What You Don't Know Can Hurt You: Leaving Welfare Doesn't Always Mean Giving Up Medicaid
From 1997 to 1999, staff at the Southern Institute on Children and Families (SICF) conducted a project designed to improve awareness among low-income families about benefits for which they are eligible, including Medicaid and child care.
During the project, staff:
- Conducted site visits to 17 southern states and the District of Columbia.
- Produced information outreach videos.
- Established a Web site.
- Convened several meetings on issues surrounding Medicaid eligibility.
- Provided technical assistance to states on implementing information outreach efforts.
The Southern Institute on Children and Families is a nonprofit public policy organization located in Columbia, S.C.
Key Findings and Recommendations
In their report on the project—Southern Regional Initiative to Improve Access to Benefits for Low Income Families With Children—project staff included the following findings:
- Many families do not understand that they may still be eligible for Medicaid benefits even if they are not receiving cash assistance.
- Federal rules may actually encourage families transitioning off welfare to apply for cash assistance in order to obtain transitional Medicaid coverage.
- While several states have implemented exemplary outreach initiatives to improve access to Medicaid and other benefits, most states have not done so.
Among the policy changes recommended by the project team were that states and communities:
- Design and implement aggressive outreach strategies to improve access to health coverage for children.
- Make the application process less burdensome for families, so more families could access these benefits.
- Do more to encourage employment among low-income families by assisting with child care and developing alternatives for people lacking transportation to jobs.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $497,250.
At the time the grant was made, The General Accounting Office estimated that 2.9 million children met the income requirements for Medicaid in 1996 but were not enrolled. In the southern states, this translates to an estimated 1.25 million children who were eligible but not enrolled. (See the Appendix.) Studies have confirmed that low-income families frequently seek to remain on or return to welfare in order to secure needed health benefits, particularly for children. Related studies have found that many low-income families are unaware that when they stop receiving welfare or federal Supplemental Security Income (SSI), they still may be eligible for Medicaid benefits.
The passage of the Welfare Reform Act of 1996, the attainment of more state options under Medicaid, and the enactment of the State Children's Health Insurance Program (SCHIP) in 1997, shifted authority over these benefit programs to the states and granted the states more flexibility in designing benefit eligibility and enrollment criteria and procedures. Insufficient attention and resources, however, have been devoted to the development of effective communication strategies to inform low-income families about available benefits. Several studies by SICF have shown that many families are not aware of government programs that can help provide health coverage for their children, assist them in paying for child care, and allow them to keep more of their income.
This project builds on previous SICF initiatives undertaken in cooperation with health and human services officials in North Carolina and Georgia. In these initiatives, SICF worked to develop brochures and other information outreach materials to convey positive messages about Medicaid, the federal earned-income tax credit (EITC), child care, food stamps, and child support enforcement benefits for low-income working families.
This grant from RWJF provided support to SICF for a project designed to improve awareness among low-income families about Medicaid, child care, and other benefits for which they are eligible. The goals of the grant were to:
- Identify policies and procedures in each state that present barriers to access for low-income families and to provide feedback to the states on policy and eligibility issues.
- Assist states in adapting information brochures for their own use and produce outreach videos to accompany them.
- Provide ongoing technical assistance to states, including establishing a Web site to promote awareness of information outreach strategies.
- Conduct a regional forum to foster a state and regional dialogue on improving access to benefits for low-income families with children.
In addition to RWJF funding, this project received a $7,500 grant from the Foundation for Child Development to support staff time and travel costs for site visits to Delaware and Kentucky.
During the grant period, SICF performed the following activities:
- Site Visits. Staff conducted site visits to the 17 southern states and the District of Columbia in cooperation with governors' offices and state health and human services officials. Four hundred forty-five people participated in the site visits. SICF-led discussions focused on outreach strategies to inform families about health coverage, child care and other benefits, and how to enroll, as well as eligibility policies related to Medicaid coverage and child care assistance. Later in the grant, SICF staff also conducted a site visit to Mayersville, Miss., a rural area, as part of its efforts to improve access to benefits.
