May 4, 2001

How Social Workers Can Link Children to Free and Low-Cost Health Insurance
by Jacqueline Patterson and Laura Cox

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National attention is currently focused on efforts to reduce the number of uninsured children. While recent Census data indicate that there has been some progress made toward this end, 7.1 million children in families with income below 200 percent of the federal poverty line ($35,300 for family of four in 2001) still are without health insurance. Nearly all of these children — more than 90 percent — are now eligible for coverage under Medicaid or a SCHIP-funded separate program, yet their families may not know that free or low-cost health coverage is available or how to apply. As professionals working in a broad range of community settings in which they have direct contact with families in need of coverage for their children, social workers can be a driving force behind efforts to enroll children in existing health coverage programs.

Social workers are employed in a variety of settings — such as hospitals, schools and social service agencies — in which it is feasible to incorporate child health insurance outreach activities and application assistance. Often, getting children enrolled in health coverage has a dual advantage: First, families obtain the means to assure their children get the health care they need. Second, providers (including social workers in community clinics or private practice) may be able to receive payment for services they provide, which helps to support and enrich the range of services available to children at that facility. Social workers who are employed in government programs or who are active in community organizations or professional associations also may be in a good position to provide input on administrative and policy decisions. In doing so, they can influence the expansion and improvement of children's health coverage programs.

This paper will describe how social workers can play an integral role in improving the health status of the children they serve by helping them obtain health coverage and by advocating for public policies that respond to the needs of families. Social workers can:

1. Reach out to families seeking medical services for their children. Many children coming to hospitals and health clinics for care are uninsured. One important goal of hospital and clinic social workers is to help families obtain health coverage for their children. Hospital social workers can help sign up children for health coverage to ensure that families leave the hospital with the tools in hand to maintain their children's health. In addition, hospital and clinic social workers can encourage their institutions to invest resources in outreach efforts that target the surrounding community.

The Children's Hospital of Buffalo employs a social worker who helps families apply for children's health coverage. A hospital social worker divides her time between the Jesse Nash Health Center and the Deaconess Family Medicine Center. One of the responsibilities of the social worker is to make sure the families with which she works have health insurance for their children. The social worker encounters many families who are eligible for Child Health Plus A (Medicaid) or Child Health Plus B (New York's SCHIP-funded separate program). She keeps a stack of applications in her office. When families come in, she walks them through the entire application process — conducting home visits, if necessary, to help the family gather required information. Then she sends the completed application to the appropriate agency. The social worker will assist the family in following up with Medicaid or Child Health Plus to check the status of the application, if the family has not received a response from the agency within a few weeks.

2. Identify eligible children through schools and help them enroll. A 1999 study by the Government Accounting Office found that 69 percent of uninsured Medicaid-eligible children were either in school or had school-age siblings. School social workers can help identify and enroll eligible children at school-based health clinics, registration events and school health fairs. Since school social workers have regular contact with children and families, they are in a good position to follow up to make sure that children get enrolled and utilize necessary services.

Social workers sign up children at schools in Virginia. Inova Health System's Partnership for Healthier Kids project (PHK) — a collaborative effort of Inova, the Fairfax Department of Family Services and Northern Virginia Family Services, a non-profit social services agency — enrolls children in health insurance programs through Fairfax County schools. Caseworkers for the project assist families with Virginia's joint Medicaid/SCHIP application at school and during school-sponsored events. Recognizing that social workers are in close contact with families, PHK has tried to increase the involvement of school social workers. During July and August 2000, PHK enlisted school social workers to help families apply for children's health insurance at the district's central registration center, where students enroll in school, arrange for transportation and receive class placements based on language proficiency. Families with children from more than 120 schools received assistance in completing children's health insurance applications.

3. Include outreach efforts in clinical practice. Clinical social work practice involves providing therapeutic interventions for individuals and families. Working with families in this capacity affords the social worker the opportunity to provide personalized assistance in overcoming barriers to progress in various areas of their lives. The social worker can help families prevent illnesses by linking them to health coverage.

The Progressive Life Center (PLC) in Maryland includes screening for health insurance coverage as part of its comprehensive model of psychotherapy. PLC is a private agency that provides a variety of services including foster care, kinship care, substance abuse treatment, juvenile justice interventions and after school care. PLC has adopted a unique form of psychotherapy called Ntu. Ntu — a word derived from the Bantu language — is a holistic approach to healing which encompasses the mind, body, and spirit. The Progressive Life Center staff, which is composed primarily of social workers found that families face a number of barriers to obtaining health coverage for their children. Some families have low literacy levels. Many families do not know how to apply or are intimidated by the process. To address this problem, the Progressive Life staff members link families to health insurance by supplying the application, walking families through the application process, and tracking the application until it is approved. Finally a staff member will go with the family to the initial health care visit to be sure that the family is on the road to maintaining a regular source of care for the children.

