The Rural Work Group of the Interagency Task Force on Children's Health Insurance Outreach

As of February 9, 1999, the Health Care Financing Administration (HCFA) has approved the Children Health Insurance Program (CHIP) plans of fifty states, territories, and the District of Colombia. In addition, eighteen states have submitted amendments to their CHIP plans to HCFA. A year into the implementation of the largest increase in federal funding for children's health insurance since Congress passed Medicaid in 1965, attention has shifted from states rushing to pull plans together to states working to enroll children in their new programs.

It is now time to enroll as many of the estimated 11 million uninsured children as possible into public health insurance programs. The movement of parents from welfare to work and the delinking of Medicaid and welfare benefits highlight the role of health insurance for children as an important factor in enabling a family to move to self-sufficiency. In addition, CHIP serves as a catalyst for increased efforts to enroll children in Medicaid as well as CHIP, since CHIP requires screening for Medicaid eligibility before a child can be enrolled in CHIP.

Some populations of American children are receiving greater attention in our outreach efforts due to higher rates of poverty and lower rates of insurance, specific barriers that make mainstream outreach efforts less effective, and disenfranchisement from the health care system in general. Hispanic children have the lowest rate of insurance of all racial and ethnic minority groups (US Census 1998). The low rate of coverage is attributed to factors such as a lack of Spanish language outreach and the concern that involvement in a government program may lead to immigration problems for family members. Similarly, African American and Native American children have higher rates of poverty than the national average, and cultural barriers can hamper attempts to enroll both populations. Native American children may be missed due to a lack of coordination between state and tribal health care programs. In addition, transient lifestyles make migrant and homeless children hard to locate and track.

Rural and frontier populations are often left out of conversations of specially targeted populations. According to the Medical Expenditure Panel Survey data for the first half of 1996, 27.9% of uninsured children, approximately 3.1 million children, live in rural or frontier areas (NGA 1998). Furthermore, rural children are more likely to be uninsured than their urban counter parts. Twenty-one percent of rural children are without insurance, versus 14% of children in urban areas (Dunbar 1998). The Urban Institute estimates that 1.7 million of these children live below 200 percent of poverty making them likely to be eligible for CHIP or Medicaid.

WHY FOCUS ON RURAL CHILDREN?

Rural areas are not just small urban enclaves in which mainstream outreach efforts can be downsized and effectively implemented without translation. The rural context, while containing some of the same elements as the urban context, is different and warrants focused attention. While rural areas are extremely diverse, there are some generalizations that can be made about rural demographics and infrastructure that help to place outreach in rural areas in the appropriate context.

Rural areas have higher rates of poverty than urban areas. In 1997, non-metro counties had a 15.9% poverty rate compared to 12.6% for metro counties (US Commerce 1998). This higher rate of poverty can partially be attributed to a higher reliance on minimum wage jobs and service sector employment in rural areas.

While rural economies are no longer exclusively dependent on farming, rural areas still have a higher percentage of small business economies than urban areas (Besser 1998 cited in the RUPRI Welfare Reform Panel 1999). Low wages and smaller business size in rural areas also mean that rural residents have lower rates of employer sponsored health insurance coverage. 51.7% of rural employees are covered by employer health plans compared to 60.4% coverage in urban areas (Coburn 1998). Lower rates of employee sponsored insurance contributes greatly to the lower rate of insurance for rural children. Therefore, partnering with small rural businesses may prove an effective strategy in CHIP and Medicaid outreach.

In addition, Rural communities have less health and social services infrastructure. Most rural areas have a lack of health care providers. Most rural and frontier areas have primary care to provider ratios of 1 to 3,500 or higher. The US Department of Health and Human Services describes an "adequately served population" as having a ratio of 1 to 2000.

Moreover, the providers and clinics that provide care in rural areas often lack the resources available in many urban areas. For example, a 1990 law mandated that federally funded health centers maintain Medicaid eligibility outstation programs. A 1998 study found that small centers in rural areas, due to smaller staffs, less revenue, and fewer resources, were less likely to engage in outstationing activities than larger centers, mainly found in ur ban areas (Rosenbaum 1998). Similarly, since social services infrastructure is smaller in rural areas than in urban areas, adding extra functions like outstationing of workers, benefit counseling, and coordination between programs is more difficult. Lack of infrastructure does not equate to a lack of need. Researchers also found that when these smaller centers undertake outreach activities they significantly increased the uptake rate for Medicaid in their communities.

