Interim Evaluation Report: Congressionally Mandated Evaluation of the State Children’s Health Insurance Program. C. Implementation Experiences

02/26/2003

Combining statewide media marketing and local community-based outreach was considered a fruitful approach. Case study respondents in four states--California, Colorado, New York, and Texas--considered the two approaches to be complementary. They suggested that broader marketing got families' attention, sparked initial interest in SCHIP, and built "brand recognition" over the long run, while community-based efforts using "trusted voices" from the neighborhood provided the crucial ingredient needed to contact families directly, discuss details of the program, answer questions and clarify misconceptions, and assist families in completing their program applications. Toll-free hotlines were seen as a critical back-up to broader marketing, providing families with a means of obtaining further information about the program. In the two states with Medicaid expansion programs (Louisiana and Missouri), state and local officials wished there was a more prominent mass-media component to their states' strategies. Although they believed that their community-based efforts were highly effective, at the same time, they felt that informing families of the program, in the absence of a broader media effort to raise awareness, posed a significant challenge.

The qualitative findings from the focus groups that follow give a flavor of the views of participants in the SCHIP program. However, since they do not represent a statistically selected sample, their representativeness is clearly limited. The focus groups suggest that awareness of Medicaid comes mainly from experience with the program or through word of mouth. By contrast, the focus groups suggest that awareness of SCHIP comes through mass media:

"I saw a poster, there was a billboard up on Sligh Avenue. It said 'If you need insurance for your kids….' over the railroad track. (I said to my friend) I keep seeing that number, let me take it down and call them. That's how I got it." (Tampa, Florida)

"Television. When Pataki started talking about it. That's how I heard about it." (Buffalo, New York)

"I heard it on the radio. I was looking for insurance for my kids, or for all three of us, and couldn't find anything and I heard this and I thought, 'Oh well, I might as well call and they'll tell me it was too much money or whatever.' And I called." (San Jose, California)

Several states reported that their marketing approach had become more targeted over time. Input from consumer focus groups and marketing consultants helped them refine their advertising messages. In both Texas and California, for example, messages included in initial campaigns were described as "too generic" and "limited." However, second-generation SCHIP advertising replaced earlier vague references to "affordable coverage" with the actual dollar costs of premiums, described the benefits in greater detail, provided testimonials from satisfied parents, and, in California, gave clearer statements about children being eligible regardless of citizenship status or participation in "welfare." In Colorado, officials avoided such phrases as "health care for low-income children," which might repel working families. Participants in the focus groups supported the emphasis on explicit, concrete messages, regardless of the medium. They indicated that the most important messages to include in marketing are:

  • Applying is simple and convenient
  • Insurance is low-cost or no-cost (with details of the costs)
  • Coverage offers many benefits
  • Working families are eligible (with details on who is eligible)

To increase enrollment, several states targeted particular racial and ethnic groups. California described how it placed advertisements on numerous Spanish-speaking radio stations in various markets across the state; and Texas incorporated into some of its radio and TV ads the well-known Hispanic nursery rhyme sung by mothers to their sick children--"Sana Sana." Participants in evaluation focus groups agreed that strategies such as these would be successful. They suggested using TV, radio, and newspapers in both English and other prominent local languages to reach eligible families. In addition, focus group participants in cities in several of the states suggested placing ads in bus and train stations, as well as on buses and trains. For example, "TV doesn't have but a couple of seconds, and half the time you're in the kitchen or something. The bus, you're sitting there and looking." (SCHIP enrollee, Kansas City, Missouri). Finally, focus group participants recommended reaching out to eligible families in all the places they go in their daily lives, such as health care providers, pharmacies, community centers, grocery stores, fast-food restaurants, shops and post offices, schools, and places of worship.

Among the study states, New York makes the greatest use of health plans as marketing partners.State officials are convinced that health plans play a crucial role in promoting Child Health Plus and boosting program enrollment. They are confident that the state can ensure appropriate marketing by health plans. Although New York continues to review and approve all plan promotional materials, health plans are encouraged to market the program; they may also assist families in completing applications for SCHIP and Medicaid, however, they may not contact families who have not called them. Other states, however, limit the extent to which health plans may assist families with information and enrollment. Such policies frustrated some health plan officials who were eager to become more involved, and who believe that state officials are missing an opportunity to capitalize on health plans' marketing expertise.

