School-Based Health Outreach and Enrollment

By Bianca Louie, BA Public Policy, 2012

Author’s Note: Under the Affordable Care Act (otherwise known as “Obamacare”), children are eligible for more choices and stronger coverage. Open enrollment in ACA’s Health Insurance Marketplace began on October 1, making it easy for Californians to compare qualified health plans, get answers to questions, find out if they are eligible for lower costs for private insurance or health programs like Medicaid and the Children’s Health Insurance Program (CHIP), and enroll in coverage. This article is based on an analysis performed in 2012, but remains relevant to the question of how to ensure that   families with children know their options. Under ACA, health plans can no longer deny coverage to children under 19 because of a pre-existing condition, like asthma or diabetes. In California, there are about 2,236,001 children with some type of pre-existing health condition that have greater access to care because of ACA. Also under ACA, many insurance plans are required to provide coverage for preventive health services without a deductible or co-pay. This increases children’s access to well-child visits and immunization services. Finally, ACA provides $200 million in funding from 2010 to 2013 to address significant and pressing capital needs to improve delivery and support expansion of services at School-Based Health Centers (SBHCs). In my article, one of my recommendations is to use SBHCs to identify and enroll children in coverage, so the partnership between ACA and SBHCs is crucial in health outreach and enrollment.

How can schools be involved in identifying and enrolling uninsured children in health care, and how effective can they be? This article examines existing school-based strategies used to identify uninsured children that are eligible for public health coverage and to enroll and retain them in public health care. The case analysis identifies common barriers that most strategies face in enrolling children, and also defines the transferrable elements from the strategies to conclude with best practices that can be adopted and implemented in schools across the nation.

There are too many children in California that are eligible for health coverage but that are uninsured. Out of all the uninsured children in California, 71 percent in 2005 and 79 percent in 2007 were eligible for Medi-Cal, Healthy Families, or Healthy Kids.[1] This is a public problem requiring intervention because children without access to primary and preventive health care create health costs and risks for society and can lead to childhood hospitalizations and deaths.[2] Children who fail to receive access to health care cannot achieve their potential in school, which limits their future contributions to society. Thus, investing in children’s access to health coverage is a long-term investment in society.

I focus specifically on school-based strategies for health outreach and enrollment because schools are essential access points that connect children, youth, and families to educational and social services.[3] Schools are also considered trusted institutions that can communicate credibly with families, and have the potential to work with parents as they become educated about health care options and ultimately complete enrollment for their children. The following school-based strategies are models that are financially sustainable for school districts that frequently have tight budgets.

• Express Enrollment (EE) utilizes the school lunch program as a gateway to identify uninsured children, and uses eligibility information already available in School Lunch Application to provide these children with immediate and ongoing Medi-Cal coverage.[4]
• Teachers for Healthy Kids (THK) educates teachers on health care programs and gives them outreach and enrollment materials. Teachers serve as a conduit of information to parents, and Certified Applicant Assistors (CAAs) help families complete the enrollment process either on school sites or over the phone.[5]
• School-Based Health Centers (SBHCs) are located on or near school grounds and provide primary care services to students. SBHCs have access to uninsured but eligible children, and enroll them through the use of on-site CAAs.[6]
• Children’s Defense Fund (CDF) Texas’ All Healthy Children Campaign: Enrollment Cards works with school districts across the state to measure the number of uninsured students in every school by adding a health insurance question to school enrollment forms. CDF Texas then works with school administrators to follow up with uninsured children and educate their parents on how to access, utilize, and renew their children’s health coverage.[7]
• Family Resource Centers are community-based entities, often connected to schools, that work to build strong families and communities by providing support and services to holistically help families become self-sufficient. They work on health through outreach for Medi-Cal and Healthy Families, and employ and utilize CAAs for the enrollment process.[8]
• Children’s Health Access and Medi-Cal Program (CHAMP) utilize CAAs at a call center that do the majority of outreach and enrollment for uninsured children in LAUSD. CHAMP also uses marketing, phone, and direct mailing campaigns to outreach and identity uninsured but eligible children.[9]

The following strategies are not school-based, but are utilized in schools to do health care outreach and enrollment.