The characteristics of rural communities also may suggest subtle differences in outreach strategies. For example, rural welfare recipients are more likely to be employed and married than urban recipients (The RUPRI Welfare Reform Panel 1999). Rural communities are smaller communities in which residents are more familiar with each other than in urban areas. This familiarity is often coupled with a distrust of outsiders and newcomers. Many rural communities also have strong religious values and have strong connections with their local churches. Rural areas also have a large elderly population. These respected elders provide much of the childcare in rural areas, and may serve as a special target for rural outreach.

Despite these commonalities, rural communities are extremely diverse. A rural population in the low country of South Carolina looks nothing like a border community in New Mexico, which bears little resemblance to a frontier county in Montana or a farming town in Iowa. Different regions of the country have varying rates of insurance. For example, the south has traditionally had the largest uninsured population (RUPRI 1993). Many rural communities face specific outreach challenges associated with ethnic minorities and transients. Border areas and many other rural communities have high numbers of Hispanic residents. Many rural areas also deal with migrant and seasonal workers. In designing outreach strategies in rural areas, it is important to focus on the local rural culture.

ENROLLING RURAL CHILDREN FOR HEALTH INSURANCE

It is this rural context that outreach efforts need to focus on reaching rural children. A United States General Accounting Office report in March 1998 discussed general reasons why children may not be enrolled in Medicaid or CHIP (US GAO 1998). The working poor may not realize they are eligible. The delinking of Medicaid and cash assistance also has created confusion for families and service providers. Outreach efforts will also have to deal with cultural misunderstanding, language barriers, and the negative perception of dependency. Efforts will also have to be made to simplify and explain the cumbersome and confusing enrollment process and health system.

These factors are important in both urban and rural communities, but may prove to be especially important in rural areas. For example, in rural areas a higher percentage of the poor work and may not realize they are eligible. Due to higher rates of poverty, a higher percentage of rural residents were on Medicaid when welfare reform began, suggesting there is more opportunity for confusion from the delinking of Medicaid and welfare in rural areas (Frenzen 1996). Rural culture may also suggest subtle differences in outreach strategies.

These factors, compounded by sparse rural populations and less health infrastructure, suggest that outreach efforts in rural areas may require more effort, more time, and a higher initial investment. While it is too early in the CHIP implementation process for a complete evaluation of rural outreach efforts, there are lessons that can be learned from "rural" states that have had some success in reaching children. We also can learn from efforts in Medicaid outreach that proceeded CHIP. There are also lessons from CHIP outreach success stories in rural communities.

What is happening in rural states?

North Carolina and Utah are two "rural" states that have had success in enrolling children in CHIP. Outreach in these states has focused more on community level coalitions and enrollment strategies and less on marketing through mass media outlets. While the states have had success in enrolling rural children, enrolling the harder to reach rural children in frontier areas and other disenfranchised communities may still prove to be a significant challenge. More attention and research into rural enrollment practices and statistics will help to shed light on the areas most in need.

North Carolina

NC Health Choice for Children, North Carolina's CHIP program, offers an instructive lesson for states with significant rural populations. The state plan was developed in consultation with their State Office of Rural Health and Resource Development. Overall, the enrollment results have been positive. As of December 1998, 11,663 of an estimated 71,000 eligible children have been enrolled in the program. Another 10,743 children have been enrolled in Medicaid.

County level coalitions have worked together to promote the program with brochures, posters, and envelope stuffers. In Avery County, for example, outreach workers went to the three major employers, a textile mill, a health care products manufacturer, and a hospital to spread the word about the program. The coalition also targeted the school system. A brochure was sent home with every school child. Teachers in elementary and middle school verified that parents had received the brochure by having students return signed sheets, and high school teachers followed up at parent teacher conferences. These efforts lead to the enrollment of 140 of 192 eligible children.

However, there are concerns that the harder to reach rural children are still being missed. While sixteen percent of eligible North Carolinian children have been enrolled, only seven percent of the most needy rural children, children living in areas with federally funded migrant and community health centers, have been enrolled thus far. For example, in rural Halifax County, only 45 of 707 eligible children have been enrolled, and in rural Henderson County, only 98 of 805 eligible children have been enrolled.

Utah

Utah created a stand-alone CHIP program that has used approximately 100 eligibility stations located across the state to get the word out about the program. Outreach workers attended preliminary training sessions and then visited community events, like back-to-school nights and PTA meetings, to talk to parents about signing up for the program.