States reported having less success with certain outreach strategies. For example, officials in both Colorado and Louisiana said that distributing program brochures, flyers, and applications at health fairs, community events, and open houses at schools resulted in little interest or sustained followup by parents. In California, local outreach agencies were surprised to learn that some of the organizations they had viewed as "obvious partners" resisted getting involved. Reportedly, both WIC agencies and faith-based organizations often were not interested in participating inHealthy Families outreach. For these groups, as well as many schools and school districts, persistence by outreach workers in educating key personnel such as school principals, nurses and administrators may be required to forge successful outreach partnerships.

States with separate state programs also reported that marketing SCHIP alongside Medicaid poses challenges. According to state and local officials in California, Colorado, New York, and Texas, some parents resist enrolling their uninsured children in Medicaid because of negative prior experiences with the program's enrollment process and/or an association of Medicaid with welfare and poverty; these impressions were borne out in the focus group discussions with working families. Parents' negative perceptions of Medicaid stemming from these associations were reported to limit the effectiveness of state and local efforts to promote health insurance more broadly; even as they were favorably disposed toward SCHIP, parents were "turned-off" by the idea of Medicaid. Notably, once they have navigated the system and successfully enrolled in Medicaid, families are generally happy; it is the experience of applying and being screened for eligibility that is considered to be unpleasant. In Colorado and Texas, concerns about stigma have persuaded community organizations to market SCHIP without mentioning Medicaid. "We can get our foot in the door with SCHIP, and then talk about Medicaid when we have to," was a sentiment expressed by outreach staff in these community-based organizations. In California, where all promotional materials display the joint logo, Healthy Families/Medi-Cal for Children, strategies are more mixed. Some community-based organizations and health plans market the programs jointly, while others avoid mentioning Medi-Cal, in order not to lose families' interest. Although advocates understood these dynamics, they took the view that outreach for health insurance should promote SCHIP and Medicaid jointly. Reflecting this perspective, officials of one health plan said they marketed both programs together because "…what we are marketing is health insurance, not Healthy Families." Of note, the focus group participants generally distinguished SCHIP (both separate and Medicaid expansion programs) from Medicaid, suggesting that even when marketed jointly, outreach workers had managed to educate families about the differing nature of the two programs.

Another factor frequently mentioned as a barrier to successful outreach was the widespread fear among immigrant families that participation in SCHIP could jeopardize their (and their children's) residency or citizenship by making them a "public charge." This issue is particularly salient in California and Texas. Also, because some illegal immigrant parents of citizen children also believe that information written on the application form will be passed to the Immigration and Naturalization Service (INS), they are resistant to outreach. It is noteworthy, however, that community-based workers reported that families tended to be considerably less fearful of public charge implications and the INS in relation to SCHIP compared to Medicaid, simply because they perceive SCHIP more as a private health-insurance program, whereas Medicaid is clearly viewed as a government program. Outreach staff have worked hard to overcome the misconception that receipt of Medicaid (except long-term care) or SCHIP is counted when determining public charge status in immigration proceedings. (29)

At the time that state officials were interviewed, support for the programs appeared strong; officials in most states were optimistic that SCHIP outreach to promote recruitment and retention would be sustained. Four of the six study states were satisfied with the amount of funding they had devoted to outreach to date. Only one state, Colorado, told us that the 10 percent federal cap on administrative spending had significantly constrained its outreach efforts.


29. The welfare reform legislation enacted in 1996 included provisions that altogether banned immigrants who arrived in the United States after August 22, 1996, from receiving Medicaid and other federal means-tested public benefits for a period of five years from the time of their entry. However, in many families, some members--those who arrived on or before August 22, 1996 and those who were born in the U.S. and are, thus, citizens--may be eligible for Medicaid even though others in the family are excluded. Although guidance issued by the Immigration and Naturalization Service (INS) has clarified that receipt of Medicaid (except long-term care) and SCHIP is not counted when determining "public charge" status in immigration proceedings, fear persists among immigrant families that Medicaid participation by some members might undermine the renewal of a "green card" or prevent a green card-holder who goes abroad from re-entering the U.S. These fears--which arose from well-publicized incidents in the 1990s of INS officials wrongly requiring green card-holders who were returning to the U.S. to reimburse the government for services received in Medicaid as a condition of reentry--may continue to affect enrollment decisions by immigrant families.

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