State and local officials and advocates interviewed in the case studies recognized that SCHIP enrollment had been made simple in important and beneficial ways. Many parents participating in the focus groups were in agreement; they found the application and document requirements simple and manageable. In addition, those who chose to mail in their applications appreciated the convenience of that mechanism, as well as being spared a trip to the social services office:
"It was a legal-size paper and there was a column for your information and whoever you wanted to put on the insurance and then there was a thing for your income and that was pretty much it and then you signed it." (Tampa, Florida)
"All they needed was proof of my income. And everything was laid out and they had a number you could call for help with the application. It was a booklet by the time I got it. It looked like a lot but it wasn't a lot." (San Jose, California)
It has been widely noted that Medicaid is adopting some SCHIP application features. In every study state, SCHIP either stimulated the creation of shorter, simpler "joint" application forms or it reinforced existing simplification efforts. In California, simple strategies adopted by the separate SCHIP program--for example, permitting applications to be mailed in, imposing no assets tests, minimizing verification requirements, and guaranteeing 12 months of continuous eligibility--were also adopted by the Medicaid program with the goal of aligning the rules of the two programs (even though these policies had been resisted by the state for Medicaid for years before SCHIP was created). Also, in Texas, much more stringent eligibility rules for Medicaid than for SCHIP spurred support for passage of a Medicaid simplification bill. Beginning in late 2001, Texas' Medicaid eligibility rules were brought into closer alignment with those of SCHIP--with an assets test persisting as the only key difference between the programs. Case study respondents in the study states predicted that such simplification progress would eventually greatly benefit families whose children enroll in Medicaid. Notwithstanding claims of simplification, focus group participants who had applied for Medicaid in New York, California and Colorado (which have separate SCHIP programs) seemed to think the process was very onerous.
More subtly, but equally important, case study respondents indicated that SCHIP may also be promoting changes in the culture and operations of traditional welfare programs. In both Louisiana and Missouri, efforts already underway to delink Medicaid from welfare eligibility systems were expanded after Title XXI, in an effort to create more consumer-friendly systems. And in each state with a separate program, the social services system was working hard to facilitate families' access to coverage, as opposed to discouraging it. Especially in high-density population centers such as Los Angeles County and the boroughs of New York City, local eligibility staff made such observations as: "…we've had a real culture shift here. No longer are we supposed to keep everybody out; we're supposed to help them get in!" Yet, some focus group participants still reported problems with rude and unhelpful eligibility workers.
Despite the streamlining of children's enrollment and the spillover effects noted by case study respondents, they reported that many SCHIP and Medicaid eligibility system issues still need to be addressed:
- While SCHIP and Medicaid eligibility have been greatly simplified, differences in the rules and procedures of the two programs persist in several states with separate programs, causing confusion among families and difficulties with application processing. As detailed above, states have simplified their eligibility rules and procedures for Medicaid, but they are not as simple as in SCHIP. The effects of the differences were clear to many study informants at the state and local levels--confusion among families and more complex administration, especially with regard to the screen-and-enroll function.
- Even with simplified forms, reduced verification requirements, and the widespread availability of application assistance for parents, many parents are confused about eligibility and many submit incomplete applications. Often, this was blamed on continued differences between SCHIP and Medicaid rules, which result in unnecessarily long joint applications (that must take into account the rules of both programs) and confuse parents. For advocates, in particular, this was evidence that SCHIP and Medicaid application procedures were still "too complex." Reported rates of "incompletes" varied from 70 percent in California to 35 percent in Texas. Interestingly (and, perhaps, discouragingly), case study respondents in California and Louisiana reported that incomplete rates are no lower among parents who received application assistance. Both California and Texas were hopeful that their Internet-based applications would significantly increase families' rates of submitting complete applications.
Low-income focus group participants often were confused about eligibility rules. Some eligible families thought they made too much money to qualify, or felt that it was not right that someone in their income bracket should qualify for a government program. Other families assumed that they wouldn't qualify for SCHIP because of experience with or assumptions about Medicaid:
"I always thought medical assistance was the medical side of welfare." (Maryland)
- In states with separate programs, screen-and-enroll procedures were described as complex and confusing for families. Families' confusion was attributed once again to differences between SCHIP and Medicaid rules that frequently require that eligibility be determined twice. The most prominent problems surrounded the logistics of sharing information between "single point of entry" vendors and county departments of social services. Depending on where an application is initiated, screen-and-enroll may require vendors to "deem" or refer applications to their social services counterparts, or vice versa. Due to differing eligibility rules (and confusion over how rules for one program may or may not apply to the other), applications are often sent back and forth between vendors and social services offices several times. Several social services staff described the vendor in California as "a black hole" because of its inability to track the status of applications. Colorado enrollers were concerned that many children referred to Medicaid were "falling through the cracks"--because the state did not have a system for tracking applications. Case study respondents viewed the vendor in Texas more favorably because this vendor can track applications (by bar codes) and electronically transfer "images" of applications to county offices.