There are an estimated 30,000 children eligible for Utah's CHIP program. As of January 22, 1999, the state had enrolled 2,329 kids in rural areas and 4,849 in urban areas in a state where eighty percent of the population lives in the four county area near Salt Lake City and the Wasatch Mountains. Enrollment is on track despite the fact the state has yet to start a statewide media campaign on TV or radio. The success has come from grassroots efforts to inform, educate, and enroll. The state has encouraged eligibility workers to get out of the office and get engaged in the community. In addition, the state is currently reducing its application from four pages to two pages.

A lesson from the past

ABC for Health, Inc. in Wisconsin

In Balsam Lake, Wisconsin, ABC for Health Inc. developed an outreach model that has been successful in increasing Medicaid enrollment. Since 1988, the project has used family health benefit counselors at local health departments to assist clients in enrolling in public assistance on a family-by-family basis. In 1998, the project began to focus on children's health insurance programs, and has since expanded to 17 counties in northwestern Wisconsin. The counties share information on available programs, rules, and regulations. These counselors do not just enroll children; they also review applications, assist clients when they have been denied coverage, and provide guidance for hearings and appeals. Public health nurses refer families to the counselors, and a small team of public interest lawyers and law students provides technical assistance to the counselors and families.

The program's success is linked to the dedication of resources by health clinics and health departments. Health clinics have found that the program is only beneficial when they can dedicate enough staff support to the effort. After eighteen months, one clinic found a 46% increase in third-party payment. Project Director Michael Rust says "the clinic administrators told us that we gave them a new outlook on working with the community. They said 'We'll do anything we can because we discovered it's to the family's benefit and it's to the clinics financial benefit.'"

Investments in infrastructure will be key to outreach success in rural areas. ABC for Health Inc. worked with state officials to release $1 million of its Medicaid outreach funding to state health departments for benefits counseling, and is the lead agency in carrying out the state's grant from the Robert Wood Johnson's "Covering Kids Initiative."

Two CHIP success stories in rural communities

AHEC Community Partners in Massachusetts

In Massachusetts, AHEC/Community Partners has achieved some success in CHIP outreach by adopting a community-specific approach. The project, initially funded by an Outreach Grant from the Federal Office of Rural Health Policy (ORHP), originally focused on Medicaid enrollment in rural areas. That project provided three outreach sites and outreach workers to 26 communities. The project has since been chosen as on of 52 community organizations to earn a state contract to enroll people in Medicaid and CHIP. The project organized regional meetings around the state to pull in 150 community organizations for working on health care access. It then developed a network of workers, some paid, some volunteer, to spread the word.

The project organizers identified a key set of lessons learned from their experiences. The most important lesson is "know the community." It is a good idea to hire people from the community who know where to go to find children and how to work with local people. For example, in the western part of the state, project organizers were having trouble enrolling children. They were having particular problems with fathers who did not want to sign on to what was perceived as a charity program. As a result, the workers targeted the dads by recruiting at the dump and raffling off a chain saw for those individuals who filled out insurance application.

B4 Babies and Beyond in Mesa CountyColorado

In Mesa County, Colorado, B4 Babies and Beyond, also funded by an outreach grant from ORHP, has conducted enrollment and outreach activities for programs such as Medicaid for the past three years. The project has recently expanded its activities to include CHIP outreach. The project's goals are to:

1) Work through schools, health fairs, and day care centers to spread the word about state benefit programs such as Medicaid and CHIP

2) Help families with the application process

3) Allocate indigent care around county provider base

4) Provide bi-cultural staff to help with a large Hispanic population.

The project organizers have found that the program offers a model for enrolling kids in the state's CHIP plan, the Children's Health Plan (CHP). The B4 Babies program has submitted applications for 1,273 Mesa County residents. After the project enrollment workers receive an application from a family, they fill out the information on a web site form that gives them an idea of where the loopholes might be in an application. The B4 Babies program has an 85-90 percent approval on its applications.

Project organizers found that traditional outreach activities got the word out about CHP, but did not necessarily translate into families filling out applications. For example, project workers spent six to eight hours at school functions but only enrolled three children during that time.

In rural areas trust and familiarity can play a large part in success or failure of outreach strategies. The B4 Babies program found they were successful when they relied on their regular role in the community, acting as a go between for the families in the community and the health system. "Because of the large number of families who have come through our program, we have built up a trust through the B4 Babies program. Trust is a big factor in the success of the program. "They may not know CHP but they know to come back to us for health care," says Linda Roper, the project coordinator. "That is why we've been successful with so little outreach. They know they're going to get care. We don't do anything medical here. We're a neutral site in the county. We don't represent the hospitals, the health department, or the clinics."

