Although Congress has never been able to agree on legislation that would provide insurance coverage to all, or virtually all, Americans, it has been able to enact laws that provide piecemeal coverage. Medicare, passed in 1965, covers 44 million people over 65 and those of any age with disabilities. Medicaid, also passed in 1965, covers the medical care of 59 million low-income people. The State Children’s Health Insurance Program (SCHIP), passed in 1997, covers 6 million children from low-income families. SCHIP became something of a political football in 2007: it was extended in 2008 only after President George W. Bush vetoed two bipartisan bills to expand the program and after the Department of Health and Human Services had issued a regulation that made it difficult for states to raise eligibility limits.
Passage of a law making coverage available is not enough; six out of every 10 uninsured children are eligible for Medicaid or SCHIP coverage but are not enrolled. There are many reasons that individuals and families do not take advantage of health insurance benefits to which they are entitled. Probably the most common is that they are simply not aware that they or their children might be eligible. But even when families do recognize their eligibility and try to sign up, they face significant barriers. Forms are often long and complicated; eligibility requirements vary among programs and change frequently; documentation requirements can be onerous; legal immigrants face both language and cultural problems; and intake workers, concerned about fraud, can make the enrollment process difficult. Once enrolled, benefits last only for a limited period of time before eligible people have to go through the whole enrollment process again. Moreover, the greater the number of people enrolled in Medicaid and SCHIP, the greater the strain on state budgets, giving state governments an incentive to keep enrollment low, especially in hard economic times.
Since 1997, the Robert Wood Johnson Foundation has made substantial investments in a variety of programs to make families aware that their children might be eligible for SCHIP or Medicaid benefits and to address the practical obstacles to enrollment and renewal. In this chapter, the journalist Irene Wielawski, who is a frequent contributor to the Robert Wood Johnson Foundation Anthology series, examines the major Foundation-funded programs with this focus. Through her visits to two sites, she offers an on-the-ground look at the way different locales have worked to enroll eligible people and what the programs have and—not surprisingly, given the many practical challenges to enrollment—have not accomplished.