Like states across the country, every state in our study undertook unprecedented levels of outreach for SCHIP. 27 All the states adopted strategies for making families aware of the new coverage, the importance of health insurance for children, and the availability of assistance in enrolling their children. After assessing their alternatives, most states decided to mount broad, statewide marketing efforts, to create a strong brand identity for their programs, and also to support more targeted, community-based efforts designed to "reach in" to harder-to-reach communities and families. To encourage SCHIP enrollment--the primary objective of outreach--most states also offered application assistance. Their strategies are described in Table 6.
|Statewide Marketing||Community-Based Marketing|
|State||New Name||TV And/Or Radio||Print Materials||Health Plans||Hotline||Web Site||Grants/ Contracts with CBOs||CBOs Involved with Application Assistance|
Notes: CBO = community based organization.
aLocal and county government organizations receive free printed materials and actively market SCHIP and Medicaid; indeed, this is the core outreach strategy in these states. There are no contracts, however, with community-based organizations
bLouisiana uses radio advertising in a limited number of urban markets.
Source: Information obtained during site visits.
1. Statewide Marketing Efforts
All the study states adopted similar strategies to market SCHIP to families with uninsured children. They created program names with positive images or brand identities, launched television and radio advertising campaigns, posted and distributed promotional print materials, worked with health plans to promote SCHIP and/or Medicaid, established toll-free information hotlines, and created program information Web sites. For example:
- Program Names. States created new and appealing names for their programs, such as Healthy Families (California), Child Health Plan Plus (Colorado), LaCHIP (Louisiana), and TexCare (Texas). State officials described these program names as "not sounding like government programs." In Louisiana, LaCHIP was described as part of the state's effort to "forge a new identity" for its Medicaid program.
Missouri set out to build on the name recognition the state had established for the Medicaid program's managed care initiative, MC+.The State called its SCHIP effort MC+ for Kids. (Reportedly, this name has confused consumers in those parts of the state without managed care.)
- Television and Radio Advertising. In California, Colorado, New York, and Texas the principal outreach component consisted of television and radio advertising, broadcast either statewide or to particular neighborhoods and/or ethnic markets. 28 State officials in these four states described the goals for such marketing as (1) creating a strong identity and promoting name recognition for SCHIP, (2) raising families' awareness of the program and of the importance of health insurance for children, and (3) persuading parents to enroll their children in SCHIP. State campaigns embraced broad slogans, including "Growing Up Healthy" (New York) and "A Healthier Tomorrow Starts Today" (California), and, in TV advertising, used bright colors and images of diverse children to promote their programs. In New York, the governor was featured prominently in several TV ads, urging parents to enroll their children in Child Health Plus.
Mass media outreach was less extensive in Louisiana and Missouri, the two states in the study with Medicaid expansions. Historically, Medicaid programs have not conducted extensive marketing and outreach campaigns. This may help to explain why case study respondents in these two states reported less support for the high-profile marketing of Medicaid.
- Printed Materials. In every study state, printed materials were a core medium of SCHIP outreach and marketing. Colorful, attractive application forms, brochures, posters, and fact sheets were designed and distributed to schools, health departments, WIC clinics, hospitals, Head Start and preschool programs, child care agencies, churches, and other community-based organizations. Billboards often were placed in communities where many families are uninsured.
Attempts were made to target specific racial and ethnic groups. In every state, program applications were printed in English and Spanish; in most states, Spanish-language brochures and posters were also available. In California, state officials found their new Fotonovelas--comic book-style magazines presenting stories about families needing health care and insurance for their children--to be an effective vehicle for promoting SCHIP to Hispanic families.
- Working with Health Plans. To varying extents, five of the six study states used managed care health plans as partners in SCHIP outreach. State officials indicated that they wished to take advantage of plans' marketing expertise but were also mindful of the need to minimize the potential for marketing abuses. For the most part, states have enlisted health plans' assistance, while continuing to carefully regulate the ways in which plans can participate. In California, Colorado, Missouri, and New York, for example, plans must submit all television, radio, and printed marketing materials to the state for review and approval before use. The plans may publicize SCHIP and Medicaid and their role as providers in these programs, but their logos typically must be less prominent than those of the state programs they are promoting. Plans may not contact potential enrollees directly, discuss health plan choice or enrollment in their promotions, or imply that they are the program or the only plan providing care under the program. Some focus group participants were confused between the program and the plan: For example, at the focus groups, participants frequently confused their plan name and the SCHIP program name, and many parents did not know the names of the plans their children were enrolled in.
- Toll-Free Telephone Hotlines. Every study state established one or more toll-free information hotlines that are mentioned prominently in television, radio, and print advertisements. Hotline operations have mostly been contracted out to vendors, whose multi-lingual staffs field questions from callers. Texas originally intended for hotline staff to take applications over the phone, but a heavy volume of calls precluded this from happening often.
