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Guide to School-Based Outreach for Health Coverage Enrollment

August 3, 2016

About This Guide

To find children and family members who could be eligible for free or low-cost health insurance coverage, schools are among the best places to look.  A 2016 report from the Urban Institute and the Robert Wood Johnson Foundation found that nearly half of the nation's uninusred people who are eligible for Medicaid or the Children's Health Insurance Program (CHIP) living in families with at least one school-aged child.[1] 

For years, community organizations, health care providers, school leaders, and other civic-sector actors have used a variety of school-based outreach strategies to increase enrollment in Medicaid, the Children’s Health Insurance Program (CHIP), and, in recent years, to subsidized coverage in the Affordable Care Act’s marketplaces.  These strategies have demonstrated that school-based efforts can be a fruitful path for expanding health care coverage. 

This guide shares strategies that school-based outreach groups identify as key to the success of their work and describes lessons learned to help groups avoid approaches that have yielded disappointing results.

This resource builds on more than two decades of health coverage outreach experience at the Center on Budget and Policy Priorities, a review of literature on school-based outreach, consultation with national experts, and interviews with key people from 11 school-based outreach programs, including groups funded by Atlantic Philanthropies.  The interviews took place between November 2015 and March 2016 and include outreach leaders, application assistance providers, school district employees, state-level coordinators and funders of local outreach, state department of education staff, and state officials.   

This guide focuses on describing key ingredients of successful school-based outreach programs so that new and experienced practitioners alike can benefit from what others have learned.  

What You Will Find In This Guide

The guide is divided into four sections:

I. Why Do Outreach in Schools?  A review of the value and benefits of school-based outreach.

II. Before Diving In.  Four steps for laying the groundwork for outreach efforts:

  • Assess the needs and resources in the community
  • Identify partners
  • Lay out a long-term plan
  • Develop a strategy for monitoring and evaluating performance

III. Five Key Ingredients for Successful School-Based Outreach.   The essential process based on lessons and experiences from successful school-based outreach programs:

  • Involve school leadership
  • Conduct strategic outreach
  • Provide application assistance
  • Safeguard privacy and confidentiality 
  • Have a realistic funding plan

IV. Resources and Contact Information.  Links to online resources and groups who can provide additional information about the work highlighted in this guide.

I. Why Do Outreach in Schools?

Health coverage is vital to the well-being of every adult and child.  Whether it is routine preventive screening or a needed medical intervention, without insurance to help cover the costs, many people end up receiving less care than they need or go without it altogether.  As a result, health conditions become worse and increasingly expensive to treat, people are less productive at school and work, families face financial hardship, and the incidence of premature morbidity and death rises.

For decades, groups from a range of disciplines have worked to make sure that free or low-cost health coverage is available and accessible to those who need it.  These efforts have included advocating to ensure that more people meet qualifications to enroll in coverage and that application processes are simple enough so eligible applicants are not deterred by unreasonable barriers.  Efforts have utilized multiple avenues, like federally qualified health centers and hospitals and programs like the Supplemental Nutrition Assistance Program (SNAP) and Head Start, to reach eligible families.

Among the many effective strategies is conducting health coverage outreach in connection with schools.  In fact, in 2006 and 2010, 29 state agencies identified school-based work to be one of their most effective outreach methods.[2]

In the simplest sense, schools are where the children and families are.  As noted above, nearly half of people who are uninsured but eligible for Medicaid or CHIP live in families with at least one school-age child.  Also, many schools routinely collect information about health insurance, which makes identifying uninsured students that much easier.

In addition, schools are trusted places.  They tend to be geographically accessible and have established methods for sharing information with families.  And they have experience communicating with their communities.  In one study, more than half of participating parents said they would be more likely to enroll their children in health insurance coverage if they could do so at their school or child care center.[3] 

“Our goal is a kid’s education. We know that every day a kid isn’t learning is a day wasted. So it is our job to make sure they are healthy enough to get into a classroom and learn.”
-- Thaddeus Lesiak, Minneapolis Public Schools Family Resource Center

Finally, because of the well-documented link between children's enrollment in Medicaid and improved academic performance,[4] schools have a direct interest in making sure their students have the insurance coverage they need.  

However, not all school-based outreach approaches have the same impact or return on investment.  Schools and groups collaborating with schools have experimented with a variety of approaches under different conditions and with different levels of intensity and investment.  Over time, these practitioners have learned that they are more successful when they have a deep understanding of their unique community context and ensure that several key ingredients are in place.

II. Before Diving In

The compelling logic of school-based outreach and the potential to reach such a large audience of eligible parents and children can generate enormous enthusiasm and excitement for this work.  Nevertheless, there is important groundwork to complete before diving in.  It is important to understand key aspects of the community to be served so that the work can be tailored accordingly.  Strategies and tactics that work in one community may not be necessary or work in another.  So, before conducting any outreach, it is essential to follow the following checklist:

1. Assess the Needs and Resources in the Community

Before designing the program, it is vital to have a clear understanding of community needs and resources in order to identify opportunities and gaps and to avoid duplication of effort. The following questions can guide this assessment:

Information to gather Relevance to the work
Does the area have large numbers of uninsured people who are eligible for Medicaid, CHIP, or the ACA marketplace? This information will help in setting the size of the potential audience and enrollment goals.
What barriers do those unenrolled face? The approach should be designed to overcome the primary barriers operating in the community.
Does the area have large numbers of people who are eligible but not enrolled in other benefit programs like SNAP?  If so, collaborate with programs that seek to enroll people in SNAP or other programs.
What are the demographics of the uninsured in the area?  Understanding these demographics is a first step to developing culturally appropriate strategies to target outreach to groups with the greatest need.  Many school-based outreach groups find, for example, that language-appropriate outreach and application assistance is a primary need that is often unmet. 
Are there already efforts in the school or school district to connect families to insurance or other benefit programs?  If so, are they meeting the need? This assessment will help in avoiding duplicative efforts and defining a partnership plan (see below).  How can this effort support and augment other ongoing efforts?
Have school-based outreach efforts happened in the past?  How did they work and are there lessons learned from them? Avoid reinventing the wheel or repeating past mistakes.  
Do consumers in the community succeed in enrolling in Medicaid, CHIP, and marketplace coverage on their own?  Are there user-friendly online or telephone pathways to benefits?  Are most eligibility factors verified electronically so that people don’t have to provide proof? In general, groups find that most people need assistance to complete the application process.  As application simplifications are adopted, assistance efforts can mainly focus on families with more complicated circumstances or who need supports like language assistance. 
Will the current application assisters in the community be able to address the additional volume generated by the school-based outreach strategy? If not, a central component of the effort should be increasing assister availability and capacity.  
 