- Regional Forum. SICF convened the Southern Regional Forum on Improving Access to Benefits for Families with Children in December 1997. The forum offered SICF an opportunity to share information gleaned from the state site visits and to promote dialogue on interagency and interdepartmental issues affecting low-income families. Some 120 people attended the forum, including state policy staffers, representatives of the National Governors Association, federal agencies (Administration for Children and Families and the Health Care Financing Administration [HCFA]), advocacy groups, and national policy researchers and foundation representatives. Five panels of state, federal, and private sector representatives provided information on:
- Supporting work through child care subsidies.
- Making health coverage available to working families.
- Implementing state and community outreach.
- Removing health coverage eligibility barriers.
- Searching for transportation solutions.
- Informational Brochures. Project personnel worked with states to adapt its three informational brochures. The number of states using at least one of SICF's informational brochures increased from 4 to 16 over the grant period; 10 states and the District of Columbia were using all three brochures. Louisiana adopted the brochures in 1999, after the end of the project, and is now using them.
- Videos. SICF produced four videos to be used by the states in conjunction with the information brochures. Two videos (English and Spanish versions) informed families and community organizations of available benefits; one video contained information for employers; and the final video was for state staff training. Results of a survey of state agencies indicated that the videos were less useful than the information brochures. Only three states were using the videos; two found them to be very useful, while one found them somewhat useful.
- Web site. SICF established a Web site that includes information about its current projects and data about the uninsured in the region. The site also describes promising outreach strategies and includes a number of special reports produced by SICF.
- Marketing and Communications. SICF held a Marketing and Communications meeting in Atlanta in August 1998, focusing on how to effectively inform low-income families about opportunities for child health coverage. Representatives from Arkansas, Florida, Georgia and Tennessee made presentations at the meeting. SICF posted a summary of this meeting on its Web site.
- Medicaid Eligibility Verification Issues. SICF held a Verification Issues Meeting in September 1998 to resolve problems and discuss issues surrounding Medicaid eligibility verification. Medicaid and/or Children's Health Insurance Program (CHIP) officials from 15 southern states and representatives of the regional and central HCFA offices attended. The meeting resulted in a report, The Burden of Proof: How Much is Too Much for Child Health Coverage?, which examined verification issues surrounding eligibility for Medicaid and the CHIP program.
- Reports. In addition to The Burden of Proof, SICF produced a report on the overall project—Southern Regional Initiative to Improve Access to Benefits for Low Income Families With Children—which addressed findings from the state site visits and offered recommendations for policy changes. The project team also completed a report on their site visit to Mayersville, Miss. (See the Bibliography.)
In its report on the project—Southern Regional Initiative to Improve Access to Benefits for Low Income Families With Children—SICF reported the following findings, which were based on its site visits to southern states:
- Many families do not understand that they do not have to receive cash assistance to receive Medicaid coverage. All states indicated that they would like to create a Medicaid eligibility system identical to the system for welfare, to eliminate the need for a separate eligibility determination for low-income families.
- Most states do not conduct an "asset test" for children. This test, which disallows assistance to income-eligible families with assets such as a savings account or an automobile, reduces the number of potential Medicaid recipients. In the south, only Arkansas and Texas use this determination.
- The major reason families lose transitional Medicaid (i.e., benefits provided to families who leave welfare due to increased earnings) is lack of compliance with reporting requirements. These reporting requirements are burdensome for families, employers, and eligibility agencies and, according to SICF, have little merit with regard to quality control. All states indicated that they would like to have the option to provide transitional Medicaid benefits for 12 months without interim reporting requirements.
- Federal law encourages some families to apply for welfare in order to obtain Medicaid coverage. Under the rule, families must actually receive cash assistance for at least three of the preceding six months in order to qualify for transitional Medicaid. All states indicated that they would like to have the option of eliminating this rule.
- Several states indicated a desire to be able to provide Medicaid benefits on a sliding income scale without having to go through what they consider an ordeal to obtain a federal Medicaid waiver.
- While some states (Arkansas, Georgia, South Carolina, Tennessee, West Virginia) have exemplary programs, outreach initiatives were not underway in most states.
- Insufficient funding for child care is a major problem that can and likely will undermine state welfare reform initiatives. Four states (Arkansas, Kentucky, Louisiana, Oklahoma) reported that child care assistance was not available to working poor families not on welfare.
