Recently in Outreach Category

By Ann Bacharach, Pennsylvania Law Project and National Covering Kids and Families Network

I took a break from my stay-cation this week to get motivated for the fall. On behalf of the National Covering Kids and Families Network, I took the early morning train from Philadelphia to Washington on Friday to attend the re-launch of Secretary Sebilius' Connecting Kids to Coverage Challenge (CK2C).

It was inspiring:

• Education Secretary Arne Duncan pledged to work with HHS to reach and enroll eligible children through a variety of school-based outreach strategies.
• A mother courageously recounted her path to Maryland's M-CHIP program.
• Sixteen national organizations, including National Covering Kids and Families Network, pledged to step up to the Secretary's Challenge.
• Pastor Wiggins from Camden reiterated the challenge of reaching and enrolling families just trying to survive day to day.

According to the recently released report from the Urban Institute, there are 129,000 children in Pennsylvania who are eligible for Medicaid or CHIP but not enrolled. That means Pennsylvania is missing about 15% of those who could be covered.

That data prompted me to remember the number of proven strategies and tactics that agencies, organizations and even individuals in Pennsylvania have utilized: stationing enrollment assistors in Philadelphia's Health Centers as well as FQHC's in Greene, Fayette and Washington Counties, providing application assistance through Children's Hospital of Philadelphia, offering over-the-phone enrollment through the State's Helpline 800-986-KIDS using Pennsylvania's web-based application, and reaching out through community-based organizations in unlikely places such as volunteer firehouses.

Why not spread these ideas to other parts of the state? And share them with other trying to help connect kids with coverage across the country?  And learn from other such as members of the National Covering Kids and Families Network?

And while we're at it, what about heading to barbershops and hair salons, laundromats, food banks? Friday night football games? Fishing and hunting license distributors? Sunday School, Hebrew School and other religious education classes?

And how do we promote retention? The number of very low-income children estimated to be eligible but not enrolled is disconcerting at best. This is, most likely, an outcome of losing eligibility at renewal. While we work to make renewal easier, how can we keep eligible families enrolled: reminders from their doctor's office, from their managed care plan or from their pharmacy? Renewal assistors working in health care settings?

And finally, the estimated 129,000 children who are eligible but not enrolled are not a finite group; children move in and out of health coverage all the time based on their family's status. If a parent loses or changes a job, if a parent divorces or remarries, if a parent gets sick, if a sibling ages out of the household, a child's health coverage can be interrupted or lost completely.

So, we need to keep up the drumbeat on available health care coverage and how to enroll going using the tried and true methods and in new and creative ways.

Let's get busy!

And if you have outreach and retention ideas, please share them with all of us avid readers and bloggers on Say Ahhh! and the National Covering Kids and Families Network.

I had a chance to go to a fantastic event this morning sponsored by Secretary Sebelius on the Connecting Kids to Coverage Challenge, which aims to reach the nation's 4.7 million uninsured children who already are eligible for Medicaid or CHIP.  She made a compelling pitch that nothing is more important to our future than the health of America's children and that is why Medicaid and CHIP were created.  Thanks to these programs, tens of millions of Americans have the peace of mind that comes from knowing that their child is safe.

In recognition that millions of our children are heading back to school this week, the event also featured Education Secretary Arne Duncan who tackled the issue from an education perspective.  He argued that some foundational things have to be in place for students to be able to excel.  If they can't see the blackboard, or if they are coping with untreated asthma, it is pretty tough to expect them to do well.  He pledged to work with some of the major school districts in the states that have the furthest to go in covering uninsured children.  (California, Florida, and Texas account for 40% of all uninsured kids, according to powerful new data released today by the Urban Institute.  See my colleague Martha Heberlein's blog for more on the report).

The star of the morning, though, was probably Bonnie, a mom from Maryland.  "I speak to you as a mother and as an American," she began before going on to explain that her husband is an auto-mechanic who doesn't have any affordable employer-based coverage.   So, when she lost her job, she found her family uninsured.  Luckily, she hooked up with a community-based organization that helped her file an application for child health coverage.  It took only 15 minutes from start to finish, and within 24 hours she got a call that her son qualified.  Since her son has asthma, it was an enormous source of peace of mind in a time of need.  As she concluded, "No mother, no parents should have to choose their mortgage and utilities over health care" for their child. 

