Personal assistance boosts SCHIP enrollment

No matter how good a health care system is, if people aren’t enrolled for coverage, it won’t be able to do its job. The Virginia Health Care Foundation in Richmond, whose main mission is to increase access to primary and preventive health care for Virginia’s uninsured and medically underserved, also is funding an initiative to help the state government enroll eligible children in its Medicaid and State Children’s Health Insurance Program (SCHIP).

Two years ago, the foundation, which is a public/private partnership initiated by the state legislature and its Joint Commission on Health Care, issued $1 million in grants to 12 community-based organizations in the state to fund efforts to enroll kids. That effort, Project Connect, targeted 47 localities and enrolled 6,500 children.

A second phase of the program, funded by the state Department of Medical Assistance Services, has made additional grants available to 11 organizations targeting 33 localities with a new goal of enrolling an additional 5,056 children by the end of 2002.

Grantees are using a variety of outreach and enrollment techniques including school-based insurance screening, pediatric clinic enrollment sites, work-site enrollment events, and special initiatives targeting existing client groups who are most likely in need of health insurance such as churches, day care centers, and legal aid offices. The foundation-sponsored efforts support a state marketing campaign to inform people about the new FAMIS (Family Access to Medical Insurance Security) program that uses posters, brochures, bus placards, and print and broadcast ads.

Need for the outreach was seen in a 2001 Health Access Survey conducted by the foundation, which estimated that 1.05 million people were uninsured in the state, more than 230,000 of them children.

Foundation officials say that FAMIS has signed up about 39,000 children to date, just over half of the state’s goal of 63,200, the number state officials believe are eligible for low-cost coverage. Some estimates have said the number of eligible enrollees is even higher. And nearly 70,000 more children are thought to be eligible for free coverage under Medicaid.

Federal funds lost

The state has been paying a steep price for the low number of FAMIS enrollees. An article in the Virginian-Pilot says the state forfeited $16 million in federal dollars the first year, according to a Joint Legislative Audit and Review Commission report, and ranks 40th in the nation in the percentage of federal funds spent for the program. The newspaper says an additional $40 million in federal funds has been lost since that report.

Foundation executive director Debbie Oswalt tells State Health Watch that when Project Connect started, the decision was made to undertake a bold and sweeping strategy rather than approach the issue piecemeal with small individual grants. "We said we’d take all the money we would put into children and some extra and use it to get kids enrolled," she recalls. "Enrollment numbers haven’t been high, and there were a lot of enrollment barriers. It became clear that one-to-one assistance was needed."

The initial $1 million in grants to 12 organizations was made for 18 months, Ms. Oswalt says, to allow times for the agencies receiving the funds to organize and experience success. "That was different for us because we were used to 12-month granting cycles. But we realized we weren’t likely to be able to repeat this program and we wanted to be sure there was enough time for it to succeed."

Because trying to resolve enrollment problems can be very frustrating for outreach workers, Ms. Oswalt says they wanted to develop the various community-based organizations into a cohesive unit whose members could support each other through what they saw as a dysfunctional project. To meet that goal, the foundation brought the groups together periodically for training and sharing of successes and problems.

"In addition to bringing the groups together four times during the 18-month period, we developed a database for each group to use to track where each person they were working with stood in the system," Ms. Oswalt says. "The database also let the workers see who had fallen out of the system, and when and why. That way they were able to document the problems and barriers their clients experienced."

Ms. Oswalt says that in the 18 months of the first phase of the program, they enrolled 75,000 children, about 60% in Medicaid and 40% in the Title XXI program. The results of the effort provided data the foundation took to the legislature to argue for changes in the Title XXI rules.

While there was a learning curve, she says, the organizations that have been working at this for a while and are now in Phase 2 "are now going gangbusters." Although the state has made some changes in FAMIS, problems still persist, demonstrating the continuing need for personal assistance. "We find that people can move quickly into the system if they have someone running interference for them," Ms. Oswalt says. If goals that have been set are met, there eventually will be 5,000 kids enrolled in the programs.

Ms. Oswalt says it remains difficult to give a hard number on the impact of the outreach effort because data have not been collected consistently. "Our new governor made full child health coverage enrollment a campaign theme last year," she says, "and already we’re seeing some wonderful changes coming from the executive offices. A lot of improvements are being made. I’m feeling very optimistic about where we’re headed."

The system remains very difficult to navigate, according to Ms. Oswalt, and thus the need for personal one-on-one assistance remains. The foundation’s goal is to get to a user-friendly system in which clients don’t need an advocate working with them. "We’ll probably need the one-to-one help for another 12 to 18 months," she estimates.

Ms. Oswalt says it is difficult to give other states advice on how to do what Virginia has done because the situation in each state is so different. "We wanted to be like North and South Carolina, where enrollment has been over the top." It’s important, she says, that the outreach program be supported by the executive branch of state government and that the governor gives the program substantive and public relations support. "Every time we’re faced with a decision about the child health insurance program, the people involved should always be asking themselves if what they’re working on will make it easier for people to enroll. If not, they shouldn’t be making any changes unless they’re absolutely necessary. The problem is to create that kind of culture within state government and local agencies. The federal government is giving a lot of flexibility, and our job is to find a way to make it simple and user-friendly. Any differences between FAMIS and Medicaid shouldn’t be visible to those who sign up for either program."

[Contact Ms. Oswalt at (804) 828-5804.]