Local outreach is the key to increased SCHIP enrollment
While significant efforts have been made to enroll people in State Children’s Health Insurance Programs (SCHIPs), millions of children and adults are eligible for public coverage programs but not enrolled. Local outreach is thought to be the key to bringing them into the fold.
A catalog of successful outreach efforts has been created by Community Voice, a program of the W.K. Kellogg Foundation of Battle Creek, MI, in which 13 community organizations across the country have been given grants to help increase access to health care, promote quality and cost-effective care, and strengthen the safety net.
Barriers to enrollment include a lack of information, cumbersome application and recertification procedures, and premiums or enrollment fees.
In addition, Community Voices has found that some populations are particularly difficult to reach — immigrant families, people with language or cultural differences, people who have had negative past experiences with government agencies, people who perceive a stigma associated with publicly funded programs, low-wage workers in small businesses, and individuals facing geographic or logistical barriers.
To make the best use of steps that states have taken to streamline application procedures, outreach is needed in community health centers and clinics, county health departments, community-based organizations of all types, churches, bodegas, and beauty parlors, a Community Voices report says. "Particularly in a time of budget shortfalls and fiscal constraints, communities must focus on effective strategies for connecting individuals and families to critical health care programs."
Examples cited
The Community Voices "cookbook" gives examples of outreach efforts including developing innovative outstationing and technical tools; addressing language and cultural differences; enlisting neighborhood residents, community health workers, or promoters; ensuring a user-friendly atmosphere and process; building relationships with community organizations; forming outreach collaboratives; participating in community events; using local media and marketing; and providing funding to help with application fees in states where they are imposed.
Community workers say there are some things states do that help them in their outreach and enrollment efforts and should be expanded. Those state policies that help community efforts include visits from or placements of Medicaid/SCHIP workers with community workers in community-based organizations; active high-profile support and involvement of the governor or other high-ranking state officials; a reduced waiting period between the end of private coverage and eligibility for public coverage; medical care or vouchers for low-income pregnant women who have not completed the application process or who do not otherwise receive Medicaid services; and retrospective Medicaid and SCHIP payments for emergency department services that motivate hospital staffs to facilitate enrollment in public coverage.
Conversely, there are some state actions that are seen as frustrating local outreach and enrollment activities. Some of the barriers are political or philosophical such as noneligibility of documented individuals and families who arrived in this country within the last five years and undocumented immigrants; state requirements for information about noncustodial fathers when mothers apply for Medicaid and other programs, and the failure of many states to recognize school-based clinics, which are accessible to children and teens and already are providing important primary and preventive care.
Most of the state barriers cited by local Community Voices programs are related to fiscal constraints. They include state imposition of enrollment freezes, stringent Medicaid eligibility criteria, limited state outreach payments to community-based organizations, and very low payments to health plans and providers.
In times of fiscal distress, states are going to be challenged to sustain current outreach, enrollment, and benefit levels. Options they face include using unspent federal SCHIP funds; obtaining federal grants for outreach; expanding Medicaid and SCHIP eligibility to populations such as childless adults; focusing policy debates toward the need to invest in health programs as a long-term strategy toward building a healthier and more productive society; providing financial and technical support for innovative, community-based coverage programs; and concentrating on developing affordable coverage options for small businesses and low-income workers.
Influencing state policy
Community Voices West Virginia has achieved significant success by outstationing enrollment workers in primary care centers and family resource centers. These workers also have been successful by visiting nursing homes to engage and educate staff and elderly residents about public coverage. West Virginia also uses parent educators who go to homes to teach child development and basic parenting skills, along with assistance with health plan enrollment.
Community Voices West Virginia director Nancy Tolliver tells State Health Watch that her organization has worked successfully on the community level as well as influencing state policy.
"The focus of both those efforts is to increase access to health care for the uninsured and underserved," she says.
A committee from the local level has influenced state benefit design decisions and under the state’s Healthy Kids Coalition, outreach workers from around the state have an opportunity to meet with state agency officials to describe their successes and problems, meetings that Ms. Tolliver says have been extremely effective.
"The reason we’re effective in meeting with state officials is that we actually have people from the grass roots speaking directly to policy-makers to resolve problems and come up with new ways of doing things," Ms. Tolliver says.
Working with the Center for Civic Life, Community Voices designed a process for community forums held to discuss access and utilization issues. This year, the forums were part of a public broadcasting radio series on health care problems. "If we can get community groups talking about issues, they often can come up with good solutions," she says.
Moving into an area where much work needs to be done, Community Voices funded a task force to work on legislation for creation of an Office of Oral Health in an effort to have more dental care made available. Ms. Tolliver says they are now trying to secure grant funds for other elements, including a media campaign to help people understand that West Virginia ranks poorly in oral health and that good oral health begins at birth.
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