California has two state-organized public health insurance programs for children in low-to-moderate income families: Medi-Cal, California's Medicaid program, and Healthy Families, California's Children's Health Insurance Program. Medi-Cal covers 3.4 million children, and Healthy Families covers 875,000 (Cousineau and Hughes 2009
). Most children in families with low or moderate household incomes qualify for Medi-Cal or Healthy Families. Those ineligible are in families with incomes higher than 250 percent of the federal poverty level (FPL), or are not U.S. citizens or legal residents. To expand coverage to these children (with an upper income limit equal to 300 percent of FPL), 26 counties organized a third program called Healthy Kids, which are financed by public and private sources but with no state or federal participation. Healthy Kids programs provide comprehensive health benefits modeled after the Healthy Families program. Counties or multicounty regions independently operate Healthy Kids programs (Stevens, Rice, and Cousineau 2007
). Separate agencies using distinct enrollment data management systems administer the three public insurance programs in California.
The percent of children uninsured in California declined from 10 percent in 2001 to <7 percent in 2007. This occurred even though employment-based coverage for children similarly declined during this period. Declines in private coverage were offset by increases in enrollment in the three public programs. By 2007, an estimated 683,000 children did not have coverage in California; more than half of these children were not enrolled but eligible for Medi-Cal, Healthy Families, or Healthy Kids (Brown et al. 2009
). To increase coverage of low and moderate income children, many California counties organized Children's Health Initiatives (CHIs). CHIs are coalitions formed to oversee the development of the Healthy Kids insurance products but also to coordinate state and private funding for outreach and enrollment activities. Their efforts like those elsewhere in the nation have led to innovative approaches for outreach designed to identify uninsured children, assist them in enrollment, retain their coverage, and obtain needed health care services after enrollment (Vistnes and Schone 2008
). These programs showed early success in enrolling children and improving access to health care services (Howell and Trenholm 2007
; Hill et al. 2008
;). Across California, the breadth of outreach has increased dramatically in the past 10 years, including the number of enrollment strategies. Counties now are using multiple strategies to identify and enroll eligible children into public health insurance programs and subsequently monitor their use of health care services (Cousineau, Stevens, and Farias 2009
Increasing use of outreach and enrollment strategies has prompted policy makers, philanthropic organizations, and others to question the efficacy of some strategies. Several studies have described outreach and enrollment approaches (Barents Group LLC 2000
; Castaneda et al. 2003
; Cousineau 2006
;). However, little is known about the comparative effectiveness of different strategies or the impact of a multiple-strategic approach on enrollment.
Administrative data systems are limited in their ability to provide accurate information and gauge the effectiveness of different strategies. There are counties with information collected in local databases related to how people heard about the program, for example, but these efforts are not comprehensive. They often miss children who enroll in programs outside the outreach and enrollment system. Furthermore, enrollment data are not linked to outreach strategies, so it is not conclusively known which outreach strategy may have led to an enrollment.
In this paper, we attempt to fill the gap in evidence by linking enrollments in a county with data specifying whether each of eight strategies was deployed in a particular county. Outreach and enrollment strategies include technology-based and non-technology-based approaches. The latter includes media campaigns and provider in-reach. Counties use media campaigns (radio, newspaper/magazines, television, and billboards) designed to disseminate a central message and promote awareness of the health insurance programs. Counties also train and deploy community health workers or Promotoras de Salud as part of their outreach campaigns. These individuals live or work in the community and are linguistically and culturally compatible with the targeted uninsured and low-income population. In addition, many community health workers complete training to become knowledgeable about various health insurance programs. Provider or clinical in-reach target individuals who are already known by the agency or program. For example, patients in a clinic would be approached and asked to enroll. Another strategy uses school resources to identify and enroll children and families into health programs. This includes expresslane enrollment
(Horner, Morrow, and Lazarus 2003
) as well as conducting outreach and enrollment events in conjunction with parent nights and athletic events, using school nurses and counselors, and establishing partnerships between schools and community-based organizations. Matching potentially eligible children against lists of those enrolled in other public programs is the final non-technology-based strategy.
Three technology-based approaches were also assessed: Health-e-App, One-e-App, and county data systems. Health-e-App is a state online system that expedites enrollment after a person is identified as potentially eligible for Medi-Cal or Healthy Families. One-e-App offers a more comprehensive online screening and application program. Through a set of queries, One-e-App categorizes an individual into one or more health and other social programs based on a program's eligibility criteria. One-e-App cuts time between when a person applies and when he or she is actually determined to be eligible and enrolled in a program (The Lewin Group 2009
). With some exceptions, online systems are available only to Certified Application Assisters (CAAs), individuals who complete special training certifying them as eligible to submit an enrollment application on behalf of people eligible for applying. Individuals are generally not able to access the electronic enrollment systems. This is true for both One-e-App and Health-e-App. Where available, One-e-App applications for Medi-Cal and Healthy Families are submitted electronically to the state through the Health-e-App portal; there is no direct line from One-e-App to the state's single point of entry, which is the mechanism for the state to receive applications for these programs. In some counties, One-e-App does have a direct link for locally organized Healthy Kids programs, but this also requires a CAA to formally submit the application on behalf of the client. Finally, some counties have developed their own data systems that help outreach workers track enrollments, follow up with clients, initiate reminders for renewals, and record their contacts with families. See Appendix SA2
for a complete list of strategies.