Michael Cousineau: California Community Health Advocate

Michael Cousineau, Dr.PH. is Associate Professor of Research in the Department of Family Medicine and Preventive Medicine at the University of Southern California Keck School of Medicine. He also directs the USC Center for Community Health Studies. Michael has researched access to care for the low-income uninsured, governance and operation of safety-net providers, community-based clinics and health centers, and health needs of vulnerable populations. His SHARE project examines the problem of California’s uninsured children who are eligible but not enrolled in public programs.

We talked to Michael about burning questions, taxing cigarettes, and leaving lab sciences.

What was the impetus behind your SHARE project?

With California’s recent health insurance eligibility expansion, everyone wanted to know the best way to enroll children in the programs. Many counties in California have initiatives to enroll all children, but we know very little about the most effective methods of outreach to increase enrollment. This is a burning question. Through our SHARE study, we will catalog the outreach and enrollment strategies of all 26 counties to systematically determine best practices around enrollment activity.

One aspect of California’s approach is to focus on the county and enroll kids by county. Is that a potential problem area for your research?

It is actually an advantage because it provides considerable variation in outreach strategies. Even within counties there is some variation, particularly with Internet enrollment programs. Assuming we can get data from every county, we will be able to measure different outcomes in relation to the various outreach strategies. Not all counties have sophisticated data systems, so that is a challenge we will be meeting.

Describe the site visits you’re planning for those counties.

The site visits will include examining the most prominent outreach strategies, such as enrollment through the schools and pre-populated forms. We will be asking about when the strategy was implemented, how much money was invested, and how many full-time employees were involved. Then we are going to link this data to actual enrollments with data from Healthy Families and Medi-Cal.

Will this entail working closely with county officials?

We anticipate an iterative back and forth process as we work to fill out the instrument completely and accurately. It also provides a great opportunity to educate counties about the importance of collecting and using data. The outreach will also include other organizations that counties contract with for First Five.

What is First Five?

First Five is a program geared for children up to age five. It started about ten years ago when California approved Prop 10 that taxed cigarettes an extra $0.25 per pack to fund early childhood needs like education, support services, child care, and health care. Every county receives a certain amount and most use some of their funds to cover the premiums for low-income children ages 0-5. In some cases, they house the outreach and enrollment apparatus.

In a state that has so many non-English speakers, will you look at language barriers to enrollment?

Yes, we will look at language barriers and issues related to immigration. Recently, we discovered a problem in Los Angeles where some community clinics were having difficulty enrolling children because the families were afraid they would get reported and deported.

Are there hopes that success stories in specific counties can be applied statewide?

Yes. In fact, California has already been implementing strategies statewide, but not in a data-driven way. For example, some directors have invested heavily in media spotlights on Spanish-speaking radio stations and newspapers. Others have been more involved with health fairs. These are both good ideas, but we don’t know if they are successful at targeting hard to reach families. My hypothesis is that Internet-based strategies that simplify the process and programs that utilize health care providers to enroll people in clinics will be most successful.

You started out studying genetics. How did you make your way to health services research?

Lab science was fascinating, but not how I wanted to spend my time, so I started volunteering at a community health center. People were coming to the clinic with a range of medical problems in addition to systems problems, like delay in getting care or dissatisfaction with past providers. That led me into public health and working with vulnerable populations in particular. After I finished my doctorate at UCLA, I directed the Los Angeles Homeless Health Care Project one of the 23 or so similar projects funded nationally by the Robert Wood Johnson Foundation.

What kind of connections do you see between research and clinical care?

I am increasingly seeing more community involvement. Many of the physicians I work with divide their time between seeing patients at our county hospital and health services research. I work well with them because they understand the limitations that providing only clinical care is for solving the problems that these families bring to the clinics and hospitals. It is easier to connect the dots between research and clinical care.