Nontraditional community organizations help states increase CHIP enrollment

As the state Children’s Health Insurance Program (CHIP) matures, outreach to the eligible uninsured encouraging them to enroll is increasingly important as states turn to local communities for help.

In its latest site visits to 12 nationally representative communities, the Center for Studying Health System Change in Washington, DC, found many organizations not traditionally involved in public health insurance activities, such as schools, employers, and religious and community groups, taking an important outreach role.

Center health research analyst Laurie Felland, lead author on the Center’s CHIP outreach report, tells State Health Watch that local outreach "is a good way to identify those who are eligible and encourage and help them to apply. It’s interesting to see the wide array of organizations and groups that put a high value on enrolling kids in the program."

Although there were approximately 2.7 million children enrolled in CHIP in December 2000, there are indications that more than 2 million more children are eligible but are not enrolled.

Urban Institute studies have reported that lack of information, confusion about eligibility requirements, and administrative hassles create significant barriers to CHIP enrollment. And a recent Center for Studying Health System Change study found that improved outreach, rather than still more expansions of eligibility, is the key to extending coverage to low-income children.

Ms. Felland says that during the past two years states have increasingly turned to communities to help identify and enroll eligible individuals in CHIP. Despite many positive features of the program designed to appeal to low-income families and reduce the stigma associated with government health care, many states initially struggled to enroll children.

As a result, many states have streamlined application processes and provided funding and training to local organizations to generate awareness about the program, identify eligible children, and help them apply. Preliminary observations of state and local leaders working with CHIP suggest that local organizations can play an important role in boosting enrollment in public programs.

There are a number of reasons for the success of local outreach, Ms. Felland says. First, because local efforts can be customized to meet the needs of a specific community, they identify and target key populations more effectively. Second, the involvement of organizations that low-income families trust and have frequent contact with has helped increase participation in public health programs.

To educate hard-to-reach populations, organizations translate CHIP program materials into native languages and hire outreach workers of the same racial, ethnic, or cultural background as target groups. Many organizations focus on minority groups and people with relatively higher incomes, reasoning that the stigma associated with government programs might deter them from applying on their own.

Also targeted are eligible immigrants who might be unable to apply because of language barriers or the fear that participation could threaten their immigration status.

Although targeted outreach can be successful, it often is costly, and the cost often exceeds the funding from state and federal CHIP and Medicaid funds that organizations receive. As a result, many organizations involved in outreach use their own resources or funds from other private resources such as foundations.

The most significant local players involved in outreach to date have been health care organizations and schools. Community and religious groups increasingly are involved, and employers are beginning to participate in some communities.

Although local health departments, providers, and health plans have conducted Medicaid outreach in the past, many have intensified efforts under CHIP. Hospitals and community health centers have particularly committed extensive resources to identify uninsured children when they seek services and then help their parents apply.

Local health departments and social service agencies often assist other providers with CHIP outreach in addition to conducting their own outreach activities. In some communities, health plans promote general awareness of CHIP through broad public information campaigns and materials. However, plans in many states are restricted from promoting their CHIP products because of concerns about potentially inappropriate influence on beneficiary plan selection.

School nurses often coordinate the effort in schools and screen students for health insurance at annual school registrations, send letters home, and discuss the program with parents at meetings. Many schools coordinate CHIP outreach with federally sponsored free and reduced school lunch programs.

To locate some of the most difficult to reach children, particularly those outside the school system, community groups play important roles in CHIP outreach. Common types of involved organizations include child-care centers, food banks, homeless shelters, children’s groups, and Volunteers In Service To America volunteers. Local organizations also distribute CHIP applications through small businesses, such as neighborhood grocery stores and beauty salons.

More religious organizations are becoming active in CHIP outreach, in part because of a change in federal rules that allows states to contract with faith-based groups if the individuals they target are not required to participate in religious activities.

Some communities target outreach to business groups or employers with low-wage workers that don’t offer health insurance to the workers or their dependents. A significant concern about employer involvement is that it will cause crowd-out, leading employers to substitute CHIP for employer-sponsored coverage. States are required to have provisions to prevent crowd-out, such as checking to make sure that a child has not had private health insurance for a certain period before receiving public coverage.

Ms. Felland says that while schools have had the most prominent outreach role and been the most successful, it is interesting to see the increase in religious group involvement in the last couple of years.

"It’s a good way to reach people outside the health care system. It reduces the stigma when neighbors are talking to neighbors," she says.

Although there are successful outreach programs that can be seen in the center’s study, enrollment problems persist, and there is a need for still more efforts to reduce the administrative hassle and stigma. However, lack of funding may present the greatest challenge to local CHIP outreach efforts. Many states are experiencing budget shortfalls along with higher-than-anticipated Medicaid and CHIP enrollment and costs per enrollee. Federal funding for CHIP is set to drop 25% in fiscal 2002 and reduced funding will continue through fiscal 2004.

A program that has achieved considerable success in CHIP enrollment is Cuyahoga Health and Nutrition in the Cuyahoga County (Ohio) Department of Jobs and Family Services. Robert Staib, marketing and communications manager tells State Health Watch the agency has contracted with a number of enrollment brokers — community agencies of various sizes — paying a flat rate per child enrolled by the broker.

In the first year of the effort, 3,200 applications were received enrolling 5,200 children. "We think those are good numbers," Mr. Staib says. They’ve also invested in a decorated van — the Kids Healthmobile — that visits community festivals and other activities, supplying health-related giveaways and program applications. And there have been TV and radio commercials and printed brochures and other literature. All the promotion contains a unified call to action — a request that people call a telephone hotline where they can speak with someone who can help them complete their application over the telephone.

Based on the numbers of children enrolled, Mr. Staib says there has been "quite incredible" success. In September 2000 there were 94,000 children in the CHIP Healthy Start program and as of August 2001 that was up to 115,000, believed to be an historical high. (The 115,000 far exceeded the goal of 104,000 that had been set.)

Mr. Staib says they can’t tell how much of the increased enrollment is specifically due to the outreach efforts since in July 2000 there was an eligibility increase to 200% of poverty and a simplified application form was introduced. He rates the various forms of outreach with the telephone hotline first, followed by the broadcast spots, print literature, and the contracted brokers last.

[Contact Ms. Felland at (202) 261-5667 and Mr. Staib at (216) 987-8433.]