Uninsured but Eligible

Last summer I worked at the Venice Family Clinic, the largest free clinic in the nation, in Los Angeles. It's an incredible organization that provides care to almost 20,000 people a year through at network of 7 clinic locations. Most patients are Latino immigrants without health insurance, but a fair number are homeless and a slim number are white but not homeless. I worked with the director of programs (the Clinic has dozens), and doing so immersed me in the contemporary debates surrounding health care in California. This, more than working at the clinic itself, was the formative experience I took from that summer.

California, with its enormous population, ballot initiatives and liberal minded legislation faces hurdles unlike most other states. The state Medicaid system is called "Medi-Cal" and covers 6.5 million people. That coverage joins another state initiative, Healthy Families, and a network of county and private orgs (like VFC) to cover the state's enormous uninsured population.

One thing we discussed often at VFC was the number of uninsured-but-eligible children in California. Numerous initiatives were undertaken in the last few years to get these kids enrolled in appropriate state programs but they met mostly failure. On Sunday, the New York Times reported that the number of uninsured children had fallen by 350,000 since 2000.

350,000 seems like a lot of kids. Until you hear how many kids remain unenrolled and think about how many billions went in to enroll less than half a million children in insurance programs. According to the American Academy of Pediatrics:

More than 6 million of the 9 million uninsured children in this country are eligible to receive health care coverage through Medicaid or the State Children's Health Insurance Program (SCHIP), but are not enrolled. The American Academy of Pediatrics (AAP), a national supporter of "Cover the Uninsured Week" (May 1-8), promotes outreach efforts and advocates for simplifying the enrollment process and other paperwork burdens so that eligible families can easily participate. In 2003, 4.1 million uninsured children were eligible for Medicaid, and 2.2 million uninsured children were SCHIP eligible, yet none of these children was enrolled.

Approximately 750,000 eligible but uninsured children live in California. Major initiatives to enroll these kids have basically thrown money down the drain as families continue to resist enrollment.

Why? Why are so many kids still without health insurance? Many in the California policy world argue that immigration status causes many families to avoid authorities altogether, and especially anything that involves taking detailed family information. The complex paperwork process forms another barrier.

And then there's a theory that my mentor ascribed to, and I'm not entirely sure she's wrong. There might be a saturation point, or a limit where, barring legal action to the contrary, the number of people who will sign up for free or low-cost health insurance is reached. Whether the parents work too much to try and sign their kids up, whether they are abusive, strung out, or otherwise, California may have reached a point of diminishing returns, where little benefit will come from additional input.

To those of us with the economic means, it seems crazy to not enroll one's children in free or low-cost health insurance. But we have to realize, despite the New York Times article's claims of extending coverage, that the efforts aren't really working. 6 million kids remain eligible for health insurance but don't have it, and the approaches we've tried thus far might have reached their limit.

Update: Ezra has more. For clarification vis a vis his arguments, I don't think we've reached a saturation point in terms of parents being too [insert negative trait here] to sign up their kids. I do think, however, that the paperwork and system involved in signing up is still too complicated and needs major simplification. I also believe that we need new outreach approaches and that the ones in place since SCHIP are almost stretched to the limit (which is why states like Illinois are passing new major legislation and programs).

Comments

[cdrone]

Let's make enrollment part of the school registration process. Sort of like free/reduced meals program. Should be if a child qualifies for "A"; he/she should meet eligibility for "B". This is monitored at the beginning of each school year. The child brings home income verification paperwork to determine continued eligibility. Parents are much more likely to participate if they understand that healthy child=smarter child. Seems simple. But as you correctly stated, sometimes we make it too complicated.