 

2. Identify Partners

Under almost all circumstances, effective school-based outreach requires partnerships and collaboration.  For example, if a school district is leading the outreach, it may want to partner with a community group that provides application assistance.  If a community group wants to conduct outreach within the school setting, it will want to partner with school leaders. 

Groups coming into schools may have to start small by working with one or two schools initially and demonstrating the value the program offers.  In 1998, Partnership for Healthier Kids (PHK) piloted in just one school in Northern Virginia, but after succeeding there it collaborated with 10 schools in the next school year and now serves approximately 400 schools each year.

Partners will vary from place to place; these are some groups often involved in school-based outreach:

  • School or school district leaders, who can ensure all policies are followed, delegate staff, and leverage forms of communication that schools commonly use to convey information to students and parents. 
  • The school or school district's nutrition services, which can send promotional materials to students participating in the free and reduced-priced meals (FARM) program.  
  • Local after-school programs, which can conduct outreach to the parents of children served.
  • Navigators and other application assistance providers, which can help families complete the process to enroll in coverage.
  • Community-based organizations — faith-based groups, neighborhood associations, or other social-services-oriented not-for-profit organizations — that have trust among the segments of the target audience.  For example, groups with expertise in working with immigrants can help craft outreach messages taking into consideration concerns unique to immigrants.
  • Parent organizers, who can identify opportunities to build awareness about health coverage during events in the schools.
  • Student leaders, who can raise awareness about the importance of health coverage among their peers and connect them to your school-based outreach group for more information and help.
  • State or county Medicaid and CHIP agencies, which determine eligibility for consumers.  These agencies may be able to provide information that can improve the quality of application assistance and tracking.
  • Attorneys, who can create and interpret contracts or other agreements and handle confidentiality issues.
“We knew there was capacity in many organizations in our com-munity, and that we needed to take advantage of that capacity. But we assumed people would just come because they thought health coverage was important. We came to realize that it would actually take a lot of trust and tenacity to get (and keep) people at the table.”
-- Eva Elmer, Mayor’s Campaign for Healthy Kids and Families, Chatham County Safety Net Planning Council

Identifying partners is just a first step.  Potential partners will have competing priorities for their time and resources, so a compelling pitch is key.  It is important to make it easy for partners to support the effort (for example, be flexible about when and how they can participate and give them the tools, like promotional materials, they need).  Providing partners with regular updates on outreach and enrollment will help them know that their participation is making a difference.  It is also important to thank partners and acknowledge their contributions.

3. Lay Out a Long-Term Plan

Success will take time.  It will require building credibility within the school system and with families, and navigating and satisfying a range of school system requirements, including confidentiality of student information.  Outreach and application assistance staff will need training, and strong working partnerships that satisfy all legal requirements will take time to build.

In addition, a single round of outreach and application assistance is never enough.  New students arrive throughout the school year, and families’ circumstances are constantly changing.  If a school successfully becomes known as a “go to” place for help in connecting to affordable health coverage, more and more people will seek help.

School leaders want to see a commitment.  They know better than anyone that one-off activities are not going to meet the needs of their communities, and they will be less willing to devote staff resources if they believe the commitment is short term.  Thus, it is important to start with a concrete plan with a timeline of several years.

Notes From the Field on Having a Long-Term Plan

The Family Healthcare Foundation (FHF) in Florida has a strong and longstanding partnership with the Hillsborough County Public Schools. The partners have a memorandum of understanding (MOU) that solidifies the relationship by outlining the responsibilities that each entity agrees to each year.  The MOU is renewed every two years, virtually automatically.  But FHF leaders say that getting to this place — by establishing trust and building the needed relationships — took time.  Annual meetings with the superintendent, in which FHF provides an overview of the referrals and number of enrolled families, help make sure the MOU is easy to renew.

 

4. Develop a Strategy for Monitoring and Evaluating Performance

As with any effective program, monitoring performance and effectiveness is key to reaching desired outcomes and sustaining partner and funder support.  Before you get started, know not only WHAT you need to measure to learn about your own effectiveness and report on to satisfy your commitments to funders, schools, and other partners, but HOW you are going to measure these things.  Note that privacy laws can restrict data gathering.  For example, Medicaid and CHIP agencies can’t share with assister groups information about a consumer’s application disposition without appropriate consents in place.  (For more, see Key Ingredient #4: Safeguard Privacy and Confidentiality.)

Common performance measures in school-based outreach include:

  • The number of people reached through conducting general outreach activities like school events.
  • The number of people reached through targeted outreach strategies like using health insurance information collected on school registration forms.
  • The number of families provided application assistance.
  • The number and percent of people successfully enrolled.
  • The number of people using coverage for preventive care.
  • The number of people assisted with renewal.
  • The number of eligible people successfully renewed.

III. Five Key Ingredients for Successful School-Based Outreach

School-based outreach can take many forms, of course, but some ingredients are essential to success. This section explores five:

  • Involve school leadership
  • Conduct strategic outreach
  • Provide application assistance
  • Safeguard privacy and confidentiality
  • Have a realistic funding plan

For each ingredient, the following reviews why it is important and lists strategies for achieving it. The discussion also offers examples from the field of practices that have worked and haven’t, and links to helpful resources.  

Key Ingredient: Involve School Leadership

Whether the initiative involves one school or multiple schools in the district, getting buy-in from leadership will help the effort to be welcomed and perceived as a credible resource by teachers, registrars, counselors, clinic aides, nurses, and parents. Moreover, involving school leadership will ensure that operations are conducted within the bounds of what is acceptable in the school setting and that the planned approach is likely to work.

“Showing community college faculty and staff the academic impact of having health insurance was powerful. Every school cares about their graduation rates and academic performance.”
-- Erin Hemlin, National Training Director, Young Invincibles

It’s important to make sure the leadership buy-in strategy matches the goals and reach of the initiative.  While involving individual school principals or other leaders is key to the on-the-ground work of connecting children and families to health insurance coverage, school leadership buy-in efforts may need to go beyond that depending on the scope of the initiative.  For example, reaching an entire school district or multiple schools within a district will require superintendent-level buy-in and support. Programs targeting only children who participate in the free and reduced-price meals program will require buy-in from the person leading that operation. 