• Certified Application Assistors (CAAs) are certified individuals employed by the state of California to help enroll children and families eligible for Medi-Cal, Healthy Families, and local Healthy Kids programs.[10]
• Health-e-App (HeA) is an automated web-based application in English and Spanish to enroll low-income children and pregnant women into public health insurance programs.[11]

My case analysis of existing school-based outreach and enrollment efforts is inspired by the collaboration between the American Association of School Administrators (AASA) and the Children’s Defense Fund (CDF). The two entities are partnering to develop systematic means of enrolling uninsured children in health coverage through local schools.

My data gathering consisted of literature and reports on each strategy, as well as quantitative data from Managed Risk Medical Insurance Board (MRMIB). I also interviewed administrators and experts of Express Enrollment, California family resource centers, CHAMP, CAAs, and Health- e-App. In the following section, I outline common policy issues and challenges that the strategies face in outreach and enrollment. I conclude this article with recommendations of best practices, as derived from the analysis of the different models.

 The Challenges

The first challenge I found that strategies commonly face relates to funding. In my interviews, experts on SBHCs, family resource centers, and CAAs reported the lack of funding as a barrier to doing effective outreach and enrollment. SBHCs struggle with the complicated and time-intensive billing process for reimbursements for health outreach and enrollment activities, if they even qualify for such reimbursement.[12] Due to lack of funding, family resource centers struggle with adequate and comprehensive enrollment follow-up with families[13] and CAAs are limited in all-encompassing and specialized training.[14]

The second challenge is in gaining access into schools. Each strategy needs buy-in from the superintendent or principal to actually gain access to the students. THK, family resource centers, CAAs (with the exemption of the CHAMP call center), and the HeA all have difficulty integrating into schools because their strategies are not easily imbedded into the school’s existing routine, culture, and structures. For THK, schools and teachers have expressed resistance and reported they would like to help in outreach and enrollment efforts, and do not want the additional paperwork.[15] Family resource centers have some connections with schools, but generally prefer to operate independently so they are not beholden to school politics and competing interests.[16] With the exception of the CAA- staffed call center at LAUSD, CAAs generally connect with schools on referral and as- needed bases. Otherwise, CAAs find it difficult to gain access into the school setting and partner with schools productively.[17] The HeA partners minimally with schools, and does school-based outreach through fliers sent to school-based organizations that have contact with uninsured children.[18] Schools not only need to see the connection between health coverage and school performance, they also need to be connected to additional resources in order for them to be more engaged in outreach and enrollment. Access into schools is difficult when outreach and enrollment strategies are detached, and cannot be easily imbedded into the school’s own existing routine and structures.

The application process also posed a barrier to outreach and enrollment. Nearly all strategies require the assistance of CAAs to complete actual enrollment, revealing that the enrollment process for public coverage is difficult. EE also faced logistical challenges in the application process. Multiple levels of communication and information sharing were required between the district and the Medi-Cal county office, which created delays, complications, and added burden to existing school staff.[19] The lack of follow-up implemented into the strategies meant that there was no way of ensuring that children have access to providers and retain coverage after initial enrollment. Without follow-up in THK, access to providers and clinics can be a challenge to newly insured children in rural areas and counties without managed care.[20]

Finally, mixed immigration is a challenge that multiple strategies face in outreach and enrollment. Misconceptions about children’s eligibility and benefits payback posed as barriers that sometimes deterred families with mixed immigration statuses from pursuing public coverage for their children.

