November 2006

Grant Results

National Program

Supporting Families After Welfare Reform: Access to Medicaid, SCHIP and Food Stamps

SUMMARY

From 2002 to 2004, the San Bernardino County Human Services System sought to increase the number of individuals and families receiving Medicaid by 15 percent and State Children's Health Insurance Program (SCHIP) benefits by:

  • Analyzing the reasons that eligible families were not enrolled in Medicaid or the SCHIP.
  • Developing short tests of strategies to address enrollment problems caused by county practices.
  • Reducing the percentage of renewal requests that were returned with incomplete information.
  • Increasing the percentage of denied welfare applications that were referred for separate Medicaid determinations.

The project was part of the Robert Wood Johnson Foundation (RWJF) Supporting Families After Welfare Reform: Access to Medicaid, SCHIP and Food Stamps national program.

Key Results
Over the course of the project, the county agency:

  • Reduced the percentage of denied welfare cases not referred for Medicaid-only eligibility determination from 25 percent to 13 percent.
  • Achieved a ten percent higher quiz pass rate for people who attended the Lunch and Learn lunch hour training session (held for employees at local business sites) than for those who did not.
  • Received 30 percent more applications or re-evaluations that were ready to process from families who got envelope reminder notices than from families who did not.
  • As of September 2004, increased Medicaid enrollment in San Bernardino County by nearly 24 percent, and increased enrollment in SCHIP by 18 percent over their levels in August 2001.

Funding
RWJF supported this project through a grant of $121,534.

 See Grant Detail & Contact Information
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THE PROBLEM

In 1996, Congress enacted welfare reform legislation (the Personal Responsibility and Work Opportunity Reconciliation Act of 1996) that:

  • Ended the longstanding federal entitlement to welfare benefits.
  • Delegated policy and operational authority to the states.
  • Emphasized helping welfare recipients find work.

According to the U.S Department of Health and Human Services, the number of families receiving welfare dropped by 44 percent between August 1996 when the legislation passed, and September 1999.

Welfare reform aimed not only to reduce families' dependence on publicly financed benefits but also to require work in exchange for time-limited cash assistance.

Many people leaving welfare under the new rules continued to be eligible for Medicaid and Food Stamps. These programs can improve a family's ability to sustain the transition to self-sufficiency. But after leaving welfare, from one-half to two-thirds of former welfare recipients were losing these benefits, according to researchers at Mathematica Policy Research.

According to Mathematica, Medicaid enrollment for children and their parents began to decline in 1996 for the first time in almost 10 years. In 1999, the number of people receiving Food Stamp benefits reached its lowest level in 20 years.

According to national program office staff at the Southern Institute on Children and Families, technical problems in state data systems and confusing eligibility procedures in social services offices resulted in denial of health care coverage or Food Stamp benefits for many families.

Technical problems included poor coordination among the various state information systems (e.g., Food Stamps, Medicaid) as well as between state and county offices.

Application forms and notices were often written to accommodate legal requirements and were so difficult for families to understand that many did not know what they had to do to secure benefits.

San Bernardino County, Calif., has a population of more than 1.7 million people, according to a 2000 report of the U.S. Census Bureau. According to data from the San Bernardino County Human Services System, the agency that administers welfare, Food Stamps and Medicaid benefits, nearly 32 percent of county residents received some form of public assistance in 2001. Data from the University of California at Los Angeles indicate that in 2001, 20 percent of residents of San Bernardino and Riverside counties lacked health insurance coverage.

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RWJF STRATEGY

For more than 30 years, RWJF has been concerned about Americans' lack of access to affordable and stable health care coverage. RWJF has funded studies, demonstration projects and symposia about this problem.

For example, in 2000, RWJF provided grant support to researchers at the Nelson A. Rockefeller Institute of Government (the Rockefeller Institute). Researchers at the Rockefeller Institute studied the effects of state implementation of welfare reform on Medicaid enrollment among low-income adults and children, and found that enrollment of low-income adults and children dropped after welfare reform, then began to increase in 1998 (see Grant Results on ID# 038230).

In 1997, Congress funded the State Children's Health Insurance Program (SCHIP) with the aim of providing health insurance coverage to children who were not eligible for private or other public insurance programs. That same year, RWJF created Covering Kids®. In 2001, RWJF reshaped the program and renamed it Covering Kids & Families®, reflecting its commitment to help states also cover parents and other adults who work in jobs that do not provide health coverage for them or their children.

Through its national program State Coverage Initiatives, RWJF assisted states in planning, executing and maintaining health insurance expansions, as well as in improving the availability and affordability of health care coverage.

RWJF also created:

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THE PROJECT

The goal of Supporting Families After Welfare Reform is to help public agencies in states and large counties solve problems in eligibility processes that make it difficult for low-income families to gain access to and retain benefits from Medicaid and SCHIP, or Food Stamps, particularly families moving from welfare to work.

In 2002, the San Bernardino County Health and Human Services System received a Supporting Families grant whose goal was to increase the number of individuals and families receiving Medicaid by 15 percent and SCHIP benefits by 5 percent, by June 2004.