Strong Strategies for Involving School Leadership

Make the Connection Between Health Care Coverage and Students’ Academic Success 

Schools are busy places and are stretched for resources.  Funding has become even more limited in recent years, with most schools spending less per student in K-12 than they did before 2008.[5]   

“Don’t be surprised when people who have not been involved want to get involved. One of our state Medicaid coordinators could see clear connections between what she was doing and the information that schools were able to capture. We shouldn’t limit ourselves to who we think might be a partner or we’ll miss someone unexpected who might end up being a champion.”
-- Tia Campbell, Virginia Department of Education

For all the same reasons that health outreach groups seek out schools for reaching families, a multitude of organizations frequently request school time and resources to support their initiatives.  While many of the initiatives have worthwhile goals, some may fall outside schools’ core mission to educate students.  School leaders want to focus their attention on what will help them achieve their goals.  Be sure to make a strong case about why health insurance coverage is central to student success.

Quantify How Schools Can Benefit Financially from Medicaid Enrollment 

School budgets are tight.  Enrolling children in Medicaid or other health coverage can help schools get funding to cover certain services provided within the school, such as speech and occupational therapy.  And Medicaid funds may also be available to cover the time school staff spend on administrative activities such as conducting outreach and helping families complete the application process.  School leaders should be made aware of the potential for financial support.  (See Key Ingredient #5: Have a Realistic Funding Plan, for information about Medicaid claiming.)

Enlist “Champions”

Getting the buy-in of school leaders may be easier when some important “champions” are lined up: school employees, parent leaders, school board members, mayors, or city council members.  Their support will bring credibility and encourage school administrators.  The champion might be the “go to” person in a school — the teacher, clinic aide, administrative assistant, or social worker to whom everyone turns for help when families are in need of services not provided by the school.

Make Participation Easy

Plan to implement strategies that do not require a lot of time and/or increased responsibility for school staff.  School leaders do not want to overcommit their staff and are more likely to support a program that requires minimal staff time and that easily fits within the school’s existing schedules and resources. 

Regularly Report on Progress 

School leaders want to know that the effort put into outreach and application assistance is yielding results.  Having data helps reassure them that they are investing their resources wisely.  Schools may want to know individual student-level results or effort-wide results particular to their school.  For example, if letters went to the homes of all students who were missing health insurance on their registration forms, how many responded?  And of those, how many enrolled in coverage?

While schools will want to quantify the success of efforts to enroll children and their families, the level of detail that you can share with them will depend on the data-sharing agreements that you have in place and the kinds of consent forms families complete.  It is important to discuss this with school leaders to make sure their expectations are realistic.  More information about data-sharing limitations appears in Key Ingredient #4: Safeguard Privacy and Confidentiality.

Notes From the Field on Progress Reporting

Partnership for Healthier Kids, which operates in several counties in Northern Virginia, regularly gathers and shares information about its work with school leaders.  Each quarter and at year’s end, PHK sends to school leaders reports on which schools participated, the types of outreach completed, the number of families that responded to outreach, the number of families assisted in applying for coverage, and the number of people successfully enrolled.  Before the start of a new school year, PHK recaps this information in meetings with school system leadership so together they can set priorities and agree on outreach plans. 

 

Key Ingredient: Conduct Strategic Outreach

There are many different ways to get a message out in a community — from “general outreach” strategies like blanketing public places with informational fliers to “targeted outreach” that seeks to reach people most likely to be eligible for coverage.  The various strategies come with different costs and levels of effort.  And, importantly, they have different impacts and outcomes.  Selecting an outreach strategy without assessing its relative costs and benefits within your local context can lead to unnecessary expenses and disappointing results.

As a rule, targeted outreach (or combining targeted and general outreach) is likely to be much more time- and cost-effective than conducting only general outreach.  In just one example, Enroll America’s team in Tennessee sent 60,000 health insurance “commit cards” to all students in grades K-8 in one Memphis school district, plus made automated (“robo”) calls, sent text messages, and produced public service announcements.  Despite blanketing the county so thoroughly, only 500 cards were returned.  In contrast, throughout the 2015-2016 academic year PHK sent 11,377 letters to children who were missing health coverage on their emergency contact forms; as of June 2016, 1,143 families had responded via mail that they wanted PHK to follow up with them.

It’s important to learn about ways the school routinely communicates with families and which forms the schools currently use.  Talk to school or school system contacts to find out what kinds of communication strategies have been most successful in reaching parents.  Every school community is different, so don’t assume, for example, that advertising in newsletters will work if most parents tend to respond only to phone calls.

Strong Strategies for Conducting Strategic Outreach

Target Students Known to Be Uninsured

In many schools, emergency contact, student health, sports registration, and other forms ask whether students have health insurance.  Parents who have not provided this information for their students (presumably because they don’t have insurance) make an excellent target group. 

Active follow-up is critical.  Schools can check back with the families through phone calls or letters to confirm a lack of insurance and then let the families know how to apply for coverage.  When parents receive messages from their child’s school, they are often receptive to them.  An evaluation funded by Atlantic Philanthropies of a school-based initiative to enroll children in health coverage in Alameda County, California found that, when schools call parents informing them of the opportunity to enroll in health coverage programs, parents remain on the line and often express interest in receiving more information or making an application appointment.[6]

Notes From the Field on Identifying Uninsured Students

Since 1998, PHK has used insurance information collected on student emergency contact forms to identify students who are likely uninsured.  PHK sends letters from the school principal to students missing information about health insurance.  The letters ask parents to provide insurance information and, in cases where students don’t have insurance, parents are told they have the opportunity to get help from PHK to connect to affordable health coverage programs.  The packages mailed home include a postage-paid return envelope.  PHK reaches out to interested families and provides application assistance to help them enroll.

Using school forms that ask about health insurance coverage has been well-documented as a successful strategy for identifying and providing application assistance for uninsured students.  However, this kind of targeted outreach must ensure student privacy.  This student information is protected under the Family Educational Rights and Privacy Act (FERPA), and cannot be released to third parties without appropriate consents.  Thus, school system employees must do the work to review the forms to identify students with missing health insurance information.  This is challenging when the school system itself is not the group leading the school-based outreach.  Many schools feel they cannot spare limited staff resources to complete a review of the student forms and send outreach letters to students identified.  Some outreach groups have helped schools overcome this resource challenge by providing funding to schools to offset the expense of staff time used for this purpose; other groups have hired school employees to work within the schools to carry out this type of outreach and assist families in completing the application process.

Target Students Who Are Likely to Qualify Based on Family Income

Students who participate in the free and reduced-priced meals (FARM) program are likely income-eligible for free or low-cost health coverage.  Schools can send information about the availability of health coverage (and how to get help with enrollment) when they inform families that their FARM application has been approved. 

The Community Eligibility Provision of the Healthy, Hunger-Free Kids Act of 2010 allows school districts, individual schools, or groups of schools to offer two free meals daily to all students if more than 40 percent of students meet certain criteria.[7]  As a result, in these schools targeting outreach to individual FARM participants won’t work.  However, since many students in community eligibility schools are likely to be income-eligible for insurance, they can be excellent targets for other forms of outreach. 

