-5%), Latino, Asian American/Pacific Islander, and Native American children are nearly two to three times more likely than White children to lack a usual source of health care. These minority groups are also less likely to have recently seen a physician. While 7% of school-age White children have not visited a doctor in two years, 18% of Native American, 16% of Latino, 12% of Asian American/Pacific Islander, and 8% of African American school-age children have not visited a doctor in the two years prior to the survey. Minority populations already experience major disparities in health status and therefore it is important to ensure coverage and access to health services and preventive health services in particular, for these groups. For instance, the infant mortality rate for African Americans is more than double that of Whites and for American Indians/Alaska Natives is nearly one and half times that of Whites. Copies of the report and individual two-page fact sheets for each of the minority groups studied can be accessed at www.kff.org/kcmu or www.healthpolicy.ucla.edu. 4. Ethical Concerns and Mixed Results from Using Punitive Measures and Penalties with Welfare Recipients States are experimenting with financial incentives and penalties in an effort to improve health-related behavior among low-income populations. For example, Georgia's Preschool Immunization Project (PIP) removed families from AFDC if they were not able to prove that their children under 6 years of age were up-to-date with their immunizations. And Maryland's Primary Prevention Initiative (PPI) penalized families $25 per month per child if their preschool-aged children were not receiving preventive health care. These policies raise ethical concerns because of their punitive nature and the potential consequences to families of removing the benefits. Two recently published studies reviewed such punitive approaches and found mixed results. The authors in a study on Georgia's PIP reported that immunization rates were significantly higher for those welfare recipients who were being threatened with loss of benefits, compared to those not being threatened. However, a study on Maryland's PPI reported little difference in immunization rates between families who were subject to the sanction and families who were not. Other studies have shown an increase in immunization rates and the use of other preventive services without the threat of benefit reduction. For instance, immunization rates increased when Chicago's WIC program required women with children who were not up-to-date on immunizations to return to receive their benefits at one-month, rather than three-month, intervals. Enrollment in WIC remained the same even with the additional requirements. Of additional concern is that welfare recipients in these policy studies were not protected in the same way that participants in medical research are routinely protected. For example, the PIP study, unlike clinical studies, did not require any informed consent of participants nor did it require an independent assessment of risks and benefits. Before states proceed with implementation of such punitive measures, more evaluations need to be carried out in an ethical manner to determine the consequences of such policies on the families that they target. States should also determine if incentives work as well, if not better than penalties, in attempting to improve immunization rates and the use of other preventive health services.