A team of three staff members from San Bernardino County participated in a Breakthrough Series Collaborative directed by the Southern Institute on Children and Families, the Supporting Families national program office. During this collaborative problem-solving process, the national program office brought together 10 teams of health and social services staff from the states and counties selected to participate as sites in Supporting Families, including San Bernadino, and a team from the Washington grantee of Covering Kids & Families.

The teams and national program staff selected a common topic area for improvement: maximizing the enrollment and retention of adults and children in Medicaid and the State Children's Health Insurance Program. Over the course of about a year, San Bernardino County's team participated in a series of face-to-face sessions during which they worked with colleagues from other Supporting Families sites and a faculty of experts in the topic area to devise strategies to increase the number of families receiving benefits from Medicaid and SCHIP. Between sessions, team members tested and evaluated the strategies developed through the collaborative.

The Breakthrough Series Collaboratives use a change model developed by a private firm, Associates in Process Improvement that incorporates Dr. W. E. Deming's Plan-Do-Study-Act model. Team members create small-scale tests with specific aims and measures of improvement that are easy to conduct in their home organization. The pilot tests provide feedback quickly, usually within a few weeks. Over time, the teams refine their strategies based on tests results, shared group learning and input from expert collaborative faculty. Strategies that are proven to achieve the team goal are implemented throughout the organization where appropriate.

During the course of the project, the State of California and San Bernardino County suffered from budget shortfalls. This resulted in loss of county agency staff, renewed emphasis on assuring that ineligible people did not receive benefits, and eligibility changes aimed at reducing caseload growth. These challenges prompted team members and other county agency staff to focus on ways to improve efficiency by simplifying administrative processes and reducing inappropriate churning of recipients in and out of programs rather than on adding new recipients to the programs. They used the Plan-Do-Study-Act framework to test the following strategies:

  • The Box Project. Project staff were concerned that in 25 percent of cases, caseworkers who had denied a family's welfare application did not send the denied welfare record to a Medicaid worker who could make a Medicaid-only eligibility determination. Under the Box Project, project staff placed a specially marked box in the work area where welfare caseworkers could place denied welfare records that needed a Medicaid determination.
  • Lunch and Learn. Project staff created "Lunch and Learn" to improve worker accuracy in eligibility decisions. Project staff developed Medicaid eligibility quizzes that workers were required to take, created teaching materials, reviewed correct quiz answers with workers, and offered optional Lunch and Learn presentations during lunch one week before quizzes were given.
  • Envelope Reminder Project. Project staff added reminder messages in blank spaces on envelopes addressed to Medicaid recipients. The envelope messages reminded recipients to sign and date material, and to include verification if required.

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RESULTS

Over the course of the project, the county agency:

  • Reduced the percent of denied welfare cases not referred for Medicaid-only eligibility determination from 25 percent to 13 percent.
  • Achieved a 10 percent higher quiz pass rate for people who attended the Lunch and Learn lunch hour training than for those who did not.
  • Received 30 percent more applications or re-evaluations that were ready to process from families who got envelope reminder notices than from families who did not.
  • As of September 2004, increased Medicaid enrollment in San Bernardino County by nearly 24 percent, and increased enrollment in SCHIP by 18 percent over their levels in August 2001. Some of this increase resulted from other activities undertaken by the state and county to publicize benefits and simplify application processes.

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EVALUATION

Researchers at Bryn Mawr College in Bryn Mawr, Pa., conducted a qualitative evaluation of Supporting Families through telephone interviews, examining documents and Web site postings, and by attending program meetings. They produced a mid-term evaluation report in 2003. There were no results specific to sites. See Evaluation in the program report for a summary of general findings.

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LESSONS LEARNED

Project Lessons were provided by the project director, Jane Hutchison.

  1. The testing cycles forced county staff to think small, act quickly and obtain valuable data in a timelier manner than is usually the case. Large and diverse counties and states traditionally take months to organize and implement pilot projects, but these cycles taught staff how to get the same amount of information more quickly.
  2. When program changes involve increasing the number of beneficiaries or possibly increasing the workload of staff, leaders have to help staff believe that "more is better." While county leaders may agree that more is better in terms of increasing the number of beneficiaries, front-line eligibility workers, receptionists and other staff have to share that philosophy.

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AFTER THE GRANT

Insights from the Box Project have been incorporated into the county's new automated eligibility system that automatically screens denied welfare cases for Medicaid-only eligibility. County eligibility staff continues to use envelope reminder messages.

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GRANT DETAILS & CONTACT INFORMATION

Project

Supporting Families After Welfare Reform: Access to Medicaid, SCHIP and Food Stamps

Grantee

San Bernardino County Human Services System (San Bernardino,  CA)

  • Amount: $ 121,534
    Dates: February 2002 to July 2004
    ID#:  044420

Contact

June Hutchison
(909) 383-9712
jhutchison@hss.sbcounty.gov

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Report prepared by: Mary Nakashian
Reviewed by: Janet Heroux
Reviewed by: Marian Bass
Program Officer: Lori K. Grubstein
Former Program Officer: Linda Bilheimer
Former Program Officer: Michael Rothman
Former Program Officer: Karen Davenport

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