Since Congress created the Children's Health Insurance Program (CHIP) in 1997, states have been trying to provide health insurance to kids whose parents earn too much money to qualify for Medicaid but not enough to buy private insurance. It has not been easy. Of the estimated 11 million children without health insurance in the United States, only two million were enrolled in state CHIP programs as of December 31, 1999. Using such novel approaches as raffling off a chainsaw and locating signup teams in shopping malls, states are doing everything they can think of to boost enrollment in the program.
Experts say states face several common barriers to finding and enrolling eligible kids in CHIP programs. Some parents with bad past experiences with government bureaucracy are reluctant to participate. Others fear coming to the attention of the authorities or the stigma of a government handout. Still others are baffled or defeated by the red tape of the application process.
There's also another reason: the CHIP law places a 10 percent ceiling on administrative costs, limiting the amount of money that states can spend on publicizing the existence of the program.
"It's a mixed message from the law to say, 'This is a great new program, go out there and get 'em, but we want to preserve 90 percent of the dollars for services, so don't spend a lot,'" says Ian Hill of the Urban Institute .
Because participation in the program has been lower than anticipated, Congress threatened to take back $1.9 billion that had been appropriated for CHIP, a move that would have affected 37 states. The threat did not materialize, but it was a wake up call to the states to step up their outreach efforts.
Emily Cornell, a policy analyst with the Health Policy Studies Division of the National Governors' Association , says that in one Massachusetts city, a chain saw was raffled off to low-income workers at a local dump. In order to participate in the raffle, workers had to fill out an application form for CHIP.
Georgia distributed 1.5 million fliers to kids at school about the program, which proved effective.Its program, called PeachCare, has enrolled 25,000 more kids so far than its target of 60,000 (which was a goal to be achieved by January 2001). Georgia has also partnered with providers. The state's largest children's hospital did a mailing about CHIP to parents whose children who had been to the emergency room on a self-pay basis.
Florida, North Carolina, Indiana, Illinois, Connecticut, New Hampshire, California, New Jersey and New York have all reduced or simplified their CHIP applications process. California, for example, cut its application form from 28 pages to four. told Stateline.org.
Other innovative approaches include:
The effort to expand CHIP enrollment represents a departure from past practice for many states. According to Carson Strege-Flora, a research associate at the Northwest Federation of Community Organizations, states have traditionally done little or no outreach to swell the ranks of people participating in the Medicaid health insurance program for the poor.
The political philosophy behind the Medicaid tradition is that too many people are on the rolls already, and that it costs the state too much to add to them.
"In a more generous mood, I might say that [states] don't know what to do because Medicaid has had such a stigma that there really has been no true outreach and there hasn't been a value on getting kids on that program. Really, there aren't [outreach] models for states to quickly implement and use to get kids on the program," says Strege-Flora, whose report "Access Denied" surveyed Medicaid and CHIP in Arkansas and Montana.
The Robert Wood Johnson Foundation has given $47 million to the states and the District of Columbia to hand out to community-based groups to do CHIP outreach under its Covering Kids Initiative .
The argument for community-based efforts is that, while labor-intensive and expensive, parents are much more likely to be convinced by someone locally, a trusted source, that signing up for CHIP is a good thing, that it is a program that works, that they won't jeopardize their citizenship if they sign up for it.