 Some Recommended Solutions

The following recommendations illustrate what I found to be the best transferrable practices that successfully reach, enroll, and retain children in health care, developed according to an assessment of effectiveness and efficiency. Effectiveness in this case is the ability to reach and enroll uninsured but eligible children in public health programs, as well as to provide follow-up to ensure they can access providers and retain coverage. Efficiency would be each policy’s ability to limit costs relative to benefits, with special consideration for the long-term sustainability of each strategy.

My first recommendation is to implement the CHAMP strategy. CHAMP’s wide-reaching marketing campaign and CAA-staffed call center is very effective in identifying uninsured children, determining their eligibility, following-up with families about documents and signature pages needed for enrollment, and completing families’ applications. CHAMP also has a comprehensive post-enrollment follow-up process to ensure children have access to care and families know how to reenroll. CHAMP is very efficient because the benefits of enrollment success outweigh the costs of the marketing campaign and the call center. The strategy is also sustainably funded by reimbursements from Medicaid Administrative Activities (MAA).

Utilizing SBHCs is another recommended practice for outreach and enrollment. SBHCs are moderately effective because they are uniquely positioned to conduct outreach and enrollment activities. They are already established resources on campus for health issues and have contact with and access to uninsured but eligible students. SBHCs involved in health outreach and enrollment have a comprehensive process that identifies the uninsured, provides uninsured families with education about health coverage options, individually assists families with enrollment with the help of CAAs, and connects families to providers. SBHCs are moderately efficient because the costs of outreach and enrollment activities are outweighed by the benefits of their success. Not only do students benefit, but families and the community often also have access to the services provided by SBHCs. However, SBHCs are less sustainable because they must complete complicated billing processes for reimbursements and their funding streams are often short-term, which prevents them from being very efficient.

My last recommendation is to incorporate health care questions into routine school paperwork. This best practice is an adoption of the EE and Enrollment Cards strategies, and is moderately effective because it reaches and identifies most or all uninsured students through existing school forms. The strategy is also successful at getting school buy-in because health care questions are strategically and easily incorporated into the school routines of enrollment forms and School Lunch Applications (SLAs). Modifying school forms for health outreach and enrollment is moderately efficient because the administrative, printing, and staff costs are outweighed by the benefits of their effectiveness, school buy-in, and minimal additional burden on existing school staff. However, steady funding streams and helpful assistance from foundations are required to make utilizing school forms for outreach and enrollment sustainable. Because such is needed but not always guaranteed, using school forms is only moderately efficient and not very efficient. Without steady funding and foundation support, EE experts from LAUSD report this strategy and its various levels of communication and information sharing required are time-consuming, inefficient, and burdensome.[21]

Conclusion

The five school-based strategies that I assess in this case study are: Express Enrollment, Teachers for Healthy Kids, School-Based Health Centers, family resource centers, and Children’s Health Access and Medi-Cal Program (CHAMP) in Los Angeles Unified School District (LAUSD). Additional strategies that are not school-based, but are utilized in schools and also included in the case study include: Certified Application Assistors and the Health-e-App. From my case analysis of these school-based child health outreach and enrollment programs, the common barriers that most strategies encounter are around funding, access into schools, the application process, follow-up, and mixed immigration.

My recommended transferrable outreach and enrollment strategies are: the CHAMP model of marketing and incorporating CAAs into school staff, utilizing SBHCs, and incorporating questions about health care into routine school paperwork. These strategies are effective in outreach, enrollment, and retention of children in public health coverage, while incorporating follow-up to ensure children have access to providers after enrollment. These strategies are also efficient, and their ability to be effective outweighs their costs of operation. They also have potential for long-term sustainability.

In light of recent developments regarding government subsidized health care, I would suggest using the listed recommendations to help parents navigate the new Health Insurance Marketplace. I would also add targeted outreach to the 2,236,001 children with pre-existing conditions that now have greater access to care, as well as awareness around immunization services that children are now eligible for. Through these recommended strategies, schools can be strategic partners to identify and enroll uninsured children into coverage and educate families on the options and services that are newly available to them.