- The need for effective transportation to employment is great and solutions have not been found.
SICF's report, Southern Regional Initiative to Improve Access to Benefits for Low Income Families With Children, was mailed to all site visit participants; state health and human services agency heads; HCFA staff; members of the House Commerce, Budget, and Ways and Means Committees; members of the Senate Finance, Budget, and Labor and Human Resources Committees; various foundations; as well as state and national organizations and federal agencies. Nearly 1,500 copies of this report were disseminated during the project period, and it continues to be requested. The project director made presentations on the initiative at a number of national and regional meetings, including the annual meeting of the American Academy of Pediatrics. Reports from the regional forum, the marketing and communications meeting, the verification issues meeting and the Mayersville site visit were also disseminated. All of the reports cited in the Bibliography are available on the SICF Web site.
AFTER THE GRANT
SICF now serves as the national program office for the RWJF national program Covering Kids®, which seeks to identify and enroll eligible low-income children into public and private coverage programs and to assure the continued enrollment of Medicaid-eligible children whose coverage may be disrupted by welfare reform. Simplification of enrollment and information outreach are primary goals of Covering Kids.
GRANT DETAILS & CONTACT INFORMATION
Improving Access to Health Benefits for Welfare and Low-Income Families in the South
Southern Institute on Children and Families, Inc. (Columbia, SC)
Dates: February 1997 to June 1999
Sarah C. Shuptrine
The Southern Region
District of Columbia
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Shuptrine SC, Grant VC and McKenzie GG. Southern Regional Initiative to Improve Access to Benefits for Low Income Families With Children. Columbia, SC: The Southern Institute on Children and Families, February 1998. 1,692 copies printed.
Shuptrine SC and Hartvigsen K. Report on Communication and Marketing Strategies Meeting. Columbia, SC: The Southern Institute on Children and Families, 1998. 35 copies printed.
Shuptrine SC and Hartvigsen K. The Burden of Proof: How Much is Too Much for Child Health Coverage? Columbia, SC: The Southern Institute on Children and Families, 1998. 1,000 copies printed.
Shuptrine SC. Mayersville, Mississippi: A Study on Improving Access to Benefits and Services for Low-Income Families in the Rural South. Columbia, SC: Southern Institute on Children and Families, June 1999. 200 copies printed.
Brochures and Fact Sheets
"Have You Heard About Benefits for Working Families?" The Southern Institute on Children and Families, 1995. Marketed and tailored for use by states, 19951998.
"Leaving Welfare for Work Isn't as Scary as it Seems." The Southern Institute on Children and Families, 1995. Marketed and tailored for use by states, 19951998.
"Employers Connecting Employees to Benefits for Low-Income Working Families." The Southern Institute on Children and Families, 1995. Marketed and tailored for use by states, 19951998.
"Survey Results of States Using the Southern Institute Information Outreach Brochures and Videos." The Southern Institute on Children and Families, fielded November 1998. 20 copies printed.
"Southern Regional Forum on Improving Access to Benefits for Families with Children," December 12, 1997, Charleston, S.C. Attended by 120 persons, including persons designated by each of the 17 governors, as well as designees from the District of Columbia. Other guests attending the forum included representatives of the National Governor's Association, Administration for Children and Families, Health Care Financing Administration, advocacy groups, national policy researchers, and foundation representatives. Three presentations and five panels.
- Mayor Unita Blackwell, "Opening Remarks."
- Sarah Shuptrine, "Forum Overview and Report of Site Visits."
- Sarah Shuptrine, "Summary of Follow-Up Actions."
- "Supporting Work Through Child Care Subsidies," Barbara Kamara (moderator), Stephanie Fanjul, Tom Jones, James Cosper, Steven Golightly.
- "Making Health Coverage Available to Working Families," Pam Leyhe (moderator), William Freeburn, Jana Leigh Key, Cornelia Gibbons, Keith Johnson, Deborah Giffin, and Richard Fenton.
- "Implementing State and Community Outreach," Alvin Collins (moderator), Rebecca W. Shoaf, Keith Johnson, Jack Frazier, and William Freeburn.