There is a lot to learn about outreach in rural areas, but there are some lessons to take from past experience. While outreach has to be carried out on multiple levels, local outreach is by far the most successful approach in rural areas. Although there has been some success enrolling rural children, we have to work harder to get to the hardest to reach rural populations. When searching out these children, resource investments may need to be made to improve social services infrastructure. We have to study how to invest these resources so the investment pays off in the long run.

Furthermore, there is no substitute for community work and skilled outreach workers who can provide assistance with the application process. Trust is a big factor in rural communities, and finding established entities within the community to work with is essential. We also know that information dissemination is only part of the solution. Help with the application process and effective follow-up are necessary to enroll more children.

A SPECIAL CONCERN: LINKING OUTREACH, ENROLLMENT, AND ACCESS

Outreach, however, is not just one thing but rather can be thought of as a continuum. In this conceptual model, the process begins with: 1) identifying and making contact with the target population; then 2) providing assistance to facilitate the enrollment procedure from application through verification and acceptance; 3) assuring that newly insured children are matched with an accessible medical, or health, home; and 4) monitoring the utilization of appropriate quality services, with a focus on preventive and primary care. (ASTHO 1998)

While the proceeding statement addresses enrollment of children in CHIP and Medicaid across the entire country, it especially rings true for children living in rural areas. The precarious state of rural health systems means that special attention needs to be spent in assuring that once a rural child enrolls in a health insurance program the child has access to a health professional.

Rural communities often have few choices when it comes to primary care providers. For the enrollment of children in CHIP and Medicaid to lead to improved health outcomes, the health professionals that currently reside in rural areas will need to participate. With many states turning to managed care as a way of increasing eligibility, it is important that these managed care programs include rural providers. It will not help a child to be insured if the only doctor that can treat him or her is 50 miles away.

It is also important to ensure that federally funded community and migrant health centers, rural health clinics, and other rural safety net providers are integrated into the CHIP program, as they may be the only health care providers in many rural areas. There needs to be flexibility in programs to allow communities to develop local strategies that reach across provider groups. Caution needs to be taken to make sure there is a provider in an area that can cover newly enrolled children. Families who find themselves insured, but without a provider, can become further disenchanted with the health care system.

Rural families will also need help accessing the health care system. Basic assumptions made by the health care system may not be true in some rural areas. For example, some poor rural families do not have phones. Transportation problems in rural areas are severe because of a lack of public transportation and farther distances to travel to get to a medical facility. Training outreach workers in rural communities that can help families enroll children in programs, and then work with families to help them access the system can help to alleviate some of these problems.

CONCLUSION

Although a strong case can be made for the need to focus on rural communities, the rural context is not completely unique and distinct from the urban setting. To the contrary, the similarities between the two settings are striking and a lot will be gained by sharing experiences between both settings. Rural areas and urban areas face many of the same problems, but many times rural communities experience these problems in different degrees or with a different spin. In addition, there are some issues that are unique to rural communities. These special characteristics should be kept in mind in CHIP outreach and implementation.

It is too early in the CHIP implementation process to say how well the program is penetrating rural areas, but it is not too early to focus on ensuring that rural children are enrolled. In many states, enrollment in rural areas can be the difference between meeting or falling short of stated enrollment goals. Furthermore, since the real goal is to raise the health status of America's children, rural children will need to have health insurance and see health professionals regularly.

For their part, the federal government, state governments, and their private sector partners are focusing more attention on rural outreach. For example, the Federal Office of Rural Health Policy provides funding for both Outreach and Network Development grants to support rural health care service and delivery. Last year, in an informal survey of network and outreach grantees, 26 grantees responded that they were involved in varying degrees of children's health insurance outreach activities.

While outreach grants do not only apply to CHIP and Medicaid outreach, ORHP is increasing the number of grantees and the total funding for 1999. Last year, ORHP made 13 awards for a total of $2 million. In 1999, ORHP plans to give grants to 40 to 50 grantees for a total of $8 million dollars.

ORHP also provides matching funds for fifty state offices of rural health. These state offices, through the National Organization of State Offices of Rural Health, have organized a subcommittee to focus on rural CHIP efforts. As more state plans and amendments are implemented this year, it is likely more of these offices will take an active role in promoting CHIP in rural areas in their states.

At the state level, state rural development councils (SRDCs) have been involved in promoting and working on CHIP through out their states. As part of the National Rural Development Partnership (NRDP), SRDCs take a broader view of rural development, and can use their wide range of local, state, and private partners to get out the word about the CHIP program. The Health Care Systemic Change Initiative, the NRDP's Health Care Task Force, has been working with SRDCs to promote CHIP in rural areas in their states.

