Getting the Word Out on Kids' Health Insurance

Harold Leibovitz
October 5, 2001

The State Children's Health Insurance Program, or SCHIP, was passed in 1997 as a way for states to fill the coverage gap for low-income children whose family incomes are too high to qualify them for Medicaid. For state officials, the program offered federal funding to cover more poor children, without creating a new entitlement program.

For children's advocates, the test of SCHIP effectiveness lies in how many previously uninsured children are now covered as a result. New evidence from the Urban Institute's ongoing evaluation suggests that while enrollment has been climbing, at least four factors still limit participation: lack of awareness; knowledge gaps about the programs; a perceived lack of need; and administrative barriers and hassles.

Who Knows about SCHIP and Medicaid?
Since 1997, states have made substantial efforts to reach parents with eligible children. By 1999, 88 percent of low-income uninsured children had parents who had heard of either SCHIP or Medicaid.

However, even when parents know about the programs, they may be confused about the rules. For example, a national survey found that 44 percent of low-income children whose parents knew about Medicaid or SCHIP did not understand that their families do not need to participate in welfare to be eligible.

Levels of awareness of and familiarity with Medicaid and SCHIP varied significantly across the 13 states studied. More than 70 percent of low-income uninsured children in Massachusetts and nearly 60 percent in Alabama have parents who know about one or both of the programs, and understand that families do not have to be on welfare to participate. That figure falls to just 41 percent in Texas. Awareness of SCHIP programs that are separate from Medicaid also varies. Over 75 percent of all low-income children in New York and New Jersey had parents who had heard of the separate SCHIP program, while in Colorado and California only 33 and 42 percent had, respectively.

Why the Difference?
Several factors help to explain state variation. First, low-income parents in general are more likely to know about Medicaid and SCHIP in states that cover a larger proportion of their low-income population. In 1999, 60 percent of all low-income children in Massachusetts were enrolled in the state's Medicaid/SCHIP program compared with 26 percent in Texas.

Second, families in states that were quick to implement SCHIP possess higher levels of awareness. In Massachusetts, state officials adopted an ambitious health care reform agenda in the mid-1990s. One key component, MassHealth, combined a Medicaid expansion program with state-funded coverage for adults and children previously ineligible for Medicaid. When SCHIP was created in 1997, Massachusetts rapidly incorporated SCHIP into the existing state-funded program. By 1999, therefore, 70 percent of low-income children had parents who had heard of MassHealth and understood that families do not have to be on welfare to participate.

Alabama was also quick to get started, using a very different—and equally successful—approach. Alabama was the first state to gain federal approval for its SCHIP plan. State officials implemented an aggressive outreach program that included sending a simplified "ALLKids" application form home with every child on the first day of school in 1998. This was coupled with widespread media coverage and strong support from the governor. By 1999, 60 percent of parents had heard of either ALLKids or Medicaid and understood that welfare participation was not a requirement.

Slow enactment helps explain why parents in Texas had a relatively low level of familiarity with the program—just 40 percent in 1999. The Texas legislature, which only meets once every two years, had just adjourned when Congress passed SCHIP in 1997. The Health and Human Services Commission used those two years to carefully plan all aspects of its "TexCare Partnership for Children," which was rolled out in April 2000.

"Familiarity with separate SCHIP programs may be higher in states with longstanding programs that have received strong political support. New York's Child Health Plus program had been in existence since 1991," said Urban Institute researcher Lisa Dubay. "This previously state-funded program, created to address gaps in coverage among children, had been well publicized and received strong, bi-partisan political support throughout the 1990s. When New Jersey's program began in 1998, it received a high level of support from the governor's office. This helped raise the program's profile and may explain why almost all parents have heard of it."

Marketing Health Insurance Coverage
Despite state efforts, almost a third of low-income uninsured children were not enrolled in either SCHIP or Medicaid in 1999, because of persistent gaps in knowledge about program specifics. The Urban Institute found states have responded with strong marketing efforts.

"To address knowledge gaps and confusion over program rules and requirements, states are investing unprecedented energy and resources in outreach and efforts to raise the public's awareness of available coverage and the importance of health insurance for their children," says Ian Hill, Urban Institute researcher.

Many states have initiated advertising, marketing and community strategies to increase enrollment. These efforts include colorful and positive television and radio advertisements, public service announcements, billboards, flyers, brochures, inserts in local and ethnic newspapers, and toll-free information hotlines.

These state-level media campaigns are frequently coupled with community-based efforts. California, New York, Massachusetts and Texas, for example, provide grants to community-based organizations to design and implement grassroots outreach efforts. State and local officials often described these "trusted voices" of the community as critical in persuading otherwise reluctant or uninformed parents to sign their children up for coverage.

Nevertheless, a small share of low-income uninsured children—22 percent—have parents who indicated that public health insurance was not wanted or needed. Enrolling this group may require raising awareness of the importance of regular check-ups and having a doctor who knows the child.

The Hassle Factor
"Once parents are aware of the program, know their children are eligible, and see the value of the insurance, the final barrier to participation in these programs may be the enrollment and re-enrollment systems," according to Urban Institute researcher Genevieve Kenney. "Administrative problems related to the application process, such as documentation requirements, transportation and language barriers, prevented the parents of at least 10 percent of all low-income uninsured children from inquiring about or applying for the programs."

Administrative hassles may also be partially responsible for the 18 percent of low-income uninsured children who had been enrolled in the previous 12 months and who then left the program and for the 11 percent who applied for coverage but who were not enrolled. In response, many states have made it easier for parents to enroll their children.

States have designed shorter and simpler forms. Thirty-two states now use a single form to determine eligibility for both SCHIP and Medicaid ; 42 states dropped assets tests from the eligibility criteria ; 40 states now permit applications to be submitted by mail and eliminated requirements that families have face-to-face interviews with county social services workers ; and 10 states reduced verification and documentation requirements. Some states, like Florida and Michigan, allow families to "self-declare" their earnings. Nationally, 22 SCHIP programs have adopted 12 months of continuous coverage, while fewer states—14—have done so for their Medicaid programs.

Recently, several states simplified the process for re-establishing eligibility for SCHIP and Medicaid. New Jersey, Vermont, and the District of Columbia preprint their eligibility renewal forms with information already collected during initial applications. Georgia and Washington have eliminated virtually all requirements for re-submitting documentation. Florida has gone so far as to implement "passive" eligibility re-determination. The state automatically continues coverage of children whose families do not respond to renewal notices.

These kinds of policy changes may be key to enrolling and re-enrolling children whose parents face many competing demands on their time.

A lack of health insurance coverage is likely to compound the difficulties low-income children face in other areas of life. Thus, strategies that lead to more uninsured children being enrolled in Medicaid or SCHIP have the potential to improve not only the health but also the general well-being of these children.

Data in this article is taken from a series of reports that are part of a comprehensive evaluation of the State Children's Health Insurance Program:

The series presents findings from the 1997 and 1999 rounds of the National Survey of America's Families (NSAF), a 42,000 household survey representative of the nation as a whole and of 13 selected states; The NSAF is part of Assessing the New Federalism, a multiyear project to monitor and assess the devolution of social programs from the federal to the state and local levels.

Additional data was taken from "Making it Simple: Medicaid for Children and CHIP Income Eligibility Guidelines and Enrollment Procedures, Findings from a 50-State Survey," by Donna Ross Cohen and Laura Cox of the Center on Budget and Policy Priorities in Washington, DC.