- Web sites. Every study state created a program Web site. These Web sites were usually designed for consumers, providing electronic versions of brochures, fact sheets, and, in California, Louisiana, Missouri, and Texas, program applications. Some Web sites also were designed to serve the needs of policymakers, state and local program managers, and researchers; in California, Colorado, New York, and Texas, the Web sites include detailed information on policies and procedures, as well as program data.
2. Community-Based Outreach
Community-based outreach complemented statewide media marketing in California, Colorado, New York, and Texas; in Louisiana and Missouri, it was the main outreach strategy. Whereas statewide outreach was viewed as a means of raising awareness and boosting SCHIP name recognition, community-based outreach was viewed as a way to tell families about the importance of coverage, explain program eligibility rules and application procedures, and correct misconceptions about SCHIP and Medicaid. Often, community-based outreach was seen as the only way states could reach such populations as ethnic minorities, working families with no prior experience with public programs, and immigrant families afraid of becoming a public charge. The states funded a broad array of local organizations to provide community-based outreach, in the hope that "trusted voices" in the community would reach parents and encourage them to enroll their children. It is important to note that these groups were charged with assisting families in completing program applications, and that they were trained to do so. State-specific examples of community-based outreach follow:
- California used two strategies to fund community-level outreach and enrollment assistance. First, outreach contracts were extended to community-based organizations (CBOs) across the state, such as community collaboratives and school-based organizations, to enable them to hire staff to engage in community-wide education, partnership-building with other organizations, and door-to-door and telephone outreach and enrollment assistance. Second, the state trained nearly 24,000 individuals, affiliated with 3,600 "enrollment entities," to serve as Certified Application Assistors who seek out families with uninsured children and enroll them in Healthy Families and/or Medi-Cal in return for a $50 finder's fee per completed application.
- Colorado's outreach and enrollment contractor has networked with local partners, including schools, hospitals, community health centers, local health departments, local social services agencies, and WIC clinics to distribute program materials and promote SCHIP to the families they serve. After training, 82 of these sites were certified as Satellite Eligibility Determination sites to assist families in completing Child Health Plan Plus applications.
- Each of Louisiana's nine Department of Health and Hospitals (DHH) regional offices was asked to develop an outreach plan for its region. Each office has marketed LaCHIP aggressively by distributing applications and brochures through schools and health fairs, outstationing eligibility staff at hospitals and other health care providers, placing articles in local newspapers and contacting and promoting SCHIP with employers, among other strategies. DHH's most ambitious effort was back-to-school campaigns in 1999, 2000, and 2001, in concert with the state Department of Education, the National School Lunch Program, and the state Covering Kids initiative (funded by the Robert Wood Johnson Foundation).
- Missouri distributed program materials, posters, brochures, and applications to local schools, social services offices, hospitals and health centers, health department clinics, and a range of community-based organizations. The state also trained 3,000 individuals to serve as "ambassadors" for MC+ for Kids, spreading the word to community-based organization staff, clients, and others in the community. Finally, piggybacking on an existing initiative, Medicaid officials integrated SCHIP promotional efforts with the activities of eight Community Partnerships, multi-agency consortia charged with addressing the needs of children in such areas as health, mental health, public safety, and juvenile justice.
- In New York, since the inception of Child Health Plus, managed care health plans have marketed the program and enrolled children. More recently, the state launched its Facilitated Enrollment initiative, which gave grants to 32 "lead agencies," representing county health departments, county social services departments, perinatal networks, hospital associations, rural health networks, and senior citizen centers--to develop partnerships with "literally hundreds" of other local organizations to reach out to families and assist them to enroll in SCHIP and Medicaid.
- Texas implemented a regional procurement process that permitted its eight regional Health and Human Services Commission offices to solicit proposals and award contracts to support local outreach and application assistance. In all, 50 community-based organizations received contracts, including community action agencies, county health departments, faith-based charities, health provider groups, hospital partnerships, and other grassroots organizations. Typically, these community-based organizations have networked with other organizations in their communities, training them in TexCare eligibility rules and application procedures and organizing regional outreach and enrollment.
Frequently, community-level outreach efforts were complemented by state support for Medicaid outreach, using funds provided in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) specifically for costs attributable to the delinkage of Medicaid from welfare. Most states distributed these funds to county departments of social services, to be used to inform former welfare recipients of the availability of continued Medicaid coverage for them and their children. Louisiana, for example, used PRWORA fundsto distribute LaCHIPmaterials to families enrolled in the Food Stamp Program. In California, the Los Angeles County Department of Social Services partnered with community organizations to publicize Healthy Families/Medi-Cal for Children, and outstationed eligibility workers at hospitals and clinics throughout the county, under its Child Medicaid Enrollment Project.
27. Ian Hill, "Charting New Courses for Children's Health Insurance," Policy and Practice, vol. 58, no. 4, December 2000.
28. In one other state, Louisiana, radio ads were broadcast only in selected, urban markets.