A private sector example is the Robert Wood Johnson Foundation's "Covering Kids: A National Health Access Initiative for Low-Income, Uninsured Children" which will eventually provide $47 million in outreach money to all 50 states. Although this project is still in its early stages, 20 states have already identified their community based pilot projects, and some are targeting hard-to-reach rural areas. There are 19 rural community based projects in nine of the states. For instance, in Alaska, one community group in the sparsely populated Matanuska-Susitna borough (1.6 persons per square mile) is pilot testing electronic filing and transmission of a simplified application, eligibility determination and enrollment process. The other projects are incorporating a variety of traditional outreach projects such as multi-lingual outreach workers, presumptive eligibility, use of lay health workers, information dissemination and outstationed eligibility workers.

As more people realize the importance of targeting rural communities, we need to continue to gather information and enhance our monitoring of rural rates of insurance and CHIP enrollment. We also have to gather and evaluate best practices that speak to the rural context. Rural outreach will play an important role in the success of the CHIP program.

Works Cited

Association of State and Territorial Health Officials (ASTHO) (1998). ASTHO Access Brief IV Children's Health Insurance Implementation: Outreach and Enrollment Overview. Washington, DC: Association of State and Territorial Health Officials.
http://www.astho.org/html/astho_access_brief_iv.html

Besser, Terry. (1998) "Employment in Small Towns." Rural Development Perspectives. Vol. 13(2): 31-39.
http://www.econ.ag.gov/epubs/pdf/rdp/rdp698/rdp698e.pdf

Coburn et al. (1998) "Urban-Rural Differences in Employer-Based Health Insurance Coverage of Workers." Medical Care Research and Review. Vol. 55 (4): 484-496.

Dunbar and Mueller. (January 1998) Anticipating the 1997 State Children's Health Insurance Program: What's Current in Five States? Bethesda, MD: The Project HOPE Walsh Center for Rural Health Analysis.
http://www.projhope.org/CHA/rural/kids.pdf

Frenzen (1996). The Medicare and Medicaid Programs in Rural America: A Profile of Program Beneficiaries and Health Care Providers. Washington, DC: US Department of Agriculture, Economic Research Service, Rural Economy Division. (Number 9604).

National Governors Association. (September 29, 1998). State Challenges and Opportunities in Rural and Frontier Health Care Delivery. Washington, DC: National Governors Association Center for Best Practices.
http://nga.org/Pubs/IssueBriefs/1998/980929RuralHealth.asp

Rosenbaum et al. (February1998) Initial Findings from a Nation Wide Study of Outstationed Medicaid Enrollment Programs at Federally Qualified Health Centers: Implications for Low-Income Children Under Welfare Reform and CHIP. Washington, DC: Center for Health Policy Research, The George Washington University Medical Center.
http://www.gwumc.edu/chpr/oe/oereport.htm

Rural Policy Research Institute (RUPRI) (1993) "Health Insurance in Rural America" Policy Research Summary. Columbia, MO: Rural Policy Research Institute, University of Missouri.

The RUPRI Rural Welfare Reform Panel (1999). Rural America and Welfare Reform: An Overview Assessment. Columbia, MO: Rural Policy Research Institute.
http://www.rupri.org/welfare/p99-3/index.html

U.S. Census Bureau. (1998). Who Goes Without Health Insurance? Health Insurance Coverage: 1996. Washington, DC: U.S. Department of Commerce, Economic and Statistics Administration.

U.S. Department of Commerce. (1998). Poverty In the United States: 1997. Washington, DC: Bureau of the Census, Current Populations Reports.

U.S. General Accounting Office (U.S. GAO). (1998). Medicaid: Demographics of Nonenrolled Children Suggest State Outreach Strategies. Washington, DC: U.S. General Accounting Office (GAO/ HEHS-98-93).
http://www.gao.gov/AIndexFY98/abstracts/he98093.htm

Rural Work Group of the Interagency Task Force on Children's Health Insurance Outreach

Convened by the Federal Office of Rural Health Policy
Dr. Wayne Myers, Director

Members

US Department of Agriculture
James C. Alsop
Larry Bryant
Clara French
Anna Mae Kobbe
Ruth Ann Morrison
Gladys Rodriguez

US Department of Education
Doris Sligh

US Department of Health and Human Services
Duiona Baker
Marcia Brand
Jim Gatz
Lillian Gibbons
LaVerne Green
Kim Harold
Jamal Harris
Dianne McSwain
Tom Morris
Judy Rodgers

US Department of Justice
Lisa Graves

US Department Of Labor
Nayda Cruz Lopez
Ann Ochsendorf
Felecia Turner Barnett