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Deborah Zahn, MPH, Sherry Hirota, Jane Garcia, MPH and Marguerite J. Ro, MPH, DrPH

Deborah Zahn is with the Community Voices Project, Sherry Hirota is with Asian Health Services, and Jane Garcia is with La Clínica de La Raza, all in Oakland, Calif. Marguerite J. Ro is with the SDOS Division of Community Health, Columbia University, New York, NY, and is a consultant for The W. K. Kellogg Foundation’s Community Voices Initiative.

Correspondence: Requests for reprints should be sent to Deborah Zahn, MPH, Community Voices Project, 1320 Harbor Bay Parkway, Suite 250, Alameda, CA 94502 (e-mail: dzahn{at}chcn-eb.org).

	INTRODUCTION

TOP INTRODUCTION ALLIANCE FAMILY... NO WRONG DOOR—AN INCLUSIVE... KEEPING FAMILIES HEALTHY DIVERSE FAMILY STRUCTURES LESSONS LEARNED IN ALAMEDA... References

 
The United States is a land of contradictions. The dominant culture holds the individual to be primary and at the same time claims to place the greatest value on the family. Despite the rhetoric of "family values," our nation’s programs and policies—which typically are based on discrete categories of individuals—often fall short of providing the support needed to truly value families. By fragmenting families into mere groupings of individuals, programs and policies often fail to provide the support families need not just to survive but to thrive. Our emphasis on this fragmentation often ties the hands of agencies that want to provide services outside limited categories or creates a labyrinth of services far too complex for most families to navigate successfully. This is certainly true in health care.

Through a series of innovations in Alameda County, California, we have taken and continue to take advantage of every opportunity to align our familycentered values with our programs and policies. In Alameda County alone, there are an estimated 162 000 people without health coverage. Of these, 15 000 are children. More than half of the uninsured adults are immigrants.^1,2 Our programmatic and policy efforts are designed to be responsive to all families and family members in our diverse communities in Alameda County. We have sought to create a broad range of support for families, and we have moved our county forward in creating seamless systems that put families and their multiple needs at the center of our efforts.

	ALLIANCE FAMILY CARE—FILLING THE GAP IN HEALTH COVERAGE

TOP INTRODUCTION ALLIANCE FAMILY... NO WRONG DOOR—AN INCLUSIVE... KEEPING FAMILIES HEALTHY DIVERSE FAMILY STRUCTURES LESSONS LEARNED IN ALAMEDA... References

 
One of the major components of our strategy to remedy the disjointed and disorienting public coverage options for low-income uninsured families is Alliance Family Care, a health coverage program designed to fill the gap left by public programs. Administered through the Alameda Alliance for Health, a local, not-for-profit managed care plan, Alliance Family Care offers subsidized coverage to families at up to 300% of the federal poverty level who have children enrolled in the State Children’s Health Insurance Program (SCHIP), Medicaid, or Alliance Family Care. This latter "gap" program also offers coverage to parents who are not eligible for public programs, thereby allowing us to keep families intact. A central feature of this program is that immigrants, including undocumented immigrants, are eligible to enroll. This is essential because the immigration status of immigrant families is often mixed—for instance, one parent may be a legal resident, another may be undocumented, and the children may be citizens.

The impact of Alliance Family Care has been profound, as measured by standard health and insurance benchmarks. Membership has far exceeded expectations as more than 7300 family members have enrolled over 3 years. The retention percentage at the last annual renewal exceeded 97%. Preliminary results from the Health Plan Employer Data and Information Set (HEDIS)—a set of standardized performance measures for managed care plans—are encouraging. In 2002, child immunization coverage for measles, mumps, and rubella (MMR) was 80%, children aged 3 to 6 years enrolled in Alliance Family Care were more likely to visit primary care providers for prevention than similarly aged children enrolled in Medi-Cal, and more than 70% of members with diabetes were screened for renal disease and monitored by means of hemoglobin A_1C assays.

	NO WRONG DOOR—AN INCLUSIVE ENROLLMENT POLICY

TOP INTRODUCTION ALLIANCE FAMILY... NO WRONG DOOR—AN INCLUSIVE... KEEPING FAMILIES HEALTHY DIVERSE FAMILY STRUCTURES LESSONS LEARNED IN ALAMEDA... References

 
We created the No Wrong Door enrollment pilot program to enable us to keep families at the center of our efforts. Using a successful community health center model, we have transformed the way our social services agency does business. Instead of continuing to divide families by processing only Medicaid applications for individuals, the agency has expanded its role. Now people who come into our office are given one-on-one assistance in applying for coverage for everyone in their family—regardless of the payer source. Again, the success of this program is evident in the data. Since No Wrong Door began, approval rates have increased from an average of 59% to nearly 83%, processing time has decreased from an average of 45 days to only 7 to 15 days, and both clients and staff consistently report feeling more satisfied with their experience.

	KEEPING FAMILIES HEALTHY

TOP INTRODUCTION ALLIANCE FAMILY... NO WRONG DOOR—AN INCLUSIVE... KEEPING FAMILIES HEALTHY DIVERSE FAMILY STRUCTURES LESSONS LEARNED IN ALAMEDA... References

 
Keeping families healthy requires more than expanding health coverage and increasing visits to doctors’ offices. Wraparound services, such as interpretation for patients with limited English proficiency, case management, and health education, are essential to providing the high-quality, comprehensive care that families need. Many of our community health centers and other safety net institutions receive little, if any, reimbursement for these vital services. All families, but particularly lowincome uninsured families, juggle many competing demands. Our fragmented health care system is ineffective in addressing the complexities of daily life and insufficient in meeting families where they are. In contrast, our community health workers and promotoras are able to assist families in navigating health care and social systems. Their outreach includes assisting families in everything from paying utility bills and obtaining food stamps to seeking protection against domestic violence. Without electricity in their homes, food on their tables, and safety in their lives, families cannot even begin to address their health concerns.

