Medical Economics Feature - December 2009
Tex Med. 2009;105(12):49-51.
By Ken Ortolon
It's a shameful statistic. No other state has more uninsured children than Texas does. In fact, state officials estimate that nearly 800,000 Texas children are eligible for Medicaid or the Children's Health Insurance Program (CHIP) but are not enrolled.
The reasons are numerous. Children in Medicaid must go through a complicated reenrollment process every six months, many parents are confused about the process and time lines, and the state does not have enough experienced workers to handle current application volumes.
Texas Medical Association officials say the state also has not dedicated enough resources for a robust, coordinated, and systematic outreach campaign to inform families about how to insure their children.
Two Texas groups plan to do something about it. They will use federal money to enroll thousands of eligible children in Medicaid or CHIP. If their outreach efforts, scheduled to start in January, are successful, the number of eligible but uninsured children in the state could soon drop substantially.
The Texas Leadership Center (TLC), a nonprofit affiliate of the Texas Association of School Administrators (TASA), and the YWCA of Lubbock received grants totaling nearly $1.4 million to identify and enroll children in the two health care programs.
"We're very excited about [the grant], mainly because there's such a need in our part of the world," said Glenda Mathis, executive director of the YWCA of Lubbock.
The two-year grants, announced in September by U.S. Health and Human Services Secretary Kathleen Sebelius, come from $40 million in federal dollars approved for Medicaid and CHIP outreach efforts as part of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
The two programs, which TMA supports, will take very different approaches to reach out to potential enrollees, but both hope to sign up tens of thousands of children for CHIP or Medicaid.
TLC and the YWCA were among 69 organizations in 41 states and the District of Columbia that received CHIPRA grants for two years ending Dec. 31, 2011. Another round of $40 million in additional grants for another two years begins in 2012.
Additionally, $10 million in CHIPRA funds will go to tribal organizations, and another $10 million is earmarked for a national outreach effort.
According to the U.S. Department of Health and Human Services, the grants went to applicants whose outreach, enrollment, and retention efforts target areas with high rates of eligible but uninsured children, particularly those in racial and ethnic minority groups who are uninsured at higher-than-average rates.
The YWCA of Lubbock received $384,680 it will use for CHIP and Medicaid outreach in a 16-county area around Lubbock. Ms. Mathis says her organization is new to this type of outreach effort, but hopes to reach many of the estimated 26,000 eligible but unenrolled children in the area through health fairs or booths in local supermarkets.
TLC will use its $988,177 grant to expand an existing outreach program that already has shown some impressive results.
Johnny Veselka, PhD, TASA executive director, says TASA is working with the Children's Defense Fund of Texas (CDF) to target children in seven school districts in Houston, San Antonio, Corpus Christi, and the Lower Rio Grande Valley. The Valley school districts include Valley View, McAllen, Hidalgo, and Pharr-San Juan-Alamo.
"In working with CDF, these seven school districts have all been identified as districts that have significant numbers of students who currently do not have coverage," Dr. Veselka said.
The Lubbock YWCA target area includes Lubbock, Hale, Hockley, Floyd, Scurry, Crosby, Bailey, Terry, Lynn, Garza, Kent, Motley, Gaines, Lamb, Dickens, and Yoakum counties.
Ms. Mathis says 22 percent of the children in the area are uninsured.
"Thirty percent of the population is Hispanic, and 20 percent of families don't speak English as their first language in the home," she said. "And in Lubbock County alone, 21.6 percent of children live in poverty. We have one of the highest teen pregnancy rates in the state, so the percentage of low-birth-weight babies is almost double the state average. We've really got a major initiative to try to do some education, but also get these kids some kind of medical care."
100 Percent Campaign
Laura Guerra-Cardus, MD, interim director of the CDF Texas, says the TLC grant will "strengthen and expand" the 100 Percent Campaign , a program that already puts outreach efforts directly in schools in Houston and elsewhere.
Dr. Veselka says TASA and TLC will act primarily as the fiscal agents for grant funds and will subcontract with CDF to conduct the outreach efforts.
Dr. Guerra-Cardus says the funds will enable the school districts to hire outreach staff to identify and enroll children in either CHIP or Medicaid. By having school district staff do the outreach, they avoid potential violations of Health Insurance Portability and Accountability Act regulations that would prohibit information on uninsured children being shared with individuals or organizations outside the school district, she says.
Each participating school district is required to add a question on their school registration forms asking whether the child is insured or uninsured. If insured, they are asked what type of coverage they have.
"For example, if they have CHIP or Medicaid, we would know then to help them with renewals," Dr. Guerra-Cardus said.
Once they identify uninsured children, district personnel will use various outreach techniques to try to enroll them in Medicaid or CHIP, Dr. Guerra-Cardus says.
"In the past we've done monthly enrollment drives at the same place and the same time every month," she said. "So you get information to parents about a current weekend event through the school district. They show up with all their documentation, and we can get them enrolled."
Some school districts also use automated telephone calls to parents to encourage them to enroll their children in the programs.
CDF launched the 100 Percent Campaign as a pilot in 2003 in a Houston school. Dr. Guerra-Cardus says Houston hospitals funded the pilot project. They saw it as a way to reduce unfunded care in their hospitals and cut the number of children showing up in their emergency rooms. The Houston Independent School District adopted the program in 2007.
Several other school districts, including Edinburg, adopted the program. Dr. Guerra-Cardus says research on the effectiveness of their model in the Edinburg school district shows it reduced the number of uninsured children in the district by 50 percent.
The additional districts funded under the CHIPRA grant bring the total number of districts using the program to 25, Dr. Guerra-Cardus says. Eleven of those districts are in the Houston area. The rest are in South Texas.
Dr. Guerra-Cardus says they hope to enroll 44,600 children under the CHIPRA grant. That represents about half the uninsured children who are eligible for Medicaid or CHIP in the smaller districts and 35 percent to 40 percent of those in the larger districts.
TMA policy vigorously supports efforts to get all eligible children enrolled in Medicaid and CHIP, and the association wrote a letter of support for the TLC grant, as did the Texas Hospital Association, Dr. Guerra-Cardus says.
"Texas has the highest rate of uninsured children in the nation, with one in five lacking coverage. More than half of Texas' 1.5 million uninsured children are eligible for but not enrolled in CHIP or Children's Medicaid," TMA President William H. Fleming III, MD, wrote in a July 31 letter supporting the grant application. "While there are many variables that influence children's health and development, the medical literature is clear: Children with health insurance are more likely than those who are uninsured to be in better health and tend to miss fewer days of school.
"TMA recognizes the need to improve outreach and support services to those Texans who are the most vulnerable," Dr. Fleming continued. "For more than a decade, TMA has advocated extensively in support of covering more children, and we fully support additional outreach efforts."
In addition to enrolling children in the seven targeted districts, TASA and TLC will use some of the grant funds to promote the program to other school districts in hopes of getting the 100 Percent Campaign adopted statewide.
The Texas Health and Human Services Commission, which oversees both Medicaid and CHIP, also has committed to working with both outreach projects to track how many children are enrolled.
"That's huge," Dr. Guerra-Cardus said. "Not for a long time has the outreach community been able to track at that level the efficiency of their outreach efforts."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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