I left encouraged about the level of commitment shown by two key leaders in the Obama Administration, as well as impressed by the broad array of national organizations they've already signed up to work on the Connecting Kids to Coverage Challenge.

Most of you know the CPS - the annual social and economic supplement (ASEC) has been our go to source for health insurance coverage on a national and state-by-state basis for years. However, given the nature of the sample, analysis has been somewhat limited, especially for those smaller states and for those interested in data on a sub-state level. 

Now there's a new kid on the block. In 2008, a question on health insurance coverage was added to the American Community Survey. Like the CPS, the ACS is a national survey, but it has a much larger sample size (the CPS looks at about 78,000 households annually, whereas the ACS surveys 250,000 per month). It may seem somewhat counterintuitive, but the bigger the sample size, the smaller the area (geographic or demographic) that you can examine. We may just be able to get answers to some of those long-standing research questions.

One such question that has long plagued those of us looking to enroll eligible children in Medicaid and CHIP is: who are those kids and where can we find them? Thanks to the ACS (and some very talented folks over at the Urban Institute) we now have a much better idea, as today in Health Affairs, Dr. Genevieve Kenney and her colleagues released a paper that looks at that very question. (The report will also be highlighted at a media event today where HHS Secretary Sebelius will relaunch her Connecting Kids to Coverage Campaign.  You can watch it live here).

They found that of the 7.2 million uninsured children in the U.S., 4.7 million or 65% were eligible for Medicaid or CHIP. Of those, about a third are concentrated in just three large states (California, Texas, and Florida), a piece of data that certainly highlights the need for outreach and enrollment efforts in those states.

But I think an equally appropriate (and far more upbeat) view of the data is the success states have had enrolling children in their Medicaid and CHIP programs. Nationwide, the participation rate in Medicaid and CHIP is 82% (high compared to other means-tested programs). And 11 states were shown to have participation rates that were close to or above 90%. Those are amazing numbers and states should celebrate their well-deserved accomplishments.

For those of you doubters who say, "well, that could never happen in my state," I beg to differ. To quote the authors: "since these states constitute a diverse group in terms of their size, income distribution, racial and ethnic composition, and region, it suggests that high participation rates can be achieved across a range of different circumstances." In other words, while it is certainly not easy to get all the eligible kids in your state covered, there are plenty of places to look to as role models, and ones that may be very much like your own.

I know I've said it dozens of times - states are different. Like people themselves, they have their own characteristics, quirks, and personalities that make them unique. But what about within states - are there differences of note? Why, of course (I'm sure we can all think of a long list of differences between, say New York City and upstate NY). And lucky for us, a recent data release from the Census highlights how health insurance coverage varies within states' very own borders.

(Quick methodological note for those of you who are interested in such things: the Small Area Health Insurance Estimates (aka SAHIE) are model-based and combine data from a variety of sources. These data represent coverage in 2007, prior to the economic downturn. They are currently the Census' only data source on health insurance for every county in the US. For more on the various measures Census has on health coverage, check out this helpful fact sheet. The Census also computes small area estimates for income and poverty (aka SAIPE).

Now back to the data at hand - at 26.8%, Texas has the highest rate of uninsured in the country. But where are those 5.8 million folks living? The range in the uninsured rate is quite wide, from 16.6% in Collin County to 49.5% in Kennedy County. What makes these two counties in the same state so wildly different in terms of health coverage? A quick look at some demographic data provides us some idea:

Collin County, located just north of Dallas, is about 850 square miles and has about 765,000 people. In 2007, the median household income was around $80,000.

Kennedy County is located on the Gulf Coast between Brownsville and Corpus Cristi. It's almost twice the size of Collin County, 1,450 square miles, but has less than 400 residents, with a median income of about $30,000 in 2007.

I think it's fair to say that we don't have to pick on Texas as an example, as other states are bound to have within-state variation (even Massachusetts - known for its low uninsured rate of 7.8% - has a range of 6.6% to 13.9%).