Although we have achieved documented success in Alameda County, there are other pressing issues that must be dealt with if we are to live up to our claim of valuing families. The notion of a family as restricted to a nuclear family comprising a father, a mother, and children is not a true reflection of reality. When we ask our community members what constitutes a family and examine caregiving among families, we see a great diversity of family structures, including extended families living in a single residence, grandparents raising grandchildren, and parents caring for adult family members. Of course, this has been true in the past as it is today.

	DIVERSE FAMILY STRUCTURES

TOP INTRODUCTION ALLIANCE FAMILY... NO WRONG DOOR—AN INCLUSIVE... KEEPING FAMILIES HEALTHY DIVERSE FAMILY STRUCTURES LESSONS LEARNED IN ALAMEDA... References

 
According to the 2000 US census, approximately 15.7 million US residents live with extended family members. Approximately 5.8 million grandparents over the age of 30 live with their grandchildren under the age of 18; of these grandparents, just under 2.5 million are responsible for their grandchildren’s care.³ As the elderly population burgeons, more people will become caregivers to aging family members. Nearly 1 of every 4 households is involved in caring for persons aged 50 years or older; by 2007, the number of such households could reach 39 million.⁴ Approximately 43% of baby boomers in immigrant families provide care for older relatives, compared with 20% of baby boomers born in the United States.⁵

The challenges families face in caring for all their members—grandparents, children, and ailing family members—are substantial. Even when programs and policies do emphasize families, they are rarely aligned with the diversity of family structures.

Nonetheless, certain workplaces are beginning to make the necessary changes to accommodate these structures. Our health and social services systems must follow suit. We also must face the reality that health and illness are family issues. The entire family is affected when one member does not have health care coverage or is sick. Efforts to provide coverage to family members must extend beyond children and pregnant women. Otherwise it assumes only heterosexual unions. Also, we cannot afford to leave men out of the health care equation, not only for the sake of our men but also for their families and our communities.

Recognition of the links between the health of adult family members and the health of their children helps providers to better understand the full range of factors contributing to the health of any individual client. Medical and health decisions are rarely made by individuals alone but are most often made in consultation with their families. Health behaviors are passed down from generation to generation.

	LESSONS LEARNED IN ALAMEDA COUNTY

TOP INTRODUCTION ALLIANCE FAMILY... NO WRONG DOOR—AN INCLUSIVE... KEEPING FAMILIES HEALTHY DIVERSE FAMILY STRUCTURES LESSONS LEARNED IN ALAMEDA... References

 
Through our experiences in Alameda County, we have learned several important lessons that may help guide future efforts to build a health care system that values families. First, programs and policies need to be altered to include a more realistic definition of families. The current nuclear family paradigm under which our systems are operating does not serve families in a way that allows them to maintain their integrity and dignity. If we value families, we must serve them as they are.

Second, building flexibility into our systems would better ensure that they work for families. Having systems that "bend" would allow us to use what we know works and try out new approaches.

Third, we must create more opportunities to enroll families in health coverage programs. Our experience in Alameda County demonstrates that offering an affordable, comprehensive family coverage product and transforming the enrollment process means families will not only enroll but stay enrolled.

Fourth, we need adequate reimbursement for wraparound services and funded opportunities to step outside traditional health care boundaries.

Finally, we need to meaningfully evaluate and share successful models for providing family-centered health care. This is particularly important for populations, such as immigrants and communities of color, that have traditionally been discriminated against in health care systems and that continue to be underserved. Our model for family-centered health care in Alameda County has grown out of our valuing families and meeting them where they are. By linking our model with others that are developing across the nation, we seek to build a connected system that will fill existing gaps and better ensure respectful health care for all.

	Acknowledgments

 
The Community Voices Project is funded by the W.K. Kellogg Foundation. Asian Health Services and La Clínica de La Raza are co-grantees for the Community Voices Project grant in Alameda County, California.

The authors thank Dong Suh, MPP, policy and planning director, Asian Health Services, for providing input and Darouny Somsanith, MPH, research and policy associate, Community Voices Project–Alameda County, California, for collecting data.

	References

TOP INTRODUCTION ALLIANCE FAMILY... NO WRONG DOOR—AN INCLUSIVE... KEEPING FAMILIES HEALTHY DIVERSE FAMILY STRUCTURES LESSONS LEARNED IN ALAMEDA... References

 
1. Advancing Universal Health Insurance Coverage in Alameda County. Results of the county of Alameda Uninsured Survey. Los Angeles, Calif: University of California Los Angeles Center for Health Policy Research; September 2001.

2. California Health Interview Survey. AskCHIS [on-line searchable database]. Available at: http://www.chis.ucla.edu/main/default.asp. Accessed September 2003.

3. Census 2000 Summary File 3. Marital Status by Sex, UnmarriedPartner Households, and Grandparents as Caregivers. Available at: http://www.census.gov. Accessed September 12, 2003.

4. Family Caregiving in the U.S.: Findings From a National Survey. Bethesda, Md: National Alliance for Caregiving and AARP; June 1997.

5. In the Middle: A Report on Multicultural Boomers Coping with Family and Aging Issues. Washington, DC: AARP; July 2001.

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This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zahn, D. Articles by Ro, M. J. Search for Related Content PubMed PubMed Citation Articles by Zahn, D. Articles by Ro, M. J. Related Collections Family Health Health Care Facilities/Services Insurance Health Policy Access to Care Other Health Service Delivery