Profile: In-Depth Look at an Initiative that Is Making a Difference
Louisiana Conducts Effective Enrollment of Children, But Post-Hurricane Outlook Is Uncertain
Summary: Louisiana has significantly reduced the number of uninsured children in the state using a variety of measures. The state streamlined its enrollment and renewal process for public coverage and improved its ability to target families with children eligible for but not enrolled in Medicaid and LaCHIP (Louisiana's Children's Health Insurance Program). Its multi-pronged effort included partnering with schools, reaching out to businesses to target low-wage workers, and cross-referencing health coverage databases with other assistance programs and the Department of Labor. In the two years prior to Hurricane Katrina, more than 52,000 of about 77,000 eligible children were enrolled in public coverage. The outreach and enrollment structures put in place are now playing a crucial role in the aftermath of Hurricanes Katrina and Rita as the state struggles to address human, health, and economic crises and is forced to consider cutbacks in many programs.
The Issue
When Governor Blanco began her administration in Louisiana in January 2004, more than 77,000 children were eligible for public coverage, but uninsured. Blanco aimed to cut that number in half—a goal that the state has surpassed. In the 18 months prior to Hurricane Katrina, 52,229 previously uninsured children were enrolled in public coverage—resulting in 667,975 children covered either by LaCHIP (Louisiana's Children's Health Insurance Program) or Medicaid. This expansion in coverage has helped to bring the portion of uninsured children in the state to less than 10 percent of all children in the state, according to a survey to be released this month from Louisiana State University's Public Policy Research Lab.
Process of Change
Several factors contributed to Louisiana's success at enrolling a substantial number of uninsured children in a short period of time. First, LaCHIP was established as an expansion of Medicaid, rather than a separate program, making it easier to understand for potential recipients. Second, Medicaid and LaCHIP delegated staff members to be solely responsible for reaching out to potential enrollees, enabling them to focus on and gain expertise in this important task. Third, the governor made covering uninsured children a major goal of her administration, so there was strong political support.
Finally, in addition to state and federal Medicaid funding, Louisiana received funding and assistance for outreach from Covering Kids and Families (CKF), a national program of the Robert Wood Johnson Foundation (RWJ). There were two grants: one from RWJ in the amount of $500,000 over four years, with matching funds provided by local foundations, and one from the Covering Kids Initiative for $985,000 from April 1999 to August 2002. The CKF program aims to reduce the number of uninsured adults and children who are eligible for, but not enrolled in, Medicaid and the State Children's Health Insurance Program (SCHIP) through three strategies: outreach, simplification of enrollment and renewal, and coordination of existing health care coverage programs. CKF operates statewide projects in 45 states and the District of Columbia, as well as 140 local communities.
The Louisiana Covering Kids and Families program (CKF-LA) was designed as a community-based, coalition-driven project. Regional coordinators work with local communities, schools, and businesses and coordinate their activities with the state. Doctors, teachers and other school administrators, businesses, faith-based groups, community organizations, state and local agencies, federally qualified health centers, hospitals, and churches have formed coalitions to reach out to eligible families. For example, CKF-LA coalitions work with regional Medicaid offices to coordinate outreach events through local stores, schools, and church events. And many regions have been successful in engaging local media to help get the message out. CKF-LA activities are ongoing, and are especially needed in light of the hurricanes this past fall.
Linking with Schools
Perhaps Louisiana's most effective strategy for expanding enrollment of children in Medicaid and LaCHIP has been its collaboration with schools, part of CKF's "Back to School" campaign.
School Flyers
Starting in 1999, CKF-LA began sending flyers with information about Medicaid and LaCHIP eligibility, instructions on how to apply, and a toll-free number to call for assistance to school districts to be given to every student to take home. In 2002, the Louisiana Department of Health and Hospitals (DHH), the state Medicaid agency, took over the production of the flyer and expanded its distribution throughout the state. Currently sent to more than 900,000 public, private, and charter school students, the flyer includes an income eligibility chart, eligibility criteria, and a hotline number, as well as a reminder to renew for those already enrolled. It is sent along with the free and reduced price lunch application. The flyer has played a significant role in the state's Medicaid and LaCHIP enrollment gains.
Free and Reduced Lunch Database
Children in Louisiana who receive reduced price or free school lunches also meet eligibility requirements for Medicaid or LaCHIP. In the summer of 2005, the state legislature passed a bill requiring that schools share information about these children with the Medicaid agency. (To address privacy concerns, the free and reduced price lunch application form includes a box that parents can check if they prefer their child's name to be withheld from Medicaid.) Once Louisiana's Medicaid agency receives the list of children in the school lunch program, it cross-checks it with the Medicaid database to determine whether these children are enrolled in Medicaid or LaCHIP. If not, the agency contacts the families. The initiative is expected to be rolled out throughout the state by the fall of 2006.
