Enrolling children in the State Children's Health Insurance Program (S-CHIP): Can we do more?
Article Outline
Uninsured children comprise one of the United States' greatest health care issues today. The 2001 Census Bureau found that 9.2 million children are uninsured (Bhandari & Gifford, 2001). The benefits of health care coverage are indispensable. Children with health insurance have better preventive care and anticipatory guidance than do children without insurance (Brach et al. 2003, Taras et al. 2002) and are rewarded significant improvements in access and quality of care (Szilagyi et al., 2004). What types of programs exist for some of these uninsured children?
In 1997, Congress passed legislation that led to the creation of the State Children's Health Insurance Program (S-CHIP), with a goal of expanding health care to children of low-income families, especially those whose income was too high to qualify for Medicaid but less than 200% to 300% of the poverty level. S-CHIP funds may be allocated as a Medicaid expansion program or separately administered as a health insurance plan, depending on each state's organization of funds (Nolan et al., 2003). Despite many states' recent efforts to simplify enrollment in S-CHIP and support community-based application assistance with grants, contracts, and training, enrollment in the S-CHIP program is not optimal (Cohen Ross & Hill, 2003).
It is estimated that more than half of the children in the United States who are uninsured are actually eligible for Medicaid or S-CHIP (Institute of Medicine, 2002). Many factors have been implicated for failure to enroll these children. Low-income families may not be aware of the S-CHIP program or its eligibility criteria, or they may perceive the application process as difficult or the government system as complex (Salsberry, 2003). Families who are working may not be comfortable receiving government assistance. Immigrant families may fear that applying will jeopardize their immigration status (Cohen, Ross, & Hill, 2003). These misperceptions can be resolved with education. Pediatric nurse practitioners (PNPs) are in ideal situations to provide this instruction to their patients and families. Recommendations for nurse practitioners include being knowledgeable about available benefits and enrollment and referral procedures, screening patients for health insurance status, and educating patients about resources available (Salsberry, 2003). Practitioners can help by distributing information in their practices (Brach et al., 2003) or even making applications available in their clinical sites (Jenkins & Faulkner, 2002).
I would like to go a step further and suggest that we can do even more for our uninsured pediatric patients. In addition to providing education and information about the S-CHIP program, we could provide application assistance right in our clinics or practices. Many community health clinics have already experienced success in enrolling larger numbers of children in S-CHIP and Medicaid right in the clinic, by employing a staff member who is dedicated to outreach and enrollment. Especially helpful in these settings is the implementation of protocols for screening uninsured children. When children are found to be uninsured and eligible for S-CHIP, they are directed to the outreach staff member (Nolan et al., 2003). Thus, patients can receive their health care and, without having to make another trip, can have personal assistance in the enrollment process. Because many uninsured children have single parents or parents with their own health care problems (Salsberry, 2003), this time-saving tactic is remarkably helpful. Perhaps you have seen such enrollment success in community clinics in your area, but I believe that any practice that sees even a small number of uninsured children could make the same accommodations for its patients. I would like to share an experience I had over 2 years in the private practice where I worked as a PNP in Northern California.
California's S-CHIP funds are allocated to a program called Healthy Families. Eligibility criteria includes a family income above that which qualifies for Medi-Cal (Medicaid), but less than 250% of the poverty level. The Healthy Families program trains application assistants to help families complete the paperwork needed to enroll in either Medi-Cal or Healthy Families. I became certified as an application assistant and was able to offer this service to dozens of qualifying patients in my practice, in addition to providing routine well and illness care to all. The setting in which I practiced was a small, private practice employing two pediatricians and myself. We served a diverse group of clients, including approximately 25% Medi-Cal insured, 65% HMO or privately insured, and approximately 10% uninsured. Approximately 20% of the patient population was Hispanic, many primarily Spanish speaking.
Despite the existence of a very well-operated community clinic within miles of our practice that offered application assistance for the federal and state programs, we still encountered many uninsured children. Once I was certified and knowledgeable about the eligibility requirements for Healthy Families and Medi-Cal, I was able to determine from a few simple questions whether a child might qualify and then offer my application assistance to families. Because of an ongoing relationship of mutual respect with many of these patients, in addition to my Spanish-speaking ability, many families were open to hearing more about the programs and were willing to apply for their children. I witnessed the improved continuity of care and increased preventive health care in the patients as they shifted from an uninsured status to coverage by Healthy Families. Additionally, I received extreme gratitude from these families who were so pleased with their new health care coverage.