Notes From the Field on Utilizing FARM Data

  • The Minneapolis Public Schools (MPS) Family Resource Center electronically compares free and reduced-price meal participation data against Medicaid enrollment data to identify students enrolled in FARM but not Medicaid.  Parents and caretakers of FARM-eligible students without Medicaid get an automated phone call from the school principal saying healthy students are more academically successful, then they get a postcard saying they can call to get help with eligibility screening and application. Resource Center staff also call families to share additional information, offer help, and set up application assistance appointments.  This outreach strategy identifies enough families that MPS staff are busy all year long.  They used to also conduct other outreach activities — like participating in local events — but found this was time-intensive and yielded low results. 
  • The Family Healthcare Foundation (FHF) included an “opt out” about health coverage information in one school district’s FARM application.  All of those who did not opt out from sharing their information could be contacted by FHF.  The foundation received thousands of pages listing families who had not opted out.  But when they reached out to these families they found that 85-90 percent already had their children enrolled in Medicaid.  The opt-out strategy was dropped!   

Target Schools That Are Likely to Have Large Numbers of Families That Qualify for Affordable Health Coverage

In addition to FARM participation, other sources of information can help identify schools with high concentrations of need.  Census data, compilations of adult uninsured rates, or a Title I school designation — meaning a high concentration of students in families with low incomes — are examples. 

Notes From the Field on Identifying the Uninsured and Income-Eligible

  • Get Covered America–Tennessee used maps created by Enroll America to identify schools in geographic areas with high concentrations of uninsured people. 
  • In Providence, RI, approximately 80 percent of students participate in FARM.  As a result, City of Providence Healthy Communities Office, a grantee of the National League of Cities Expanding Health Access for Children and Families initiative, funded by the Atlantic Philanthropies, targets the full school system in all of its outreach.

Take Advantage of Multiple Opportunities in Schools and School Districts

Reinforcement of the health coverage message through multiple communications and various sources can boost enrollment results. Research by Enroll America, for example, found that uninsured African Americans, Latinos, and young people were about twice as likely to enroll in coverage after the third follow-up than they were after the first or second outreach effort.[8]

School-based outreach groups have found that building an event or communication strategy around the health coverage message alone is not a highly effective strategy — it can be difficult to get a strong showing by eligible families.  But because schools are constantly communicating with families, there are likely to be many different vehicles — like routine mailings and newsletters, backpack stuffers, information bulletin boards, school events, robo calls — on which to “piggy back” information about health insurance.

Every school is different, and staff will know which kinds of events and communication vehicles are most effective within the community.  For example, some schools that have struggled to engage parents have found that robo calls have the greatest impact while others have found them unhelpful. Finally, while eligible families can enroll in Medicaid and CHIP year-round, it is important to consider how to fit in multiple outreach and enrollment opportunities within the time constraints of open enrollment periods for marketplace coverage, too.

Notes From the Field on Imaginative Outreach Methods

  • Some school systems have central offices to register newly entering students.  Often these sites house special services like language assistance for parents who have limited English proficiency or placement testing for students.  City of Providence Healthy Communities Office and the Minneapolis Public Schools Family Resource Center each has tapped into this central registration process by providing fliers and encouraging staff there to ask all registrants if they need health insurance coverage.
  • The Partnership for Healthier Kids takes advantage of the fact that many students are required to have physical exams and immunizations prior to newly enrolling in the school system.  In the summertime, the school systems invite newly enrolling but uninsured students to “free school physicals events” that are collaborations between PHK, schools, the local health department, community providers, and nonprofit groups.  PHK sets up appointments for the events and provides application assistance to families to enroll in health coverage.  At the events, PHK assister staff collect supporting documentation or provide additional application assistance as needed.  Each summer hundreds of new students benefit from these services. 
  • Young Invincibles (YI) is a national research and advocacy organization representing the voices and interests of 18- to 34-year-olds on a range of issues, including health care.  YI conducts general outreach on college campuses and has found its efforts are most successful when professors give them time during class to talk to students.  The professor’s endorsement means a lot to students.  YI focuses on professors with large, lecture-style classes to maximize reach.
  • City of Providence Healthy Communities Office has engaged with an entertainer-advocate called "Mr. Deep Positivity" who goes to schools and has students take a "Healthy Pledge."  Mr. Deep Positivity has a public television show and hundreds of songs on student life and health, including raps that use personal stories about sick family members who are uninsured.  Mr. Deep Positivity also works with students to create videos and other art about the importance of health insurance.

Educate School Staff

“This work is all relationship-based, and it takes a lot of time to develop those relationships.”
-- Melanie Hall, Executive Director, Family Healthcare Foundation

For school-based strategies that seek to become part of the institution — as opposed to being a drop-in or short-term activity — it is important to make sure that a wide swath of staff know about the effort, know how to refer students, and have fliers or other promotional materials on hand.  Whether at the school-system level or the school-building level, a dedicated information and training session for key staff on health insurance outreach is ideal.  Many school districts convene staff by disciplines on a regular basis to receive training, share updates, and have the opportunity for peer-to-peer learning and discussions.  Some school-based outreach groups get on these agendas so they can reach key district employees — like social workers, counselors, parent resource staff, nurses, and clinic aides —- who are likely to encounter uninsured students. 

“Many people focus on elemen-tary schools where it’s easier to connect with parents. But in high schools, connecting with teachers of elective classes like business is good because they can connect you with the students.”
– Liz Tansey, Outreach and Enrollment Coordinator, Colorado Covering Kids and Families

It is important to remember that in some school districts staff may also be eligible for coverage, if not for themselves then for family members.  Some school districts provide generously subsidized health insurance for their employees but no or modest subsidies for spouses or dependents.  Outreach efforts can help those staff members see if they qualify for coverage too.  Their positive, first-hand experience with the program can be a powerful motivator for them to take interest and engage students’ families.

Getting on the agenda of school-system-wide meetings can take time.  Administrators may be more likely to offer this access to a program that has demonstrated its effectiveness and built up trust and relationships.  As a result, system-wide training sessions may not be a successful year-one strategy, but over time they are an important one if the aim is to institutionalize outreach efforts.