4. Enrich services provided through the child welfare system by helping families obtain health coverage for their children. Social workers in child welfare agencies serve a disproportionately high number of families with low incomes. In most cases children in these families are eligible for free or low-cost health insurance. Recognizing this, child welfare agencies nationwide have enriched the services they deliver by screening for health insurance status, as well as by providing application assistance.

In Maine, Southern Penobscot County Community Health and Counseling Services (CHCS) views linking families to health insurance as an integral part of fostering stability for the families they serve. CHCS has been serving families in Bangor, Maine since 1883. CHCS currently has 30 social workers on staff who offer a variety of services including foster care, crisis intervention, case management and individual, group and family therapy. During the intake process, families are routinely asked if they have health insurance. If staff finds that a child is uninsured, the social worker works through the application process with the family and then tracks the application through the system until coverage is confirmed. Subsequently Medicaid and CubCare, the state's SCHIP-funded separate program, can be billed for mental health services CHCS provides to the family.

5. Forge partnerships between social workers and other entities interested in children's health. Alliances among several organizations can strengthen efforts to help families obtain health coverage. Collaborations can be made at the statewide or local level, with each partner organization contributing according to its expertise. For example, one partner that understands the eligibility rules for Medicaid and SCHIP may join another group that has strong ties to the families the programs seek to serve. A social worker who is a supervisor in a state child welfare organization could enlist the county Medicaid office to provide training on application procedures for her staff. As a result of the training the staff members could become proficient in helping families complete children's health insurance applications, thereby upgrading their skills and improving access to health coverage for the families they serve.

The Society for Social Work Leadership in Health Care and the Maine Hospital Association team up to enroll children in Maine. In 1998, the Maine Hospital Association (MHA) worked with the state Department of Human Services to increase children's enrollment in Medicaid and Cub Care. Throughout this effort, social workers championed hospital-based enrollment activities. To build on their involvement, in 2000, MHA approached the statewide association of hospital social workers, the Society for Social Work Leadership in Health Care, to plan a statewide Family Sign Up Day in hospitals across Maine. In preparation for the sign-up day, MHA, in conjunction with the Department of Human Services and Consumers for Affordable Health Care, conducted four regional technical training sessions for hospital staff on how to publicize Family Sign Up Day in their communities. The sessions provided instruction on the application procedures and eligibility guidelines, including a recent expansion of eligibility for parents. The Family Sign Up Day — which occurred on January 10, 2001 — drew more than 1,000 families to hospitals across Maine. All 39 of Maine's hospitals participated in this effort, providing information to families and having social workers and other hospital staff assist families with Maine's one-page health insurance application. Completed applications were submitted to the Department of Human Services for a final eligibility determination — and the effort didn't stop there. In the week following Family Sign Up Day, the state's toll-free enrollment hotline received 500 calls — more than 30 times the hotline's normal call volume. MHA estimates that hundreds of children and parents will ultimately be enrolled in Medicaid or Cub Care as a result of Family Sign Up Day.

6. Incorporate children's health insurance outreach activities in training for students and young professionals. Encouraging students and young professionals to take on outreach activities can promote children's health insurance coverage in two ways — more children are signed up for the program and young social workers learn about the need for outreach and the benefits that children's health coverage can provide to families. Also, training interns to take on these activities can enable organizations that may not otherwise have the resources to conduct children's health insurance outreach.

Social work students help enroll children in schools and clinics in Kansas. The Kansas Association for the Medically Underserved enlisted the aid of a social work student participating in the Americorps program to help enroll eligible children in Kansas City. The Americorps fellow solicited donations from businesses to provide free school supplies and frisbees to families that received application assistance at school-related outreach events. At one such event, 1,000 families completed Medicaid/HealthWave applications. The Americorps fellow also partnered with two health centers to contact families that reported having no health insurance for their children. He contacted these families and offered assistance with the application process.

7. Improve access to free and low-cost health insurance through grassroots community organizing efforts. Through community organizing, social workers work closely with a neighborhoods on concerns that are mutually agreed upon by residents. The health of children is at the heart of every family's core needs. Therefore bringing together families to share their experiences and express their concerns about access to children's health insurance programs is a critical task for community organizers. Such efforts can encourage further program simplification.