I was able to incorporate this added service into my daily practice in the following manner: whenever a patient was checked in and found to be uninsured, the secretary or nursing assistant would notify me. I would take 2 to 3 minutes between my scheduled visits to explain the Healthy Families/Medi-Cal program and offer assistance. Based on a few screening questions related to family income and citizenship status, I was able to identify the children who would most likely qualify for one of the two programs and offer a free appointment for application assistance. The family would then make a half-hour appointment with me at a later date (usually within a week), at which point I would verify their documents and help them fill out the application. The family would then mail the completed application along with necessary documentation to the Healthy Families/Medi-Cal office and would receive word within 2 weeks regarding whether the children were enrolled.
My service was cost-effective because of a stipend of $50 per qualifying applicant that the Healthy Families Program provided to application assistants. Because the screening interview was fairly predictive of enrollment eligibility, almost all of the half-hour appointments were compensated at a rate of $50. The two-minute screening interview was not a hindrance because of the relaxed pace of the office and my ability to address the families either before or after their appointment. Of course we had many busy days, and I would have to perform my 2-minute screening as a phone call later in the day.
The application assistance I offered was not typical of the role of a PNP, and surely almost any other employee in our practice could have been trained to provide the assistance. However, because I had ongoing relationships with these families and they had already developed trust in me, I believe they were more open to my advice. In several community health centers studied, involving clinicians in outreach proved very successful because the frontline staff was often reported to be very busy taking phone calls, scheduling appointments, and juggling patient inquiries (Nolan et al., 2003). Perhaps the greatest contributing factor in the success of enrolling these families was streamlining the process with teamwork. The moment a child was identified as uninsured, the process began right there in the office and was expedited by the availability of an appointment at a familiar setting within a week. Many families who went through the process in our practice noted how different it felt to be offered assistance by “people who knew them and cared.”
Because of a move to another state, I retired my position in this practice. I was not able to pass on my duty as a Healthy Families application assistant because at the time government cutbacks were eliminating the reimbursement for application assistants. Because of this unfortunate change, my practice could not justify the expense of training another employee as an application assistant. Indeed, only a handful of states have instituted such incentives as reimbursing application assistants (Cohen Ross & Hill, 2003). By what other means can clinics and practices afford to offer application assistance? That is the challenge for each practitioner. Community health clinics have success with a variety of small state, local, and foundation-supported grants (Nolan et al., 2003), and perhaps there are funds available to providers in other settings as well.
As health care providers, we should investigate possible funding sources on a local level and lobby for improved state-supported funding. Nurse practitioners have been encouraged to stay abreast of legislative issues related to S-CHIP funding at federal and state levels and to join together in professional nursing organizations to disseminate information and lobby on behalf of improved S-CHIP funding, outreach, and enrollment support (Jenkins & Faulkner, 2002). It is only when we find a cost-effective solution that we will be able to provide this valuable service to our uninsured patients. But what a difference it can make! If only I could describe to you the many gracious greetings I received from these families who were thrilled to learn they qualified for such a comprehensive health care plan. As a provider of health care, as well, I was fortunate to see firsthand the difference in care when children were insured. Primary care appointments were more consistent, and follow-up visits, when needed, were reliable. Prescription medication was more obtainable, and referrals to specialists were not such a challenge as before the children were insured. In general, my Healthy Families experience helped develop healthier children.
As the number of children in the United States continues to grow, let's make sure they are insured. It is a responsibility of our profession to develop and enhance means of offering optimal health care to our patients. Health insurance is a component of health and wellness. I hope this example of increasing enrollment in a valuable health care plan inspires other PNPs to do the same. We need to be creative and insightful in the challenge of providing the means for quality health care to all individuals, starting with the ones we see every day.
References
- References
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PII: S0891-5245(04)00270-6
doi:10.1016/j.pedhc.2004.09.001
© 2005 The National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