Notes From the Field on Involving School Staff

  • Each August, the Family Healthcare Foundation in Florida makes a presentation to the Hillsborough County school district’s nurses and social work staff.  FHF also attends the district’s holiday lunch each year and, to incentivize participation in outreach, offers a prize drawing for staff who have provided referrals of parents to learn more about health coverage options.  FHF also recognizes staff who have gone “above and beyond” in their efforts.
  • The Mayor’s Campaign for Healthy Kids and Families in Savannah, GA has found success in working with the system’s Title I parent facilitators, who provide hands-on services in 32 of the district’s high-need schools, and with nurses in 54 schools.  These staff are knowledgeable about the parents in their schools and, most important, are trusted by them.  The campaign provides a one-hour education session and provides material for nurses and the parent facilitators to distribute directly to families. The campaign is a grantee of the National League of Cities initiative funded by the Atlantic Philanthropies.

Get Students Involved — Especially the Older Ones

A tough target for outreach efforts is adolescents, and this group continues to fall behind in Medicaid and CHIP participation levels compared to younger children.[9]  Often, parents of older students are less “hands on,” so some of the techniques like sending home letters and raising awareness at events may prove to be less successful in reaching parents of adolescents.  However, some school-based outreach groups have had success in directly engaging with middle and high school students themselves. 

Notes From the Field on Reaching Adolescents

  • In the county and city of Denver, Colorado Covering Kids and Families has partnered with the Bridge Project to develop a curriculum focused on teaching high school students about the important of health insurance.  Similarly, in Savannah, GA, the Mayor’s Campaign for Healthy Kids and Families has developed and implemented a curriculum for middle and high school students so they can learn about the importance of health care, health insurance coverage, and ways to get it.  Students receive extra credit if their parents complete a survey providing information about their health insurance status and whether they want to learn more about coverage options.  
  • Health Occupations Students of America (HOSA) is a national organization supporting future health professionals.  In Hillsborough County, FL, a local high school with a HOSA chapter invited the Family Healthcare Foundation to present information about outreach and application assistance work.  The HOSA students were enthusiastic and chose to support FHF’s efforts.  After being trained, they accompanied FHF staff to school events and jointly conducted health coverage education and awareness activities.  The students were especially helpful in raising awareness among younger students.  As a result of their work, the students won a competitive event at the statewide HOSA convention.

 

Key Ingredient: Provide Application Assistance

Securing affordable health coverage can be challenging.  Many consumers need help navigating the complicated application questions and figuring out what documents they need to prove their circumstances.  They often do not understand why it is necessary to disclose private information, or they worry that applying will have negative implications for their families.  In a recent study, researchers found that receiving help from a navigator or application assister increased the probability of obtaining coverage by nearly 10 percentage points and was the strongest predictor of successful enrollment.[10]

“Outreach without a connection to application assistance is just useless…. With just outreach, you're replicating the systems that communities of color already deal with as they try to navigate public systems.”
-- Brightstar Ohlson, Principal and CEO, Bright Research Group

Because of the complexity and the personal nature of people’s concerns, outreach groups have found that directing consumers to complete paper, online, or telephone applications for health coverage programs on their own to be less effective than providing for more localized, hands-on application assistance. 

This aspect of the outreach initiative will also directly impact the ability to understand results.  Conducting outreach that is not directly connected to application assistance makes it difficult to know whether communication efforts resulted in actual enrollments.

Effective school-based outreach efforts should include — or link strongly to — application assistance.

It’s important to assess the application assister landscape in the target area.  Determining the best way to include application assistance in the initiative requires knowing who’s out there: how many assisters there are, where they are located, their language capability, their capacity to serve consumers, and, perhaps most important, their reputation in the community. 

Strong Strategies for Providing Application Assistance

Promote a Single Phone Number for Consumers to Use

Having one central number for all inquiries eliminates consumer confusion about whom to call.  Also, using a central number that all assister staff can access helps ensure that all staff are optimally available to answer calls — even if one staff person is on vacation or out sick, others can be answering calls.

Provide for In-Person Assistance

Some families will only be comfortable completing the application process face-to-face.  Additionally, there may be obstacles to helping families complete and submit online applications while providing application assistance over the phone.  For example, states often prefer consumers to complete applications online, but depending on the structure of the application, the only way to submit an online application may be to have the consumer present when completing it. 

In-person application assistance can take place in a school or almost anywhere eligible families are likely to be: community events, health clinics, or libraries, for example.  If the outreach program has one main application assistance site, it should be as centrally located as possible and accessible via public transportation.  To ensure families’ confidentiality, interview spaces should include privacy barriers.

“We spend at least as much of our time helping families resolve issues as we do helping them complete the application itself.… The applications are the easy part of this.”
-- Melanie Hall, Family Healthcare Foundation

Application assistance takes time.  Based on its experience, the Minneapolis Public Schools Family Resource Center allows 45 minutes to assist a small family and 90 minutes for larger families.  More time is added for multiple applications, such as if a grandparent living with the family wants to apply for coverage. 

To ensure that time spent with families yields the best results, it is important to ask families to come prepared to complete the entire application.  This means they should bring information such as:

  • Social Security numbers for all family members applying for coverage
  • documents that prove immigration status or citizenship (as applicable)
  • pay stubs, recent tax returns, or information that can be used to document income for everyone in the family who has it

Notes From the Field About In-Person Assistance

City of Providence Healthy Communities Office invites other community groups that provide application assistance to join them at well-attended school events, like wellness fairs.  The assisters provide application assistance tasks onsite, including scanning supporting documents needed to complete an application.  If families are not ready to complete the application during the event, City of Providence Healthy Communities Office sets up appointments for them to do so at a later time.

Provide Follow-Up Support

Completing an application for health insurance coverage is only the first step in what can sometimes be a long and complicated process.  Families often need help providing documentation to prove their circumstances, responding to erroneous denials, renewing their coverage before (or after) it expires, and navigating and optimizing their new coverage.  Although this additional support can be resource-intensive, it is vital to achieving the overarching goal of this work: healthy children and families connected to coverage that meets their health care needs. 

Notes From the Field About Follow-Up Support

  • The Family Healthcare Foundation tries to prepare families for any additional steps their application or renewal may require.  Generally, outreach groups do not have access to Medicaid or CHIP case files that include information about steps consumers must take — such as sending in a pay stub to prove income — to complete an application.  Not having this information makes it difficult for groups to provide follow-up assistance.  Because FHF is a grantee of KidCare (the state’s CHIP program), it can access the KidCare database and get specific information about actions families need to take.  For example, it can check renewal dates or see which documents are missing. 
  • When Partnership for Healthier Kids provides application assistance, staff always explain what to expect when it comes time to renew coverage.  This advice includes letting families know about managed care plans and things to consider when selecting a primary care provider.  Staff also let families know that they must report life changes and that they will have to renew coverage in about a year.  They give families a refrigerator magnet that shows their scheduled renewal month; the magnet includes PHK’s contact information so the family can reach out if it needs help with renewing or any other matter.  PHK also sends letters and makes phone calls alerting families about their upcoming renewal date and offering support with the process. 