Integrating Databases
In addition to coordinating with the lunch program, Louisiana has cross-referenced with other state databases to enhance enrollment and retention. LaCHIP and Medicaid are linked with the Food Stamps and Temporary Assistance for Needy Families enrollment databases, thus easing documentation requirements for families. The state also accesses the Department of Labor's Web site to check household incomes. Both of these measures have simplified the enrollment and renewal process and minimized the churning on and off of coverage that often occurs in public programs.
According to CKF-LA Communications Coordinator Nancy Buratto, "Louisiana Medicaid has left no stone unturned in their attempts to find and enroll all eligible children into LaCHIP. They have proactively addressed policy issues to reduced barriers for families to get and maintain coverage."
Working with the Business Community
CKF-LA regional coordinators focus their outreach efforts on businesses that either do not provide health benefits or provide coverage that is cost-prohibitive to workers. Such businesses tend to employ low-wage and uninsured workers, who may earn too much to be eligible for public programs but whose children may be eligible for Medicaid or LaCHIP (the eligibility threshold for children to enroll in LaCHIP is family income of 200% of the federal poverty level or less).
Regional coordinators establish relationships with business owners and managers, informing them their workers' children may be eligible for Medicaid and LaCHIP. Employers are encouraged to pass on this information to their employees through educational sessions, flyers inserted with pay stubs, or other measures. Since these efforts target uninsured workers, they generally result in covering children, rather than shifting coverage from private insurance to public programs.
In northeast Louisiana, Mike Walsworth, a state representative for an area known as the "Delta Parishes," which includes some of the poorest regions in the country with high rates of uninsurance, partnered with LaCHIP and the CKF-LA coalition. He invited area employers, managers, and human resources personnel to a "lunch and learn" session on health coverage and its benefits; the session was well attended and positively received.
Buratto notes that, "the state has welcomed partnerships to support their outreach efforts and the fruits of these labors is resulting in great benefits for Louisiana's families."
Post-Hurricane Response
Since Hurricane Katrina in August 2005, followed by Hurricane Rita in September, Medicaid outreach teams and CKF coalition partners have worked diligently to help families enroll, replace cards, and find providers. They have conducted outreach at disaster relief sites, grocery stores, churches, schools, and other atypical locations. On-site application assistance was made available at more than 200 shelters. The state's LaCHIP/Medicaid Web site has been enhanced to provide as much information as possible, including an application form, advice about enrolling in other states' Medicaid Katrina Disaster waiver programs, change of address cards, and instructions on how to get replacement cards. In addition, the Medicaid toll-free hotline extended hours and days of operation, allowed out-of-state calls, and upgraded their system to include four simultaneous operators.
A simplified Medicaid application was available within five days of Hurricane Katrina, as were change of address forms with prepaid postage. Applications were triaged and redistributed as needed to speed up processing. Eligibility verification was also waived. DHH coordinated with the Department of Education to train 150 agency representatives for outreach, and sent out a joint letter from the Superintendent of Education and the Secretary of Health to local school districts.
Challenges
While Louisiana has made great strides in enrolling uninsured children in Medicaid and LaCHIP, the state will be coping with the after-effects of the hurricanes in the coming months and years. In one respect, helping so many eligible children gain coverage in the past few years should help ensure that these children will be able to retain their coverage wherever they go. However, locating those families for renewal notices will be difficult, as homes and entire neighborhoods were destroyed.
What's more, the damage to the state—in human and financial terms—has been severe. In certain areas, the entire health care infrastructure has been badly damaged, or even destroyed. Significant funds will be required to rebuild the system to ensure access to needed medical services for the insured and uninsured alike. There have been numerous proposals for federal assistance (e.g., "disaster relief Medicaid," section 1115 waivers, heavily subsidized tax credits), but they have not been passed or have not offered significant relief to the state. In early November, the secretary of DHH announced that the department must plan for a 6% to 7% across-the-board cut in Medicaid payments to providers, and the state commissioner of administration recommended cutting Medicaid spending by nearly $300 million, in case federal help is not received. DHH estimated that 108,000 low-income children and 2,500 low-income pregnant women could lose coverage if these cuts go through—turning back the great successes in enrollment achieved in recent years.
On November 10, the Centers for Medicare and Medicaid Services (CMS) reached an agreement with Louisiana to grant a waiver related to Hurricane Katrina. This waiver allows the state to access an uncompensated care fund to help pay health care providers who gave emergency medical treatment to Katrina survivors. This waiver covers services not covered by Louisiana Medicaid, such as additional mental health services as well as prescriptions and medical equipment for those not eligible for Medicaid, primarily adults without children. The waiver also allows Louisiana to grant temporary enrollment in Medicaid for up to five months to evacuees ages 19 and under and their parents, pregnant women, individuals with disabilities, low-income Medicare beneficiaries, and those who need long-term care and meet certain income requirements. They will be required to complete a simplified application form declaring their income and assets, if any, and will not be charged any out-of-pocket costs during the temporary enrollment. They will receive the standard Louisiana Medicaid benefit package, and can apply for Medicaid or SCHIP with normal eligibility rules once the temporary enrollment period ends on January 31, 2006. It remains to be seen if this waiver will be able to help the state maintain its progress in covering uninsured children.
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