Democrats say a top priority for them in the new Congress will be providing health coverage for uninsured children. But, ironically, little has been done in recent years to reach 2.7 million children under age 11 who are eligible for Medicaid, but are not receiving it. Most of these children are from families that do not not receive cash assistance, so their parents have few opportunities to find out that their children are eligible for Medicaid, according to a study by the Center on Budget and Policy Priorities (CBPP). Children from households that received assistance under the Aid to Families with Dependent Children (AFDC) program have been automatically enrolled in Medicaid under federal law. A handful of state Medicaid agencies, along with non-profitss such as CBPP and the Southern Institute, and local advocacy groups, have been working to find ways to reach young Medicaid eligibles through outreach efforts that extend beyond the local human services agency. These efforts target early childhood centers, schools and hospitals and sometimes include home visits. Now that the Medicaid program and the welfare program have been "de-linked" under welfare reform, children’s advocates argue that the need for better outreach to Medicaid-eligible children is more crucial than ever. But CBPP’s Cindy Mann says most states have been so preoccupied with implementing the new Temporary Aid to Needy Families (TANF) program that they have been slow to focus on the issue. In one of the first pieces of legislation to address the "de-linking" problem, Massachusetts State Rep. Joseph McDonough is seeking to require the state’s Division of Medical Assistance to automatically determine Medicaid eligibility for all applicants denied cash assistance under TANF. The legislation (no bill number has yet been assigned) addresses one of the key concerns both of advocates and top officials in the Health Care Financing Administration—that the elimination of automatic enrollment in Medicaid for all families who qualify for cash assistance may create large numbers of newly uninsured. Sarah Shuptrine of the Southern Institute on Children and Families, Columbia, SC, says her studies have shown that a key reason for the wide gap between those eligible and those enrolled is the very high percentage of poor working families who don’t understand "that their children can apply for Medicaid with no connection to the welfare program." Even if children already have some insurance, they may be eligible for the more comprehensive benefits offered under Medicaid. Outreach in Georgia The most aggressive statewide effort to educate families that their children do have access to health insurance is overseen by Georgia’s Medicaid agency. The state’s 3 1/2-year-old Right from the Start Medicaid Project (RSM) deploys 143 case workers to do outreach in a wide range of community settings, often before and after normal working hours. The outreach workers "go to people’s houses, employer sites, hospitals, daycare centers and public libraries," notes Georgia Medicaid Program Consultant Theresa Johnson. The approach is a shift in thinking from a culture that has traditionally done nothing to make it easy for applicants, Ms. Shuptrine says. Typically, case workers are penalized for enrolling people ineligible for benefits, but are offered no incentives to encourage enrollment or help parents meet paperwork requirements or navigate the bureaucratic maze. Children from families with income less than 150% of the poverty level who are not eligible for Medicaid are referred to the Georgia Caring Program for Children administered by Blue Cross and Blue Shield of Georgia, which provides limited voluntary services of physicians, hospitals, pharmacists and many health provider agencies. During RSM’s first three years, it received 114,000 applications for health services. Lowering the hoops In a 1994 study, Ms. Shuptrine found that 50% of children denied Medicaid coverage were turned down for "procedural reasons," such as not having the money or the time to get a a copy of their children’s birth certificate or difficulties getting required pay stubs from an employer rather than because of the applicant’s financial means. Solutions to some of the procedural barriers can be quite simple, Ms. Shuptrine says. In Greenville, S.C., for example, the city’s Department of Social Services works with Vital Statistics so that birth certificate information can be automatically transferred from one agency to the other. Many states have taken steps to simplify the eligibility process. About 80% of states have eliminated an assets test for Medicaid and some 20 states now allow Medicaid applications to be mailed in. Among those states that have simplified the Medicaid application are Washington State, which now has a one-page form, and Pennsylvania, which has a four-page form. In Pennsylvania, the settlement of a lawsuit against the state three years ago by 20 advocacy groups, has resulted in one of the most comprehensive efforts to address many of these procedural barriers. Under the leadership of Philadelphia Citizens for Children and Youth (PCCY), some 236,000 of the city’s children are enrolled on Medical Assistance, up from 187,000 in 1990. Overall, PCCY estimates that only 3% of the city’s children today have no insurance at all. Pat Redmond, project director of PCCY’s Child Health Watch, identifies several keys to the program’s success, including the development of "strong relationships with local administrators who are committed to doing this right." Other keys include "saturating the community" with "user friendly materials" such as brightly colored fliers that try to make a government program less intimidating and that seek to destigmatize Medicaid by stressing that it is an insurance program, not cash assistance. PCCY also has trained neighborhood agencies ranging from a local settlement house to a community housing group to help identify people who may be eligible for medical assistance and other programs. The city’s 300 school nurses have been trained to determine whether children who seek care have insurance and to follow up with their families if they don’t. Children not eligible for Medicaid are referred to the state’s Childrens Health Insurance Program, which now covers some 9,000 children in the Philadelphia area alone and some 50,000 statewide. PCCY also has worked with 150 small businesses to publicize the program’s hotline number on placemats, shopping bags and magnets. Tie-in with child-care centers The Washington, D.C.-based Center on Budget and Policy Priorities is in the midst of a national effort to beef up outreach by taking advantage of the natural connection between child-care programs and Medicaid. In Washington State, for example, the Center’s Start Healthy, Stay Healthy program has worked with the Children’s Alliance and the state’s Child Care Resource and Referral Network to train child-care agencies on how to conduct Medicaid outreach and referral activities. The groups also have revised the CCR intake questionnaire to include a Medicaid income eligibility screening question. One of the advantages of working with the child-care groups, says Donna Cohen Ross, director of outreach for the Center on Budget and Policy, is that eligibility for the child food program, in which many participate, is set at 130% of poverty, very close to the 133% level for Medicaid eligibility in many states. The Center hopes to finish work shortly on a package of outreach materials, which includes examples of strategies community organizations can use in their outreach work. The high level of interest in this area is demonstrated by the waiting list of 2,000 organizations that have already requested the material. Contact Ms. Cohen Ross at 202-408-1080; Ms. Shuptrine at 803-779-2607; Ms. Johnson at 404-657-7263; and Ms. Redmond at 215-563-5848.