Make it a One-Stop Shop

Every family has its own unique priorities, and they often shift over time.  At one moment, for example, a family may feel a greater need for food support than for health insurance coverage.  But regardless of which priorities are predominant, applying for multiple benefits through discrete processes at different times can be overwhelming.  As a result, many choose to do without benefits that are not pressing at the moment.

Combining benefit application processes is good for families and systems alike: it reduces duplication, speeds up enrollment, and helps ensure families consistently have all the benefits and supports for which they are eligible.  To facilitate this, many states and localities have taken significant steps to create streamlined application processes.

Having a one-stop shop is also important within the health coverage world itself.  In some families, various members will qualify for different programs.  For example, the children may qualify for CHIP, while the parents may qualify for subsidized marketplace coverage.  Application assisters should be prepared to help families apply for any of the available free or low-cost health coverage options available in the area.

Notes From the Field About One-Stop Shops

Since 2005 Chicago Public Schools has had a Children and Families Benefit Unit (CFBU) that facilitates enrollment in a variety of programs.  The CFBU raised awareness about the availability of key benefits through the schools and provided individualized application assistance.  In addition to Medicaid, CHIP, and ACA marketplace coverage, CFBU staff are trained to help with benefits under the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families.

 

Key Ingredient: Safeguard Privacy and Confidentiality

In school-based health outreach efforts, student and family privacy is protected by the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA).  FERPA protects the privacy of student information maintained by a school (defined broadly as “student records”).  Schools are required to have written permission from parents or students to release any information from a student's education record, with some exceptions. 

HIPAA requires entities to protect patient privacy and confidentiality and defines standards for transferring health information electronically between health providers, health plans, and third-party payers.  Under the HIPAA Privacy Rule, information that is considered individually identified health information like a name, address, or Social Security number is considered protected health information (PHI), and organizations must obtain patient authorization to use that protected information with other entities.

School-based outreach that uses student data to target potentially eligible families and/or that conducts application assistance (which may involve gathering, sharing, and collecting personal information) will need to ensure that all activities are in compliance with FERPA and HIPAA.  Private information must be treated with care so that only people with permission to see it can do so.

It is important to review an outreach and application assistance plan against FERPA and HIPAA requirements.

Given the wide variety of programmatic options for doing school-based outreach and application assistance, each group’s privacy and confidentiality considerations will be different.  For example:

  • If the outreach and assistance strategy involves gathering existing information about students’ insurance status from school forms, only a school employee can see that information without additional releases.  
  • If the assister group wants to find out whether people it helped were successfully enrolled in coverage, it needs to get special releases of information from those consumers.
  • If the assister group wants to share with the school system information about the enrollment of specific students, a release of information will be needed.  Without such a release the assister group can report back only in the aggregate.

In other words, just about any planned activity — for targeted outreach and referral, for feedback loops on coverage disposition, or for data collection and sharing — should be discussed ahead of time with all of the involved organizations and partners, so that appropriate agreements and releases can be created.  This can help set expectations at a consistent level from the start.  For example, if there is agreement early on that releases of information will not allow outreach groups to release information about individual students’ health coverage disposition, school partners will know to anticipate a report that includes the number of students enrolled but not a list of individual students.  Early discussions can also help determine the level of involvement of school staff.  For example, if the outreach group wants to target students who indicate on their emergency contact forms that they are without insurance, but schools cannot commit staff time to going through the forms, consent to release information can be built into the form.  In sum, understanding the full landscape around privacy requirements and actively preparing for their impact on the outreach and application assistance strategy are vital.

Strong Strategies for Safeguarding Privacy and Confidentiality

Practitioners around the country have found that FERPA and HIPAA requirements do not have to derail a planned approach to outreach and application assistance.  Creating “release of information” forms that cover various kinds of information sharing is perhaps the most direct route. Other strategies include:

  • Use school staff for targeted outreach.  Since school system employees are allowed to review student data, they can take the first steps in targeted outreach: reviewing forms, identifying those who might be eligible, and making the initial contacts.  A third party could pay existing school staff (or hire new school staff) to do this extra work. 
  • Embed a release on the health coverage application.  To make sure application assisters can find out whether people they helped were determined eligible and received coverage, the state could include a release of information on the application itself.
  • Create a single release form.  With careful attention to wording, all necessary releases for both outreach and application assistance activities can be incorporated into a single form so that families will not have to contend with additional paperwork.  PHK uses this form posted on its website:  http://www.inova.org/upload/docs/Community/Partnership%20for%20Healthier%20Kids/english.pdf.
  • Add an opt-in.  School forms that already request health insurance information could be modified to include an opt-in so parents or guardians could give permission for a third party to reach out to them. 

No matter which strategies are chosen, it is always a good idea to have signed agreements between partners that outline roles and responsibilities.  Such memoranda of understanding can ensure that all participating groups know which activities will be conducted and the steps that will be taken to ensure student confidentiality is maintained.

If an opt-in is included, the program should ensure that it has the capacity to follow up with families who take the option.  In the early years of school-based outreach, many schools included opt-ins in their free/reduced-priced meals applications for third parties to contact families about affordable health coverage options.  But in many cases, neither the outreach groups, the schools, nor the state agencies had the staff capacity to reach out to everyone who opted in. 

Engaging with school leaders about these issues is especially important in that some of the strategies may require more work than a school is able or willing to do. Asking school staff to conduct the first wave of outreach to families is an example.  Plan together with school leadership.

As noted, without releases of information, an assisters group can report to schools only in the aggregate, and only if a sufficient number of people have been helped.  For example, if a school refers ten people to the program for assistance, it would be a breach of confidentiality to share that seven people were enrolled. Only with larger numbers does aggregate reporting retain confidentiality.  As a result, the anticipated referral volume will be key to determining the release and reporting strategies. 

Notes From the Field About Safeguarding Privacy

  • The Chicago Public Schools did not have to share information with a third party for outreach because it hired its own staff to do this work.  The Children and Family Benefits Unit team was trained on FERPA and took the steps needed to ensure student confidentiality, such as having application assistance meetings in private settings and maintaining records under FERPA guidelines. 
  • Because it was public knowledge that 80 percent of the Providence school system’s students were eligible for free and reduced-price meals, City of Providence Healthy Communities Office’s outreach strategies were not targeted; it used general outreach that tried to reach all students throughout the district.  Because it did not target anyone based on specific information, its outreach efforts did not require much attention to privacy issues.  Families interested in coverage either contacted a general 211 number to get application assistance or could get help in person at community events.  Application assisters had their own consent forms but shared no information with City of Providence Healthy Communities Office, so no special releases were needed. 
  • Staff in the Minneapolis Public Schools Family Resource Center wanted to identify all children participating in the free and reduced-price meals program who were not enrolled in Medicaid and then target them for outreach.  They worked hard to determine how to match data across these programs.  By taking the time to identify exactly how they would use the data, and addressing in advance as many of the potential privacy issues as they could, they were able to cut down on the time needed to consult with the district’s legal team.

