California officials overhaul outreach efforts for Healthy Families CHIP, MediCal programs

More than 1 million children eligible but not insured

Hoping to rescue its sputtering children’s health programs, California has streamlined its application, increased incentives to processors, and now channels applications into a central processing point. Even so, the state is a long way from enrolling even a fraction of its uninsured children, and still has major hurdles to get over, including how it will treat immigrants.

The state’s actions come against the backdrop of a September report by the 100% Campaign, which found that more than one million uninsured California children are eligible for either MediCal, California’s Medicaid program, or Healthy Families, the state’s Children’s Health Insurance Program (CHIP).

At this point, even the state’s own goals for CHIP enrollment appear distant. As of November, the state had enrolled about 50,000 of the 400,000 children targeted for enrollment through fiscal 2000.

California’s outreach efforts were behind the curve in a number of areas, says Dawn Horner, manager of policy and research for the Children’s Partnership, one of the member advocacy groups in the 100% Campaign. Advocates have cited numerous problems, including the complexity of the application, the lack of a central entry point, and how the state has dealt with immigrants who may be eligible for coverage.

The most significant recent change is in the application form for Healthy Families and MediCal. It has been shrunk from an intimidating 28-page document that required a variety of financial calculations to a far simpler four pages.

"Having a form that was 28 pages long seemed to be a deterrent, where individuals would not even try to complete it," says Teri Hodges, spokeswoman for the state Department of Health Services. "A lot of income definitions, a lot of computations" were removed from the application, says Ms. Hodges.

Instead of requiring applicants to figure out the numbers, the state will rely on application assistants—workers with various community organizations where families can apply for the programs—to do the math and understand the eligibility rules. The state has raised the reimbursement to those community assistants from $25 to $50 per application as an added incentive for participation, Ms. Hodges says.

Another important change is that families will be able to apply for health coverage for their children without first determining the program for which they are eligible. The streamlined forms will be mailed to a central processing location, where staff will determine whether applicants are eligible for MediCal or Healthy Families, and then channel them into the appropriate program.

"A number of states have had a single point of entry from the beginning of their programs," Ms. Horner notes. Unlike many other states that allow applicants to certify that they’re eligible for the programs, California continues to require a large number of documents demonstrating eligibility.

The state also is pressuring the federal government to make it clear that members of immigrant families who apply for the programs will not damage their chances of becoming citizens or resident aliens. This concern also has cropped up, though to a lesser extent, in other states with large immigrant populations, such as Texas and Florida. In California, it is a major stumbling block to signing kids up for coverage.

The children themselves are eligible for health benefits regardless of whether they are citizens. The problem arises when the eligible child is a member of a family of legal immigrants who may seek to become citizens.

If a member of a family is receiving any sort of public assistance—a "public charge," in U.S. Immigration and Naturalization Service lingo—the assistance can complicate other family members’ immigration statuses. Parents worry that if they sign their kids up for Healthy Families or MediCal, they may lose their chance of becoming citizens themselves.

"All the advocacy groups that work with immigrants we’ve talked to say they don’t feel they can tell families to go ahead and apply," Ms. Horner says.

The INS says if the child of an immigrant was born here and is therefore an American citizen, signing up for one of the programs won’t affect his or her parents’ immigration status. But the agency has not said what the impact would be on families whose children are not citizens.

Some states also have tried to avoid problems with immigration status in its outreach efforts. New York, for example, does not ask the parents of children applying to its Child Health Plus program for their Social Security numbers, and never inquires about citizenship.

Despite the problems, Ms. Horner praises California officials for their responsiveness to advocates’ concerns.

"What California’s done that’s unique is it’s brought the advocates into the program to develop it," she says. California may become even more responsive under new Gov. Gray Davis, Ms. Horner adds.

The 100% Campaign is pushing for expansion of Healthy Families to children in families earning between 200% and 300% of the federal poverty level (about $50,000 for a family of four in California). During the gubernatorial campaign, Mr. Davis supported an expansion of the program, "although he didn’t give specifics," Ms. Horner says. "He said he wanted to use the federal money remaining on the table."

Ms. Horner is referring to the roughly $2 billion in federal funds for which the state would be eligible but would not have spent by fiscal year 2000, even if the current Healthy Families program were fully implemented.