Community organizing efforts in Idaho have resulted in key changes in the application procedures for the state's children's Medicaid program. The Idaho Community Action Network (ICAN) is a membership organization that provides a forum for Idaho's families with low incomes to have a voice in decisions that impact their lives. A social worker employed by ICAN helped organize community members to push for improved access for health insurance coverage for children. She worked with families on a "testing project" that documented procedural barriers they faced in applying for health coverage. During February l999, ICAN identified 25 families believed to be eligible for Medicaid coverage. ICAN helped the families apply for the program, and as a result, identified significant barriers. They called upon the Idaho Department of Health and Welfare (DHW) to reform the program's enrollment procedures. The project, along with the efforts of other organizations, paid off. Idaho has since shortened and simplified the Medicaid application, allowed for self-declaration of income, and established 12-month continuous eligibility. The testing project has become a national model for documenting barriers families encounter in the process of applying for health insurance coverage.

8. Engage professional associations in outreach activities. Professional associations are a great resource because they bring together individuals and organizations that are committed to working on common interests. They can be a source of information for their members, communicating on a broad scale, though newsletters, websites, listservs, and individual networking. Social work associations, as representative of large numbers of professionals, can influence policymakers on critical matters related to improving the lives of families.

The National Association of Black Social Workers (NABSW) includes children's health insurance outreach as an action item on its platform. NABSW has distributed outreach materials to its members and has conducted children's health insurance outreach training workshops at annual conferences. At the July 2000 steering committee meeting the association hosted a public policy institute for chapter delegates on children's health insurance. NABSW has distributed information to its 70 chapters on the role community-based organizations can play in ensuring outreach activities are effective.

The Child Welfare League of America (CWLA) encourages outreach efforts among its member agencies. CWLA consists of more than 1,000 member agencies nationwide. Under a grant from the federal Bureau of Maternal and Child Health, CWLA is examining the role of child welfare agencies in connecting children to publicly-funded health insurance. In addition, a packet sent to private agencies included an introductory letter describing the need to include health insurance outreach in their programming, a fact sheet on Medicaid and SCHIP, and an "Insure Kids Now" poster, which advertises the availability of coverage and gives a national toll-free number that families can call for more information.

9. Encourage social workers to take on volunteer efforts that include child health insurance outreach. Many social workers are involved with community organizations outside their place of employment. As community leaders, they can share information about the need for children's health insurance outreach and enrollment activities. For example, volunteers who provide free or low-cost counseling services at a community organization can encourage the organization to incorporate children's health insurance outreach into its mission and materials.

The Tennessee branch of the National Association of Social Workers (NASW) uses volunteer time to share information about children's health insurance. In 1999, the Tennessee branch of the NASW asked a member of its Board of Directors to be a volunteer liaison to social workers in a variety of settings across the state. The volunteer makes presentations on the need to educate legislators about the impact of specific legislative proposals on children's health care. During these presentations, she encouraged social workers to view these activities as an opportunity to advocate for the families they serve.

10. Use professional expertise to advance policies and practices that will improve children's access to health coverage. Social workers can help make sure child health insurance policies and practices are more responsive to the needs of children and families. Social workers can be the link between consumers and policy makers who are working toward improving the well-being of their constituents.

The Child Welfare League of America (CWLA) advocates for children in need of health insurance coverage. CWLA, whose member agencies are often staffed by social workers, advocates on behalf of people involved with the child welfare system. Families served by CWLA agencies receive a variety of services including family preservation, reunification and support to foster care parents. Many of the families have children who qualify for Medicaid or SCHIP-funded health insurance programs. CWLA supported legislation which would allow youth who are transitioning out of the foster care system to qualify for Medicaid coverage. To garner support, CWLA members wrote letters, sent e-mails and made telephone calls to members of Congress. Some local agencies invited congressional representatives to visit their facilities; others testified before Congress. Legislation has since passed which allows youth who are transitioning out of foster care to qualify for Medicaid coverage.

Social workers can make a valuable contribution to the national effort to link uninsured children with health coverage. In addition to being congruent with the overall mission of social work, outreach activities can be viewed as a way to bring financial resources into the hospitals, schools and community organizations where social workers are employed.

Support for this report was provided by the David and Lucile Packard Foundation. The views expressed are those of the authors, and no official endorsement by the David and Lucile Packard Foundation or its trustees is intended or should be inferred.