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BY: FELICIEN "FISH" BROWN

It has become a sad ritual in Washington every year, a scorecard on how well this country treats its poor and vulnerable populations. In September, the U.S. Census Bureau announced the latest figures on the number of Americans without health insurance: 43.4 million in 1997, an increase of 1.7 million people over the previous year.¹ This is a frightening trend, particularly in light of the impressive, sustained economic progress in the 1990s for American families as well as for federal and state governments.

Buried in the data, however, is some good news: The number of uninsured children did not increase at all last year. Moreover, there is every reason to believe that the new Children's Health Insurance Program (CHIP) will bring health coverage to another 3 to 5 million uninsured children over the next few years. By mid-October, the federal government had approved 42 state CHIP programs and earmarked $40 billion to spend over the next 10 years. These CHIP expansions are in addition to the Medicaid option for states wishing to cover children up to the poverty level, and the federal funds for these expansions are unlimited.

Soon almost two-thirds of the 10.7 million uninsured children will be eligible for free or very low-cost health insurance. This will not be universal coverage, mind you, but it is not a bad outcome either, particularly at a time when the national political environment is still smarting from the 1993-1994 failure of the president's healthcare reform proposal. But the immediate challenge in children's health coverage is less about eligibility than about making certain that those eligible are signed up for the programs.

Outreach, Outreach, Outreach
A recent General Accounting Office study found that "3.4 million Medicaid-eligible children — 23 percent of those eligible under the federal mandate — were uninsured. The majority were children of working poor or near poor, and their parents were often employed by small firms and were themselves uninsured."² As CHIP programs expand eligibility beyond the lowest income brackets, getting families to sign up for them may present even more problems. What is needed is a smart, coordinated campaign that will reach out to families of uninsured, eligible children and make signing them up for coverage as simple as possible.

Better outreach will not only improve the health status of children; it will also improve the chances for future advocacy efforts on behalf of universal coverage. You do not need to be a cynic to recognize that some politicians are willing to exploit the gap between kids eligible for Medicaid/CHIP and those actually enrolled in the program. From the well of the U.S. Senate, they will say: "If we can't get families to enroll their kids in a free government-run program, then maybe we're going about it in the wrong way. The private sector can do a better job of getting families the health insurance they need." In similar fashion, some federal and state legislators may use the situation as a reason to "wait and see" before moving further to expand eligibility.

As a Catholic health ministry, as proponents of universal coverage, and as providers of healthcare services to vulnerable groups, we must work to increase the number of eligible children enrolled in Medicaid/CHIP programs and thereby reduce the number of uninsured. Here is how we can do it.

Advocacy Efforts
First, advocacy efforts are needed to encourage state governments and the federal government to clear away bureaucratic barriers to enrollment. In September, the Health Care Financing Administration established a simple model application — just two pages long — that states are encouraged to use in enrolling eligible children.³ (California parents must fill out a form of more than 30 pages to apply for Medicaid.)

States also can and should eliminate asset tests for enrollees and rely solely on income determinations that are more representative of the families' financial status and easier to monitor. Other measures to make signing up easier are common sense: extending office hours, allowing mail-in applications, speeding up the processing of forms. In addition, states can reduce the stigma associated with a low-income, government program by giving Medicaid/CHIP more of a "middle class" feel — perhaps by changing the program's name or by devising different advertising strategies for it.

The federal government, for its part, needs to pay particular attention to the current fear among immigrant families that signing up for Medicaid/CHIP will jeopardize their immigration status. A few months ago, CHA and other groups asked the White House to clarify its policy on "public charge" determinations made by immigration officials. We are still hopeful that the administration will take this step and others to expand the number of legal immigrant children with health coverage

Children's Health Matters
Second, Catholic hospitals, social service agencies, and schools that serve low- and moderate-income families have an excellent opportunity to help enroll uninsured children in Medicaid/CHIP. An inspiring example of this is Children's Health Matters, a joint initiative by Catholic healthcare systems and Catholic Charities USA to encourage and support community outreach efforts (see "When Children's Health Matters,"). CHA is working in conjunction with Children's Health Matters and will help the initiative expand its activities in the coming year. Federal law allows states to designate hospitals and other entities as temporary enrollment centers. A recent survey found that only 27 states have chosen this option, and even in these states the opportunities are too limited.

Broad Publicity Campaign
Third, a broad campaign is needed to get the word out, on billboards, on television and radio, and in school-parent meetings. Publicity campaigns are a fundamental part of any program or product these days, and children's health insurance should not be an exception. Low- and moderate-income working families are often incredibly busy and need direct access to information on Medicaid/CHIP. State programs are all different, but the White House is working with the National Governors' Association and private companies to establish a national 800 number that is catchy and easily recognizable and remembered. Under this plan, a family calling the number would be seamlessly patched into the state's own enrollment office and would be able to sign up for coverage immediately. Catholic healthcare organizations should help publicize the campaign and the 800 number.

No one has the answer yet — certainly not a politically viable one — to the question of how to guarantee health coverage for all. We need to continue to advocate this goal in Washington, DC. But we also need to make sure that we help get kids enrolled in the Medicaid and CHIP programs for which they are already eligible. These programs can help:

• Push the national debate toward expanded coverage
• Offer examples of how government can be a positive force in this effort

But, first, we need to get the kids and their families in the door. So we should all be shouting loudly: "Outreach, outreach, outreach!"

NOTES

1. "Health Insurance Coverage: 1997," U.S. Census Bureau, Washington, DC, 1998.
2. Demographics of Nonenrolled Children Suggest State Outreach Strategies, U.S. General Accounting Office, Washington, DC, 1998, p. 2.
3. Health Care Financing Administration, letter to state health officials, September 10, 1998.

Mr. Brown is director, public policy, in the Catholic Health Association's Washington, DC, office.