State officials and advocates should find these data very helpful in identifying which areas of their states have the greatest number of uninsured residents and possibly understanding the reasons for such differences. (Note - although I didn't do it here, you can also look at the data by age ranges and income levels). And when making the case for targeting outreach efforts, both for those who may already be eligible for coverage through Medicaid and CHIP and, in 2014, for those who will become newly eligible, having data to support your claims will make your case that much stronger. 

Last week, Cindy Mann blogged about the importance of kids' coverage on healthcare.gov. "As back-to-school time approaches, families are thinking about making sure their children have every opportunity to learn. Now is also the time to make sure that kids have the coverage they need to be healthy - the first step to a successful school year."

Luckily, many kids already have an affordable coverage option through Medicaid and CHIP. As part of the challenge to get all eligible kids signed up, CMS has launched Get Covered. Get in the Game. to bring coaches, schools, families, and communities together to raise awareness. (Maryland's Suzanne Schlattman blogged about the campaign for us earlier this month.)

Check it out to see how you or your organization can help get children covered and in the game.

By Suzanne Schlattman, Maryland Citizens' Health Initiative Education Fund, Inc.

This week, the U.S. Department of Health and Human Services (HHS) announced the Get Covered. Get in the Game  initiative which will be launched in seven pilot states across the country including: Colorado, Florida, Maryland, New York, Oregon, Ohio and Wisconsin. The initiative brings together coaches, schools, and communities to educate families with children who are eligible for Medicaid or CHIP about the immediate availability of free and low-cost health care programs for children.

What a great idea! In public health, we stress prevention and leading an active lifestyle is one health behavior that pays the greatest dividends for preventing poor health. However, uninsured kids often miss out on organized youth sporting activities because they cannot afford the necessary physical or because their families are afraid that they won't be able to pay the medical bills if their child gets hurt. Providing coaches with information about affordable health insurance options for children is a great way to promote coverage among eligible families and promote the adoption of healthy behaviors.

In Maryland, we played around with this theme when we launched our "Got healthcare?" campaign after the state expanded Medicaid eligibility for adults in 2007. Local sports heroes from the Baltimore Ravens and Washington Redskins volunteered to help promote the program. We ran radio ads, partnered with local hotlines and put up posters in every hospital to alert people.  Having sports celebs promote enrollment in Medicaid helped raise awareness about the program, break down the stereotype that Medicaid was only for pregnant women and children, and again repeated the theme of leading an active lifestyle.  Over 200,000 Marylanders have gained access to free and low cost health care services since this campaign began.

Check out one of the great radio ads that was part of this campaign:

Chris Samuels of the Washington Redskins with Maryland Governor Martin O'Malley

And the poster with Ed Reed of the Baltimore Ravens:

It makes a lot of sense to involve youth sports leaders with our enrollment efforts as an estimated 44 million children participate in organized youth sports.  Coaches for youth sporting leagues are local celebs in their communities too -- and to have these folks promote enrollment in children's health insurance programs across the country is great news.  

In announcing the initiative, HHS Secretary Kathleen Sebelius reminded us of why we all work so hard to connect children with coverage:  

"Healthy kids do better in school and in life because they are able to participate fully in activities that develop their bodies and their minds," Secretary Sebelius said. "Kids should not have to miss out on their favorite sports and other activities that get them moving because they lack health insurance coverage."

All states can use the materials developed for the pilot states to get coaches involved in outreach efforts to enroll eligible children.  More information about the Get Covered: Get in the Game initiative is available at www.InsureKidsNow.gov.

The views expressed by guest bloggers do not necessarily reflect the views of the Center for Children and Families.

By Tom Birch, National Child Abuse Coalition

For the first time, with the passage of health care reform in March, federal funding will be available to states to support a range of voluntary home visitation services to pregnant women, young parents and their children, designed to improve maternal and child health, foster healthy child development, and prevent child maltreatment.  Priority for services would go to low-income families living in communities in need of services. 

