SCHIP sails on with a narrow focus

Founded in 1997, the State Children’s Health Insurance Program (SCHIP) has evolved from broad-based efforts to raise general program awareness to a tighter focus on specific hard-to-reach groups, researchers report.

A new Mathematica Policy Research survey of the evolution of SCHIP outreach efforts has lessons learned that policy-makers can apply to other public health care programs as well.1

Mathematica researchers Susan Williams and Margo Rosenbach report that over the years, states have shown creativity and adaptability in developing a wide range of strategies to promote SCHIP enrollment, including providing assistance in the application process and educating families about appropriate use of services.

"As the program has matured and the fiscal environment has tightened, states have learned what efforts are successful and have tailored their approaches accordingly," they report.

Before SCHIP was enacted by Congress, states did little to actively market Medicaid or other public programs to children and adults. But Title XXI explicitly gave states limited funds for administrative costs, including marketing activities. And the legislation required states to describe outreach efforts in their plans and to document their progress in annual reports.

The initial efforts at state and local levels were intended to educate families about SCHIP, answer their questions, and assist them with program enrollment. Later, using evidence from focus groups, hotline referrals, surveys, and other sources, states learned important lessons about how to reach eligible uninsured children and their families. Responding to the lessons learned, they shifted from broad efforts intended to establish name recognition to more targeted approaches directed at families who were eligible but not enrolled.

Closing gaps

In a report published in Health Care Financing Review, Ms. Williams and Ms. Rosenbach give the first national assessment of how states have adapted their outreach campaigns to close the gaps in reaching hard-to-reach populations, looking at target populations, messages, communication methods, and organizational strategy. They note that early evidence about the large proportion of uninsured children who were potentially eligible for Medicaid but not enrolled reinforced the need for effective outreach for SCHIP as well as Medicaid.

So outreach could become entrenched at the grass-roots level, many states established funding mechanisms to help community-based organizations conduct outreach.

Gaining access to families

Many states also found that outstationing their workers to conduct outreach and application assistance at community-based organizations, schools, or health-care provider sites gave them access to families who were eligible but not enrolled.

In addition to reaching out in different ways to those who were eligible for SCHIP but were not enrolled, states saw a need to ensure timely renewal and appropriate use of services for current SCHIP enrollees. Communication with current enrollees has become known as "inreach" and is a key to improving retention.

The analysts say studies have shown that roughly 50% of all enrolled families drop coverage during the renewal period, even though they continue to qualify under a state’s eligibility criteria. "Some experts suggest that helping those who already have insurance retain their coverage may be an important and cost-effective method not only for reducing the uninsured rate, but for improving the continuity and quality of people’s health care," they say. "States have found that it is less expensive to retain eligible enrollees than to have them drop off the program and later reapply after a break in coverage. In addition, continuous coverage through SCHIP saves money because enrollees use fewer services over time."

Enrollment freezes heightened the need for clear communication to families in states that were not able to maintain open enrollment due to fiscal constraints, the study found. Seven states—Alabama, Colorado, Florida, Maryland, Montana, North Carolina, and Utah—froze SCHIP enrollment at differing points in time. While some of the states discontinued outreach efforts, others redirected communication efforts to inform current enrollees about the freeze to ensure they protected their eligibility.

The researchers say the ongoing evolution of SCHIP outreach has had a spillover effect on traditional Medicaid enrollment. State refinement of messages to emphasize eligibility for and the value of health insurance led not only to increased SCHIP enrollment, but also to increased Medicaid enrollment. Many families who applied for SCHIP coverage were found to be eligible for Medicaid, thereby increasing overall rates of public insurance coverage.

Learning from experience

While there hasn’t been any formal evaluation of SCHIP outreach effectiveness, Ms. Williams and Ms. Rosenbach say their study has shown how states assessed their own efforts and learned from their experiences. They say that for policy-makers seeking to increase enrollment in other public programs, such as the Medicare prescription drug program, such a longitudinal assessment of state efforts under SCHIP provides valuable lessons. Thus, early outreach efforts may include universal strategies to reach the general population, whereas later efforts may involve selected strategies aimed at specific, high-priority populations.

To better gauge the effectiveness of state outreach strategies under SCHIP, they say, future research is needed to explore quantitative approaches that can be used to measure the impact of outreach strategies on enrollment rates overall and within specific target populations. Thus, because most states have used statewide mass media and local one-on-one outreach efforts in combination with each other, little is known about the relative success of the strategies. Little also is known about the return-on-investment of specific outreach strategies relative to various enrollment simplifications such as using joint applications, mail-in or Internet applications, or reduction of documentation requirements.


1. Williams SR, Rosenbach ML. Evolution of state outreach efforts under SCHIP. Healthcare Financing Review 2007; 28(4):95-107.