 

Key Ingredient: Have a Realistic Funding Plan

As described earlier in this guide, school-based outreach and application assistance efforts are best understood as a long-term enterprise.  While it may be tempting to commit to one school year, practitioners find that it takes substantial time to navigate the school system, get the necessary leadership buy-in, and get staff hired and trained.  It is not really possible to become and then serve as a “go to” resource for health coverage within a single school year.

It is easy to underestimate how expensive this work can be.  Outreach and application assistance are time- and labor-intensive activities.  Multiple outreach strategies are likely to be needed simultaneously, and one-on-one assistance and follow up often take many encounters. And though it may seem mundane, the cost of paper, copying, and postage needed to communicate with large groups of people quickly adds up.  

In short, this is long-term and expensive work.  It is important to have an upfront, realistic plan for sustaining it for at least a few years.

“It’s important to understand that Medicaid in schools is not a fund-ing stream, it’s a reimbursement stream.”
-- Tia Campbell, School Health Specialist, Virginia Department of Education

As with any endeavor, the budget must reflect the goals of the initiative and take into consideration the costs associated with each strategy.  The variety of outreach activities that are potentially worth pursuing makes accurate budget development a challenge: 

  • Will staff be hired and trained to provide application assistance, or will consumers be referred to community partners?  What are the relative costs of each?  If the initiative will provide assisters, what will it cost to pay salaries and benefits, rent space, purchase equipment, and train staff?  Is there space accessible to the community being served?  Do community partners have the capacity to meet the demand created by the outreach, and can increased capacity be financially supported?    
  • Will school staff be able to support the effort without additional funds or does the level of work required mean they will have to be paid?  How much time will be needed from them and how much will it cost?
  • Are mailings to be sent to the full school community or to a smaller, targeted group or a combination?  What are the costs?
  • Is a subscription to a telephonic interpreter language line needed?  Do legal matters such as developing releases of information and agreements with partners need to be contracted out?
  • Do staff need laptops or tablets to take with them to school events or other offsite locations?  How much is needed for transportation reimbursement for staff to go out to events in the community and meet families at schools and libraries? 

These are just a few examples of low- and high-ticket items that need to be factored into a budget.  Given the complexity, it may be extremely helpful to connect with groups that have pursued similar strategies to make sure all the potential costs have been anticipated. 

Strong Strategies for Attracting and Sustaining Funding

Explore Medicaid Administrative Claiming

Schools can be reimbursed for directly providing certain services, such as speech therapy and counseling, to students who are enrolled in Medicaid.  They can also receive funding for certain administrative activities, such as conducting outreach to promote Medicaid enrollment and providing assistance with applications.

There is great value in providing “one-stop-shop” assistance to help families apply all at once for any program for which they are eligible.  While Medicaid claiming is only available for efforts focused on Medicaid enrollment, funding from other programs like SNAP may also be available to support the part of your work that focuses on enrolling families in that program. 

Notes From the Field on Medicaid and SNAP Funding

Chicago Public Schools has consistently funded about 50 percent of its benefits access unit with U.S. Department of Agriculture funds for enrollment in the Supplemental Nutrition Assistance Program.  Many families served get help to apply for SNAP, Medicaid, and/or CHIP at the same time.  The school system also gets funding from Medicaid administrative claiming for staff time spent on activities such as case management when it directly works with Medicaid-enrolled children getting medically necessary services.

Explore Other Federal, State, and Local Funding Opportunities

There are a number of potential opportunities for federal, state, or local funding for school-based outreach and application assistance:

IV. Online Resources and School Outreach Contacts

Connecting Kids to Coverage National Campaign: School-Based Outreach and Enrollment Toolkit:  This U.S. Department of Health and Human Services resource provides non-school groups valuable information about cultivating relationships with schools and guidance on how to structure outreach.

Linking Kids to Health Coverage and Health Care: A Toolkit for School-Based Health Center Outreach and Enrollment in Medicaid and the Children’s Health Insurance Program: This toolkit is designed to support school-based health centers in the development of outreach and application assistance activities that help enroll children in Medicaid and CHIP.

Together We Can Make Sure All Children Are Happy, Healthy and Ready to Learn! Let’s #InsureAllChildren: The Children’s Defense Fund (CDF) and AASA, The School Superintendents Association toolkit on school-based outreach provides lessons learned from years of outreach conducted in 14 school districts. 

Measuring for Success: Using Data to Reach Your Target Communities and Improve Enrollment Strategies Webinar: This webinar (accessible through a recording, slides, and transcripts) provides guidance on identifying and tracking metrics.

The Effect of Child Health Insurance Access on Schooling: Evidence From Public Insurance Expansions: This study presents compelling evidence that exposure to Medicaid when young increases later educational attainment.

School Nurses’ Perceptions and Practices of Assisting Students in Obtaining Public Health Insurance: This research demonstrates the importance of children's health insurance coverage based on school nurses' perceptions of positive, long-term benefits for students.

Eligibility for Community Eligibility Provision: This searchable database developed jointly by the Center on Budget and Policy Priorities and the Food Research & Action Center provides information about which schools were eligible to adopt community eligibility and which schools had already implemented it as of 2015.

Enroll America Uninsured and Assister Maps:   Enroll America (EA) is a national nonprofit organization working to bring cutting-edge tools, data and policy analysis, and best practices to health care enrollment under the Affordable Care Act.  Among a range of tools, EA uses consumer data and predictive algorithms to assess an adult’s likelihood of being uninsured, then creates interactive “heat maps” that identify areas with high uninsured rates.  School-based outreach programs can use these maps to target schools in areas where large numbers of uninsured but eligible people live. 

Young American Engagement Toolkit: This toolkit focuses on health coverage outreach to young adults, including helpful information about how to engage with colleges and universities.

Forum Guide to Protecting the Privacy of Student Information: State and Local Agencies:  This guide helps state and local education agencies and schools develop policies and procedures to protect information about students and families. It includes helpful examples of requests, notifications, consent forms, and releases, and a memorandum from the U.S. Department of Agriculture on disclosure of children’s eligibility for free and reduced-price meals.