The new measure authorizes $1.5 billion over five years - with $100 million in 2010 - for the Maternal, Infant, and Early Childhood Home Visiting Program funded by HRSA, in collaboration with the HHS Administration for Children and Families (ACF), through the Title V maternal and child health block grant.  A three-percent share of the funds is reserved for grants to Indian tribes.

Research over the years has produced a strong body of evidence that early childhood home visitation programs are effective in reducing the incidence of child abuse and neglect and in improving child health and development.  While a majority of states already provide early childhood home visitation services to a relatively small number of families, the challenge has been to take this proven effective prevention approach to scale.  The new home visiting program can help to move toward that goal.  

The new funding promises potential for a significant positive impact on children's health care.  Home visiting programs link families to health care resources and focus on healthy outcomes.  Through a strong emphasis on prenatal care, significant costs associated with pre-term births and developmental disabilities are reduced.  Linking families to consistent primary care and immunizations means reduced emergency room costs and reduction in chronic illness. 

Studies have proven the results we hope to see.  Families who received home visiting services were found to be more likely to have health insurance and a medical home, to seek prenatal and well-child care, and to get their children immunized.  Instances of child maltreatment have been lowered significantly.  Babies of parents enrolled prenatally in home visitation services have shown fewer birth complications and higher birth weights.  

On July 21, HHS announced the allocation of $88 million for the first year of funding of the home visiting grants to states, the District of Columbia and each of the five territories.  The allocations are based on the size of the population of children under the age of five living at or below 100% of the federal poverty level in each state. The grant amounts to the states in the first year range in size from $7.78 million to California down to $557,408 to Vermont.

States have completed or are now in the process of conducting statewide assessments to identify existing home visiting programs and areas of high need. States each have immediate access to $500,000 of their allocations for preparing the needs assessments and begin planning their programs.  The remainder of the grant funds will be released in September, after approval of a state's plan for addressing the home visiting needs identified. The law directs states, in conducting a needs assessment, to coordinate with and take into account other needs assessments already ongoing, including those required by the Maternal and Child Health Block Grant, Head Start, and Title II of the Child Abuse Prevention and Treatment Act (CAPTA).

The Administration for Children and Families (ACF) is taking the lead, in partnership with HRSA, in administering grant support for the Tribal Maternal, Infant, and Early Childhood Home Visiting Grant Program.  Applications are being accepted for a total of $3 million in funding available for award in fiscal year 2010.

In applying for the home visitation grants, states must establish quantifiable benchmarks to demonstrate improvements at intervals of three and five years for families participating in the program.  The benchmarks address maternal and newborn health, prevention of child maltreatment, school readiness, reduced crime or domestic violence, family economic self-sufficiency, and coordination with community support services.

The new grant program requires states to allocate at least 75 percent of funding to support home visiting models that are research-based and rigorously evaluated through randomized control trials or quasi-experimental research designs.  The remaining 25 percent of grant funding could go to support promising approaches yet to be evaluated by a similar rigorous process. 

On July 23, HHS published proposed criteria for evidence of effectiveness of home visiting program models to inform the funding decisions for the new program. Comments on the proposed criteria are due by August 17, 2010. 

In future years, the funding for the program would increase from $100 million in 2010 to $250 million in 2011, $350 million in 2012, and $400 million in each of 2013 and 2014 -- HHS plans to allocate the additional funds competitively.  While HHS proposes to give significant weight to the strength of the available evidence of effectiveness of the model or models employed by a state, HRSA and ACF are open to comments on what criteria are appropriate to judge states competitively.  It is anticipated that the criteria for evidence-based models will need to be altered over time as the state of the field changes, so HHS intends to review the evidence base for home visiting models on an ongoing basis to ensure that new evidence is incorporated.  How program models are evaluated and rated will be the key to allocating the competitive funds. 

The views expressed by guest bloggers do not necessarily reflect the views of the Center for Children and Families.

One of the many lessons learned about advancing children's health coverage is how critical retention in Medicaid and CHIP is to our coverage goals. Dr. Benjamin Sommers drove this point home in a study that concluded that one-third of all eligible, uninsured children in 2006 had actually been enrolled in Medicaid or CHIP in the prior year. A recent update of Dr. Sommer's study in Health Affairs shows that we have made progress on this front with this key statistic dropping to 25% in a little over two years.