In addition to screen and enroll problems, families in focus groups reported not always being told about the availability of SCHIP when they were denied Medicaid. Although families in focus groups in Georgia and Colorado report that caseworkers told them about the availability of another program, families in other states where focus groups were held said that caseworkers had not told them about SCHIP. Participants mentioned finding out about SCHIP from friends and from TV.
- Community groups sometimes criticized retroactive "finder's fees" as an ineffective way to pay community-based application assistors.Despite considerable praise voiced for community-based application assistance efforts, those states that pay agencies retroactive finder's fees for successfully enrolled children (California, Colorado, and Louisiana) tended to be criticized by community groups. Fees vary from $12 in Colorado to $50 in California. Regardless of the fee level, community-based organizations in each of these states reported that fees did not cover the time and costs involved in assisting families with applications. Furthermore, satisfaction was undermined in California by slow payment by the state's vendor. Not surprisingly, community groups tended to prefer grants or contracts to support application assistance activities. In particular, they praised up-front funding because it enabled them to add capacity by hiring new staff.
- State eligibility data systems also were criticized by case study respondents for their inability to track applications through the process and report precise figures on SCHIP and Medicaid eligibility outcomes. While every state strongly believed that Medicaid enrollment of children had increased as a result of SCHIP outreach and enrollment efforts, the states in our sample could not quantify this claim with precise program data.
- Changes in culture, approach, and attitudes in county social services departments have occurred in many localities, but many counties have been "slow to give up their welfare mentality and practices." Case study respondents in California, Colorado, New York, and Texas spoke of the wide variation in practices between counties, with some cooperating with community application assistors and others seemingly resentful that other groups were determining eligibility. They also noted instances where counties' actual eligibility-review procedures differed, despite uniform state policy. These problems contributed to difficulties with screen-and-enroll and perpetuated some families' negative feelings toward Medicaid. Moreover, some focus group respondents pointed out that a welfare mentality persists. Many parents stated that they felt hostility and condescension from the social services workers and some felt that they were discriminated against based on their race, ethnicity, or gender:
"I think they should treat people like they're people and with a little bit of more respect. Like I said before, if you don't need these services you certainly wouldn't put yourself out to go down there and take the treatment." (Cleveland, Ohio)
Case study respondents reported that family resistance to Medicaid was strong in several states and believed that it was undermining states' efforts to achieve high enrollment in public insurance programs. However, it is not clear how common resistance to Medicaid is, since very few low-income families with uninsured children say that they would not enroll their child in Medicaid if told their child was eligible. Moreover, as demonstrated in the next section, in the six states examined here, Medicaid enrollment by children dwarfs SCHIP enrollment, which suggests that many families overcome whatever resistance they may have felt toward Medicaid. Case study respondents indicated that some of the resistance stems from prior negative enrollment experiences at county welfare offices--advocates and others noted families feeling "…intimidated by local DSS offices," and of being "treated rudely." The focus groups strongly supported this point. Families with experience with the Medicaid program were particularly critical of eligibility staff at social services agencies. "I think the people who work in that office should be conscientious about that they are helping people who truly need it." (Miami, Florida, translated from Spanish)
Family resistance to Medicaid was manifest most clearly during screen-and-enroll activities. In California, New York, and Texas, we repeatedly heard that families were attracted to SCHIP's promise of health coverage for children, but did not want to participate if their children were found to be Medicaid-eligible. Local enrollers reported that "…families have begged us to stay on SCHIP and even offered to pay premiums to do so."
Community-based enrollers have had mixed success in persuading these families to sign their children up for Medicaid. In New York, Facilitated Enrollers reported they were able to convince the majority of the families with whom they worked to follow through with Medicaid enrollment for their children. (This may be related to the fact that fears of public charge seem to have largely dissipated, due in part to New York's decision to use state funds to cover immigrant and noncitizen children in Child Health Plus.)The challenge was, however, far greater in California and Texas. One Application Assistor in California noted "…I lose 90 percent of the children that I find Medicaid-eligible…they simply walk away." The fact that 43 percent of parents check the box on the Healthy Families/Medi-Cal for Children application form indicating that they do not want their application forwarded to DSS was described as further evidence of Medicaid welfare stigma, and of the fact that the fear of public charge has been "very slow to fade." In Texas, case study respondents stated that only 25 percent of families referred to Medicaid ultimately enroll in the program.