With a $400,000 federal grant and a charge to get more eligible children enrolled in public health insurance programs, Khadija Gurnah and her staff at Community Health Center Inc., set out to find uninsured kids.
Working with schools, they got 100,000 letters sent to families about the HUSKY health insurance program for low-income children and parents. They developed an online tool to screen people for HUSKY and other public programs, and worked with community organizations to try to find parents of uninsured children.
But they found only a small number, far from the estimated 43,000 children in Connecticut who don’t have health insurance, Gurnah said.
And so, after examining research and consulting with experts, she determined that the effort needed a new focus: Keeping kids in HUSKY from being dropped from the program.
“What I was doing before, and what a lot of people across the country were doing, we worked so hard trying to find parents, trying to find uninsured kids,” Gurnah said. “Whereas this system allows us to get ahold of them before they lose their health insurance.”
At the root of the refocused effort is a relatively new premise: One of the most effective ways to reduce the number of uninsured children is to make sure those who are already covered stay covered.
“Over the last five years, in particular, there have been an increasing number of studies out there showing that a lot of this is a retention problem,” said Dr. Benjamin D. Sommers, a Harvard professor who studies Medicaid and the uninsured.
In one study, Sommers found that one-third of children who were uninsured in 2006 had lost public insurance coverage–Medicaid or the State Children’s Health Insurance Program–the year before. Another study found that nearly two-thirds of uninsured children in the U.S. are eligible for public health insurance.
In Connecticut, two recent reports underscore the problem of young people wrongly losing coverage. Connecticut Voices for Children Senior Fellows Mary Alice Lee and Sharon Langer found that nearly one in six teens lose HUSKY coverage after turning 18, even though the program covers teens until age 19. In another study, they found that thousands of infants are inadvertently removed from the program after turning 1.
Donna Cohen Ross, senior policy advisor at the federal Centers for Medicare & Medicaid Services, said making sure kids are insured requires both outreach and simplifying the renewal process, not just one or the other.
“We still have a lot of children who are uninsured and could get covered right away through these programs. We’re not going to lose sight of them,” Cohen Ross said. “But one of the goals of our program is to keep children enrolled once we have them enrolled, keep them enrolled for as long as they qualify, and that means paying just as much attention to the renewal process as we do to the initial enrollment process.”
Gurnah, Community Health Center’s program manager for the outreach grant, hopes other outreach efforts will focus on keeping children insured, not just trying to find uninsured kids.
“We never thought retention would be such a problem as it is,” she said.
1,700 phone calls
Community Health Center treats about 70,000 Medicaid patients at sites across the state. Under the system Gurnah developed, CHC gets data on its child and teen patients from the state Department of Social Services. From that, CHC can determine who will lose their coverage if it’s not renewed that month. Typically, it’s about 1,700 kids a month.
DSS sends renewal forms to families when their coverage needs to be renewed. But Gurnah thought phone calls, rather than letters that can get lost amid junk mail, would be a more effective way to notify parents. “I’m a mother, and I know I always forget when my children are due to go see their doctors,” she said. “The way I remember is that they call me.”
So CHC makes an automated phone call to the family of each patient at risk of losing coverage that month. AmeriCorps members who work for the health center follow up with any parents who do not submit the renewal paperwork. So far, Gurnah said, 95 percent of CHC’s child and teen patients whose cases are up for renewal maintain coverage. Another 2 percent are no longer eligible for the program, and 3 percent are unreachable.
Gurnah said the system is sustainable and cost-effective enough that CHC can continue its outreach efforts to find eligible uninsured kids too. The calls get made through an automated system CHC already had.
“I can only do this for our patient population,” she said. “If other people could replicate this, I could see this having a tangible impact on the number of uninsured children across the country.”
Lee said CHC is onto something in focusing on keeping more children enrolled.
Even community programs that don’t have the ability to identify specific families at risk of losing coverage could inform their clients about the need to renew coverage at least once a year, and alert them that they’ll be getting a renewal form from DSS that needs to be completed, she said.
Sommers said states can prevent children from losing coverage by taking steps to remove the burden from families and make renewing coverage more automatic.
“The more cracks in the system you create, the easier it is for someone to fall through,” he said.
One option is “fast lane eligibility,” in which a state gathers information it already has about a family’s qualifications from other assistance programs. That reduces the need for families to fill out additional paperwork, Sommers said.
Some states offer 12 months of “continuous eligibility,” in which children are assumed to be eligible for coverage for a year. The family is not required to notify the state of income or circumstance changes during the year. Connecticut had a continuous eligibility system, but eliminated it in 2003.
States have looked at tweaking application forms or changing requirements for applying in person, but Sommers said there’s not strong evidence that it makes a big difference.
“It’s really more changing the fundamental approach” that works, he said.
The problem of 1-year-olds and 18-year-olds mistakenly losing coverage stems from issues that arise during changes to how the infants and teens are categorized. Federal rules require DSS to categorize Medicaid recipients into different coverage groups, which have varying requirements. One is only for newborns up to age 1; another only covers teens under 18. The infants and teens that age out of those groups could still be eligible for HUSKY and could stay in the program if DSS assigns them to different coverage groups, but that does not always happen seamlessly.
DSS sends families notices if their kids are about to age out of those coverage groups. Because the notices are triggered by an infant or teen’s birthday, they generally do not coincide with the usual schedule for the family to renew coverage. “Families get confused, and understandably so, when the cycles are out of alignment and a notice comes,” Lee said.
DSS has been working to address the problems, including simplifying the notices sent to families of 1-year-olds and developing an alert to notify workers of newborns at risk of losing coverage.
Lee said DSS could also improve retention by making caseworkers responsible for ensuring that children who are eligible remain covered.
Part of improving retention also involves changing the mindset of caseworkers, supervisors and the department as a whole, Lee said, “to make the goal keeping everyone in the program, instead of keeping people out who are not eligible”
DSS spokesman David Dearborn said, “The fact is that DSS staff has worked hard over the years to insure the health of many hundreds of thousands of children and parents. We need to focus on improving the processes and technology that support that mission, and be careful about generalizations.”
At Community Health Center, the focus on retention hasn’t stopped the more traditional efforts to find uninsured children and enroll them in HUSKY. With the down economy, people who never qualified for Medicaid before are becoming eligible and might not know about the program or know they qualify, Gurnah noted.
Part of the federal outreach grant went toward developing an online screener that people can use to determine if they qualify for Connecticut health insurance programs.
AmeriCorps members visit food pantries and other sites in various communities to help people find out if they qualify, and apply if they do. They carry signature pads so people can sign their applications and portable scanners for documents needed for the application, all of which can be faxed electronically to DSS.
Shana Peruti and Jaimie Tyler, two AmeriCorps members who do outreach, said they encounter many people who need health insurance–adults.