Over the years the importance of customer retention, a long-standing best practice in the business world, has gained equal footing with outreach and streamlining enrollment as effective strategies to reduce barriers to coverage. Dr. Sommer's report is good news for states that have made retention a priority and is a contributing factor in our continuing success in reducing the number of uninsured children. 

While the drop-out rate improved, there was some evidence in the study that take-up or new enrollment may have slipped. Dr. Benjamin Sommers points out that this change in trend coincided with new federal rules imposing complex paperwork requirements on states and applicants to document citizenship. The negative impact of the citizenship verification requirement on eligible, citizen children has been well documented. 

I'm optimistic that if Dr. Sommers updates his report in another three years we'll see improvement in both areas. More than one-third of states have had impressive results with a new data exchange with the Social Security Administration (SSA) to verify citizenship rather than requiring paperwork from individuals. Many more states are testing or planning to develop the SSA electronic interface as a means of documenting citizenship.

Additionally, states continue to innovate and replicate effective enrollment and retention strategies through major initiatives such as the Robert Wood Johnson funded Maximizing Enrollment for Kids and the State Health Access Grant Program.

Dr. Sommers research shows how policy and procedural decisions can make a difference, both positive and negative.  Taking stock of what is working in Medicaid and CHIP to promote enrollment and retention is essential to the expansion of coverage as we implement the Affordable Care Act efficiently, cost-effectively and with optimal results.

Summer vacation is not even half over and I'm already thinking about getting my kids ready to go back-to school.  It's not that I don't enjoy their company; I just want to get a jump-start on my to-do list so that I deliver them to school ready to learn.  Along with back-to-school shopping, they need their annual physicals and 6-month dental check-ups.  Child health advocates around the country have another major item on their back-to-school checklists - reaching out to the five million children who are eligible for Medicaid or CHIP but are unenrolled. 

This is an ideal time of year as the media and huge segments of our population are focused on children's needs as they prepare to head back to school. The National Covering Kids and Families Network (NCKFN) is helping groups leverage the increased attention to children's issues during the back-to-school period to help reach enroll eligible children in state Medicaid and Children's Health Insurance Program plans. They recently hosted a webinar to discuss messaging and strategies that work. (Georgetown CCF is providing technical assistance to NCKFN). 

Many of the NCKFN participants and other groups have been working on back-to-school efforts for many years and had a wealth of experience to share with each other. Some excellent messages have been developed for groups working on this initiative by GMMB with the support of the Robert Wood Johnson Foundation.  The trick is getting the right messengers to use the messages to reach families of uninsured children. Many of the NCKFN groups have had a lot of success working with school nurses, school administrators, social workers, community outreach workers and teachers. Two participants on the webinar focused on more non-traditional messengers - school board members and youth sport leaders. 

First, Donna Cohen Ross, senior advisor to the Office of External Affairs at CMS (and an expert on outreach), announced HHS's plan to launch a coaches campaign "Get Covered: Get in the Game" which will enlist youth sports leaders to help find uninsured children and get them enrolled (more details on the campaign to come in August). Coaches are great messengers.  (Just compare the sports section to the health section of your local newspaper if you doubt the ability of sports leaders to get a message across in your community.)  Coaches can pitch a different message to families by linking the importance of coverage with the ability to compete in team sports. As Donna pointed out, there is a strong link between good health care and sports as kids frequently are excluded from school sports participation if they don't have a physical.  Parents are also understandably reluctant to allow children to participate in sports if they aren't insured for fear of an injury that they can't afford to treat. 

As the mother of three boys, I'm involved with my fair share of youth sports teams and recall one heart-breaking incident when one of my son's soccer teammates suffered a concussion during a tournament.  I offered to drive him and his mother to the hospital but she said she didn't have insurance so she would just wait to see if he really needed care.  No mother should be faced with that choice and coaches could help make sure they are not.  Good coaches teach children more than just about sports, they teach them about the importance of teamwork, perseverance, and hard work and they make sure kids are doing as well off the field as they are doing on the field.   Youth sports participation helps children learn many valuable life lessons and it is tragic that some children are unable to fully participate in this aspect of childhood due to the lack of insurance coverage - especially for those who are eligible but unenrolled in CHIP or Medicaid. 

