welfare, such as by changing the name of the Medicaid program (e.g., Dr. Dynasaur in Vermont). The SCHIP program will pay a limited amount for outreach activities and also includes a ''presumptive eligibility" option that will allow states to immediately enroll Medicaid-eligible children in the program, pending the results of the determination process. In the course of implementing new programs, states are adopting easier application processes, such as mail-in or telephone applications, which may help to enroll more eligible children.

In Somerville, Massachusetts, they required every child coming into the school not only to show their immunization record, but to document whether or not they had either Medicaid or private coverage. They were then able to enroll a whole host of kids who were eligible for Medicaid and who had not been enrolled, but who were legally entitled.

James Bentley

American Hospital Association, Washington, DC

Public Workshop, June 2, 1997

Historically, Medicaid eligibility was tied to eligibility for cash payments under welfare. For the Aid to Families with Dependent Children (AFDC) program, states set the financial standards for eligibility. Enrollment in the Medicaid program involved the rigorous, inconvenient, and often complex or burdensome administrative procedures of qualifying for welfare. Lengthy applications requiring documentation of income and assets, limited hours and locations for the submission of applications, and other challenges made it difficult to enroll in the program.

Although many states have been developing innovative outreach and enrollment strategies, millions of children who are eligible for Medicaid are not enrolled in the program. Estimates of the numbers of these children range from 2 million (Holahan, 1997) to 3.5 million, or 30 percent of uninsured children ages 0-11 (GAO, 1996). About 80 percent of these eligible children have a working parent, and parents who work and who are not themselves eligible for cash assistance are less likely to enroll their children in Medicaid (GAO, 1996; Summer et al., 1997).

Eligible children may not be enrolled for a variety of reasons. Some working parents are likely to be unaware of the program or unable to leave work to go through an enrollment process. Other parents do not trust the health care system for cultural, racial, ethnic, or other reasons; some find the application process difficult; and some do not want to participate in a program that has traditionally been associated with welfare. Other parents' applications have been denied for procedural reasons other than the lack of eligibility, such as the lack of written documentation of income.

Targeted outreach efforts, culturally sensitive public information campaigns, simpler enrollment procedures, and strategies that distinguish the program from welfare are a few ways for improving the rate of enrollment. Outreach and public education efforts will need to include providers, to allow them to become familiar with program changes and to recruit them to participate.

Provider Participation

Medicaid has no premiums and permits only nominal cost-sharing for its enrollees. However, even when children have Medicaid coverage, providers may not be available to see them. A disproportionate number of low-income children and children who are members of racial and ethnic minorities live in areas where there are shortages of medical providers. Even when providers are locally available, there may be few who accept Medicaid payments, and those few may be too busy to accept appointments.

On average, Medicaid payment rates have been about 40 percent lower than the rates paid by



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