Nearly two-thirds of uninsured children in the U.S. are eligible for a public health insurance program, according to a new study.

The study, released as Washington is pushing for coverage of more children, says Connecticut does better than the country as a whole, with a higher rate of children participating in public insurance programs. Even so, the bulk of Connecticut children without health insurance are eligible for public coverage – in many cases, at no cost to their families.

It’s a stubborn problem that requires more than just signing children up for health insurance, researchers and advocates say.

“Connecticut has done a good job, generally speaking, of enrolling kids in coverage,” said Sharon Langer, senior policy fellow at Connecticut Voices for Children. “One of the challenges in Connecticut is keeping children enrolled.”

Nationally, an estimated 7.3 million children were uninsured on an average day in 2008, and 4.7 million, or 65 percent, of them were eligible for either Medicaid or the Children’s Health Insurance Program, according to the study, by researchers at the Urban Institute and published in the journal Health Affairs.

The study offers a detailed look at who and where the eligible uninsured children are. Participation in Medicaid and the Children’s Health Insurance Program varied from 55.4 percent in Nevada to 95.2 percent in Massachusetts. Connecticut’s participation rate, 85.2 percent, beat the national average, 81.8 percent.

The study authors noted that current state budget problems could hinder efforts to add more children to public health insurance programs, although they wrote that increased federal matching rates for Medicaid could help.

“Without strong economic growth, states may be reluctant to seek aggressively to increase enrollment among eligible children in the near term, or even to maintain recent coverage improvements,” they wrote.

Barriers to Coverage

In Connecticut, 44,000 people under 18 had no health insurance during 2008, according to the U.S. Census Bureau. And 21,000 state residents under 19 had no health insurance and lived at or below 200 percent of the federal poverty level, income that would qualify children for free public health insurance in Connecticut.

So why are so many of them uninsured?

In some cases, families don’t know coverage is available or might think their incomes are too high to qualify, U.S. Department of Health and Human Services Secretary Kathleen Sebelius wrote in an article published Friday in Health Affairs. In February, Sebelius launched the Connecting Kids to Coverage Challenge, aimed at getting 5 million more children covered in the next five years.

Connecticut offers public insurance coverage for children through the two-part HUSKY program. HUSKY A, part of Medicaid, is available to children and parents in families earning up to 185 percent of the federal poverty level, or $33,873 for a family of three. As of last month, it enrolled 250,526 people under 19, and 130,644 adults.

Children whose families earn too much to qualify for Medicaid can receive coverage through HUSKY B, part of the Children’s Health Insurance Program. There is no upper income limit, although families at higher income levels must pay premiums. The program has always served far fewer people than HUSKY A; last month, 15,094 people were covered.

For families whose children qualify for HUSKY B, premiums can be a barrier to enrolling, Langer said.

Misinformation, or messages that get “garbled in transmission,” can also pose a problem. When the federal government changed requirements for proving citizenship, for example, some non-citizens believed – wrongly – they were no longer eligible for coverage, Langer said.

State insurance programs can be complicated, and frequent changes to them can make it difficult to get people enrolled – or to keep them covered. Reaching people who don’t speak English as a primary language or who have disabilities requires continuous, targeted outreach efforts, Langer said.

The state has not funded an outreach program for more than a year. Earlier this year the Rell administration tried to close a toll-free information line for budget purposes, but legislators objected and the line remains active.

Some community-based organizations are continuing to try to enroll eligible children, using money from federal grants. One, the Community Health Center Association of Connecticut, is using a $988,177 federal grant to conduct outreach outside the health centers. Staff members have been visiting farmers markets, health fairs, community events, churches, businesses and other gatherings to find people who are eligible but not enrolled, and help them get enrolled, said Jennifer Granger, the association’s chief operating officer. They plan to track what methods are most effective for enrolling people.

Middletown-based Community Health Center, Inc., is also using a federal grant to find uninsured children, in many cases, through schools, and enroll them in coverage programs. They developed a computer program that workers can use on laptops – complete with portable scanners and electronic signature pads – to fill out applications with people wherever they are, said Khadija Gurnah, program manager for the grant.

“That is our mandate right now, to find those uninsured children,” she said.

Langer said Connecticut has made good efforts to reduce paperwork requirements, such as verifying applicants’ income without requiring them to show up with documentation.

The state also allows “presumptive eligibility” for children and pregnant women who go to community health centers and other sites for care. And, for newborns eligible for HUSKY B, the state pays the first four months of premiums if they are required.

Losing Coverage

But enrollment is only part of the issue.

One key reason children do not have regular access to medical care is “churning,” Sebelius wrote – the cycling on and off of health coverage that many families go through. Often, it occurs when families are required to renew their eligibility by submitting lengthy applications and instead lose coverage, she wrote.

“One of the most effective simplification strategies for ensuring continuity of coverage is adopting twelve months of ‘continuous eligibility’,” she wrote. Under such a policy, a child is assumed to be eligible for public coverage for a full year. The child’s family is not required to notify the state of any income or circumstance changes that occur during that time.

Connecticut used a continuous eligibility system but eliminated it in 2003. As a result, more than 7,000 children lost HUSKY coverage, according to Connecticut Voices for Children.

Currently, families must renew their enrollment in the program each year, but are also expected to report changes in income or household size, which could affect their eligibility for a particular program, according to the state Department of Social Services.

Langer said families in HUSKY can face problems when they are required to do something to remain enrolled.

And it’s not just a problem in Connecticut.

In 2006, at least 42 percent of uninsured children who were eligible for public coverage had been enrolled in Medicaid or the State Children’s Health Insurance Program the year before, according to research published in 2007.

“Policymakers do not have to find eligible children to get them enrolled. Rather, for many of these children, public insurance programs simply need to keep them enrolled,” wrote the author, Benjamin D. Sommers, then a medical resident at Brigham and Women’s Hospital in Boston, Massachusetts. “It is not accurate to describe the presence of eligible but uninsured children as simply a problem of take-up; it is equally a problem of retention.”

Arielle Levin Becker covered health care for The Connecticut Mirror. She previously worked for The Hartford Courant, most recently as its health reporter, and has also covered small towns, courts and education in Connecticut and New Jersey. She was a finalist in 2009 for the prestigious Livingston Award for Young Journalists, a recipient of a Knight Science Journalism Fellowship and the third-place winner in 2013 for an in-depth piece on caregivers from the National Association of Health Journalists. She is a 2004 graduate of Yale University.

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