Medicaid School-Based Administrative Claiming Guide: This guide from the Center for Medicare and Medicaid Services (CMS) provides states and schools information about appropriate methods for claiming federal reimbursement for the costs of Medicaid administrative activities performed in the school setting.

Medicaid Payment for Services Provided Without Charge (Free Care): This CMS guide for states clarifies the “free care” policy for Medicaid administrative claiming in school settings.  Medicaid reimbursement is available for covered services that are provided to Medicaid beneficiaries, regardless of whether there is any charge for the service to the beneficiary or the community at large

School Based Outreach Contacts

Chicago Public Schools
Sergio Obregón, Manager, Office of Student Health and Wellness, Social Service Programs
Email: sobregon@cps.edu

Colorado Covering Kids and Families
Contact: Liz Tansey, Outreach and Enrollment Coordinator
Email: LTansey@cchn.org 
Website:  http://ckf.cchn.org/ 

Enroll America Tennessee 
Contact: Jacob Flowers, Tennessee State Director 
Email: jflowers@enrollamerica.org  

Family Healthcare Foundation (Florida) 
Contact: Melanie Hall, Executive Director 
Email: melanie.mshconsulting@gmail.com
Website: http://familyhealthcarefdn.org/

City of Providence Healthy Communities Office
Contact: Azade Perin, Program Manager, Healthy Communities Office, City of Providence
Email: Aperin@providenceri.gov
Website: http://www.nlc.org/find-city-solutions/institute-for-youth-education-and-families/family-economic-success/providence

Minneapolis Public Schools Family Resource Center  
Contact: Thaddeus Lesiak, Coordinator
Email: Thaddeus.Lesiak@mpls.k12.mn.us  
Website: http://ecs.mpls.k12.mn.us/family_resource_center

Partnership for Healthier Kids
Contact: Jill Christiansen, Program Director
Email: jill.christiansen@inova.org 
Contact: Sandra Mwila-Martial, Program Manager  
Email: sandra.mwila-martial@inova.org
Website: http://www.inova.org/inova-in-the-community/partnership-for-healthier-kids/index.jsp

Savannah, GA Mayor’s Campaign for Healthy Kids and Families
Contact: Suzanne Donovan, Executive Director of Step Up Savannah 
Email: sdonovan@stepupsavannah.org
Contact: Eva Elmer, Campaign Manager, Campaign for Healthy Kids and Families, Chatham County Safety Net Planning Council 
Email: evaelmer@chlink.org
Lisa Hayes, Executive Director, Chatham County Safety Net Planning Council
Email: lisahayes@chlink.org
Website: http://healthykidssavannah.org/

Young Invincibles 
Contact: Erin Hemlin
Email: erin.hemlin@younginvincibles.org
Website: http://younginvincibles.org/

Acknowledgements

The Center on Budget and Policy Priorities thanks Atlantic Philanthropies for supporting this paper, including Kimberly Chin, Benjamin Kerman and David Colby for reviewing a draft version. The authors express gratitude to representatives of the following organizations that generously shared their time, information and insights about school-based outreach: AASA, The School Superintendents Association, Bright Research, Chicago City Public Schools, Children’s Defense Fund, Colorado Covering Kids and Families, Enroll America, Enroll America Florida, Enroll America Tennessee, Families USA, Family Healthcare Foundation, City of Providence Healthy Communities Office, Minneapolis Public Schools Family Resource Center, National League of Cities, Partnership for Healthier Kids, Savannah, GA Mayor’s Campaign for Healthy Kids and Families, Virginia Department of Education,  and Young Invincibles.  The authors also thank Wendy Jacobson and Patrick Watson for editorial contributions, Rebecca Segal for help with the research, Judy Solomon for providing valuable technical and editorial feedback, and Rob Cady who formatted the final paper.

Topics: 

End Notes

[1] Linda Blumberg, Michael Karpman, Matthew Buettgens, and Patricia Solleveld, “Who Are the Remaining Uninsured, and What Do Their Characteristics Tell Us About How to Reach Them?” Urban Institute, March 2016, http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf427898.

[2] Sheila Hoag et al., “Children’s Health Insurance Program: An Evaluation, 1997-2010,” Mathematica Policy Research, December, 2011, https://aspe.hhs.gov/sites/default/files/pdf/76386/index.pdf.

[3] Stacy Moody, Brittney Peterson, and Christy Trimmer, “Innovative School-Based Outreach and Enrollment Tactics for Medicaid and CHP+,” Colorado Covering Kids and Families,

http://www.pueblostepup.org/wp-content/uploads/2011/04/White-paper0001.pdf.

[4] Sarah Cohodes, Daniel Grossman, Samuel Kleiner, and Michael Lovenheim, “The Effect of Child Health Insurance Access on Schooling: Evidence From Public Insurance Expansions,” National Bureau of Economic Research, May 2014, http://www.nber.org/papers/w20178.pdf.

[5] Michael Leachman and Chris Mai, “Most States Have Cut School Funding, and Some Continue Cutting,” Center on Budget and Policy Priorities, January 2016, http://www.cbpp.org/research/state-budget-and-tax/most-states-have-cut-school-funding-and-some-continue-cutting.

[6] Brightstar Olsen and Kristina Bedrossian, “Thriving Students Healthy Outcomes: The Role of School Districts in the Age of Health Care Reform,” report prepared by Bright Research Group for Alameda County Center for Healthy Schools and Communities, March 2015.

[7] Becca Segal and Zoe Neuberger, “The Community Eligibility Provision: Alternatives to School Meal Applications,” Center on Budget and Policy Priorities, June 19, 2014, http://www.cbpp.org/research/the-community-eligibility-provision-alternatives-to-school-meal-applications.

[8] Ricky Gonzales, “#StateOfEnrollment: How Targeted Follow-Up Can Increase Enrollment and Reduce Disparities,” Enroll America, April 11, 2014, https://www.enrollamerica.org/blog/2014/04/stateofenrollment-how-targeted-follow-up-can-increase-enrollment-and-reduce-disparities/.

[9] Genevieve M. Kenney, Jennifer M. Haley, Clare Wang Pan, Victoria Lynch, and Matthew Buettgens, “Children's Coverage Climb Continues: Uninsurance and Medicaid/CHIP Eligibility and Participation Under the ACA,” Urban Institute and the Robert Wood Johnson Foundation, May 2016.

[10] Benjamin D. Sommers, Bethany Maylone, Kevin H. Nguyen, Robert J. Blendon, and Arnold M. Epstein, “The Impact of State Policies on ACA Applications and Enrollment Among Low-Income Adults in Arkansas, Kentucky, and Texas,” Health Affairs 34, no.6 (2015):1010-18, doi: 10.1377/hlthaff.2015.0215.

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