Second, April Griffin, a school board member from Hillsborough School District in Florida, spoke about the importance of getting buy-in at the top. (In other words - cultivating the grass tops as well as the grass-roots).   She pointed out that school district staff and teachers are stretched thin and are under pressure to raise test scores.  According to Ms. Griffin, the more groups are able to link children's health coverage with school performance, the more successful they should be in getting the buy-in of school system personnel. 

Her message also hit home.  A friend of mine tried to get our school district to include information about our state's Medicaid and CHIP programs in back-to-school packets.  The school district staff refused and said it was against school district policy.  My friend appealed to a school board member by pointing out that the school district included promotional materials of for-profit insurance companies in the packets.   The school board member was able to look at the "big picture" rather than reading a policy manual and gave the staff person the go-ahead to include the CHIP & Medicaid information in this fall's packets. 

There were a lot more great ideas shared on the NCKFN webinar and I encourage readers to check them out here.  In collaboration with the network, Donna Cohen Ross of CMS has scheduled a second webinar on school-based outreach efforts on July 29th. (All those of you who have read Donna's posts on this blog or have worked with her over the years know that Donna cares deeply about this topic and you won't want to miss this opportunity.)   

By Eugene Lewit and Liane Wong

The David and Lucile Packard Foundation

The percent of uninsured children has consistently declined, despite deterioration of coverage for adults and the economy. This is one of the significant but frequently overlooked good news stories of recent years.

The gains in children's coverage have been due in large part to actions taken by states to simplify enrollment and retention processes for their Medicaid and CHIP programs while expanding eligibility for those programs. In many states, policy advocacy groups have played important roles in spurring and supporting progress in their states. These organizations are likely to continue to be important players in the implementation of CHIPRA and broader health care reform. Yet, there has been little rigorous, systematic research on how advocacy groups do their work and the strategies they employ to achieve their objectives.

Two recently released issue briefs based on findings from an on-going evaluation of the David and Lucile Packard Foundation's Insuring America's Children: States Leading the Way (IAC) grantmaking strategy attempt to fill some of this knowledge void. The briefs examine some of the state-based advocacy work supported through IAC and identify the lessons that have been learned regarding how to effectively support and promote growth of children's health coverage.

In the first brief, State-Based Advocacy as a Tool for Expanding Children's Coverage: Lessons from Site Visits to Six IAC Grantee States. Evaluation Brief 1, the authors summarize key findings gleaned from in-depth site visits to states where IAC has made its most substantial investment in advocacy through multiyear "Finish Line" grants. These findings describe how persistence, flexibility, creativity and commitment to conducting effective states-based advocacy, especially in a changing environment, can benefit coverage expansion to all children. They also describe the importance of building strong and broad-based coalitions that include both grassroots and state-level stakeholders, an often key step toward maintaining a unified voice among a sometimes crowded community of advocates working to improve children's well being. While acknowledging that much work remains, the brief pinpoints a number of important gains in children's coverage since the IAC efforts began -- gains that have resulted despite a severe and ongoing economic downturn.

The second brief, Strategic Engagement of Policymakers is Key to Advancing a Children's Health Care Policy Agenda. Evaluation Brief 2, examines the benefit that positive engagement of policymakers can have for advocates to move the children's health care coverage agenda forward in states, as well as the strategies for making this engagement happen. Understanding states' unique political environments is one important first step toward this engagement. Further strategies include identifying, nurturing, and supporting political champions; creating strategic links between grassroots organizations and policy advocacy groups; creating effective, appealing messages for policymakers; establishing advocacy groups as the "go-to" resource for reliable data and information; and sharing ownership of agendas and successes with champions and key policymakers.

These briefs provide objective validation of the advocacy strategies and tactical innovations employed by veteran advocates throughout the country. They also offer practical and field-tested ideas for advocates looking for new ways to accelerate the pace of change. Most importantly, they remind us that tough, smart advocates can guide and support leaders in continuing the children's coverage success story.