- "Removing Health Coverage Eligibility Barriers," Margaret Dunkle (moderator), Susan Woodbury, Peggy Peters, Gwen Powers, Deborah Giffin, and Roger Neptune.
- "Reaching for Transportation Solutions," Lee Alexander (moderator), Robert Goble, Jerry Ross, and Brian Menzies.
"Southern Institute on Children and Families Eligibility Verification Meeting," September 1516, 1998, Charleston, SC. Attended by 37 individuals from the 17 southern states and the District of Columbia and federal officials from central and regional offices. This meeting was an open discussion on the following topics: Income verification, resource verification, citizenship verification, age of child verification, and family composition verification as well as state suggestions for reducing verification requirements.
"Southern Institute on Children and Families Marketing and Communications Meeting, August 6, 1998, Atlanta. Attended by representatives from four states (Arkansas, Florida, Georgia, Tennessee) as well as representatives from various national organizations. The meeting focused on how to effectively inform low-income families about opportunities for child health coverage.
Presentations and Testimony
Sarah Shuptrine, "Outreach: Private and Public Sector Efforts That Work," at the National Institute for Health Care Management's Child Health Forum on Outreach, March 31, 1998, Washington.
Sarah Shuptrine, "Toward a National Child Health Care Policy: Potential and Promise," at the American Academy of Pediatrics, 1998 Spring Sessions, April 6, 1998, Atlanta.
Sarah Shuptrine, "Outreach to Low Income Uninsured Children and Effective Communication with Families," at the Federal Regions V and VII Children's Health: Improving Outreach Conference, April 9, 1998, Chicago.
Sarah Shuptrine, "Future of Outreach: A Call for Action," at the Health Care Financing Administration, April 14, 1998, Baltimore.
Sarah Shuptrine, at the Capitol Area Rural Health Roundtable Forum, April 29, 1998, Washington.
Sarah Shuptrine, "Children, Race and Poverty Action Strategy Meeting, Part III," at the Children's Defense Fund, May 5, 1998, Memphis.
Sarah Shuptrine, at the March of Dimes National Public Affairs Conference, May 31, 1998, Washington.
Sarah Shuptrine, "Future Directions in Child Care: Concerns, Challenges and Commitments," at the Administration on Children and Families, June 3, 1998, Atlanta.
Sarah Shuptrine, at the Casey Journalism Center for Children and Families Annual Conference, June 15, 1998, University of Maryland.
Sarah Shuptrine, "Building Healthy Partnerships: Supporting Community Based Outreach," June 18, 1998.
Sarah Shuptrine, "Health Insurance for Kids Who Lack It: An Update," at the Alliance for Health Reform, July 6, 1998, Washington.
Sarah Shuptrine, at the Annual Meeting of State Child Care Administrators, July 27, 1998, Washington.
Genny McKenzie, at the "Southern Institute on Children and Families Meeting on Child Health Coverage Communication and Marketing Strategies," August 6, 1998, Atlanta.
Sarah Shuptrine, at the Texas Association of Community Health Centers Fifteenth Annual Conference, October 26, 1998, Austin, TX.
Sarah Shuptrine, "Delivering on the Promise: What's Next in Children's Health," at a meeting cosponsored by the Children's Defense Fund, Families USA, and the National Association of Child Advocates, November 5, 1998, Washington.
Sarah Shuptrine, at the Grantmakers in Health Sixth Annual Washington Briefing, November 20, 1998, Washington.
World Wide Web Sites
www.thesoutherninstitute.org provides information about those states and regions where the Southern Institute's work is concentrated, its current projects and data on uninsured populations. Columbia, SC: Southern Institute on Children and Families.
Audio-Visuals and Computer Software
Information on Benefits for Low Income Working Families. Two 5-minute videos (in English and Spanish) for families and community organizations, one video for employers, and one video for state agencies/employees. Columbia, SC: Southern Institute on Children and Families, 1998.
Report prepared by: Rebecca M. Loew
Reviewed by: Patricia Patrizi
Reviewed by: Richard Camer
Program Officer: Michael Beachler
Program Officer: Judith Y. Whang