How Policy Changes Impact Enrollment: A Look at Three County Efforts May 2004 How Policy Changes Impact Enrollment: A Look at Three County Efforts Prepared for CALIFORNIA HEALTHCARE FOUNDATION by The Lewin Group Authors Lisa Chimento Joanne Jee Pooja Shukla May 2004 Acknowledgments This report would not have been possible without the following county agency and health plan administrators who generously contributed their time and input to describe the history and development of their county policy initiatives. From Alameda County: Hannia Casaw, Joyce Kennedy, Paul Reeves, and Jo Robinson, Social Services Agency; Jose Carvajal, Vana Chavez, and Patricia Lebron, Health Care Services Agency; Renee Shiota, Alameda Alliance for Health. From San Mateo County: Glen Brooks, Elsa Dawson, Lorena Gonzalez, Arlette Hess, Angela Romero, and Michel Vasquez, San Mateo County Human Services Agency; Marmi Bermudez, Toby Douglas, and Claudia Lopez, San Mateo County Health Services Agency; Ellen-Dunn Malhotra, Health Plan of San Mateo; Rob Fucilla, Lupe Gutierrez, and Carolyn Thon, San Mateo Medical Center. From Santa Clara County: Mary Cardenas, Cliff O’Connor, Hector Garza, and Dorothy Smith, Santa Clara County Social Services Agency; Margo Maida and Robin Roche, Santa Clara County Health and Hospital Systems; Janie Tyre, Santa Clara Family Health Plan. In addition, eligibility supervisors, eligibility workers, outreach coordinators, and other specialized enrollment staff in each county provided valuable insights into the specialized eligibility and enrollment processes in their respective counties. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s healthcare delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information, visit us online at www.chcf.org. ISBN 1-932064-65-6 ©2004 California HealthCare Foundation Contents 4 I. Introduction 6 II. Background 8 III. Overview of County Initiatives Alameda County’s SCHIP Project and “No Wrong Door” Pilot San Mateo County’s One Stop Model and the Children’s Health Initiative Santa Clara County’s Children’s Health Initiative 13 IV. Lessons Learned and Remaining Challenges Leadership Drove Initiative Development Collaboration Made Initiatives Viable Initiatives Needed Broad Stakeholder Buy-in Financial Interdependencies Were Recognized Action Steps Made a Difference Many Challenges Overcome, But Some Issues Remain 20 V. Using Technology to Support County Enrollment Initiatives 21 VI. Next Steps 22 Endnotes I. Introduction Three counties — Alameda, THE GROWING NUMBER OF PERSONS WITHOUT health insurance continues to be a policy concern nationwide San Mateo, and Santa and in California. Across the country 41 million people — Clara — have gone beyond almost 17 percent of the population — lack insurance. The state requirements, not only problem of the uninsured is especially acute in California, where more than 20 percent of the state’s residents are without in expanding eligibility for coverage. This critical policy issue is currently being explored coverage, but also in creating at many levels in California. One recent statewide initiative to improve California’s health insurance rates is the California a more seamless process Health Insurance Act of 2003 (Senate Bill 2), a “pay or play” for enrollment in county measure, which was signed by Governor Davis in October 2003.1 programs, Medi-Cal, and California counties also have been proactive in addressing the Healthy Families. continuing concern about the state’s uninsured population. A number of counties have been at the forefront of implement- ing initiatives to expand public health insurance coverage and to improve access to coverage for families. Three counties — Alameda, San Mateo, and Santa Clara — have gone beyond state requirements,2 not only in expanding eligibility for cover- age, but also in creating a more seamless process for enrollment in county programs, Medi-Cal, and Healthy Families. These gains were only possible through a series of policy changes and with the concerted efforts of county collaboratives to identify possible improvements in enrollment processes, to think creative- ly about solutions, and to make changes to daily operations. The Lewin Group was asked by The California HealthCare Foundation to prepare this report to share the experiences of Alameda, San Mateo, and Santa Clara Counties with other California counties. The report explores the policy, operational, and other considerations of implementing partnerships among county agencies, health plans, and other community stakehold- ers to change and improve the process for enrolling families into public health care programs. The Lewin Group conducted site visits to each of the three counties to learn about their enrollment initiatives. Lewin staff interviewed key individuals at the counties’ health and social services agencies to understand the steps taken to develop and launch the outreach and enrollment initiatives. Lewin staff also interviewed county eligibility and outreach workers during site visits to understand how “application processing” changed as the counties centralized their eligibility screening processes and 4 | CALIFORNIA HEALTHCARE FOUNDATION ways in which future efforts to automate enroll- their actions would also benefit their county’s ment will impact their day-to-day tasks. Finally, overall fiscal situation. Lewin staff interviewed representatives from the ■ A common set of actions helped to build local health plans involved in the development and strengthen the initiatives’ underlying and implementation of the expansion and enroll- foundations. Action steps often were taken ment initiatives to gain perspective on their concurrently and required the participation successes and challenges faced. of each initiative partner. The actions steps While each county took a different approach resulted in real progress toward counties’ toward increasing enrollment in public health goals, strengthening their partnerships. care programs, the following lessons were Additional information about each county’s learned: enrollment initiatives, as well as a more detailed ■ Strong leadership drove initiative development. discussion of the lessons learned, are presented In each county, one or more champions of the below. initiatives brought stakeholders to the table, gaining their commitment and support. This leadership made initiative development and implementation possible. ■ Intra-county collaboration made the initiatives viable. County agencies, health plans, and other community stakeholders shared common goals. By working in partnership, agencies benefited from each others efforts. Collabora- tion among initiative partners previously had been inconsistent, but became the norm with implementation of county initiatives. ■ Broad stakeholder support was critical to the success of the initiatives. To advance initia- tives, county collaboratives considered the needs of and input from various stakeholders, such as eligibility workers, other agency line staff, health plans, community-based organizations, hospitals, and schools. Stakeholder involvement began early in the initiatives and secured ongoing support. ■ County stakeholders acknowledged the financial interdependencies that exist between each county’s organizations. The financial future of initiative partners is interwoven. Partners across agencies within each county recognized that their upfront financial commitments would not only bring them closer to reaching their policy goals, but that How Policy Changes Impact Enrollment: A Look at Three County Efforts | 5 II. Background ALL THREE COUNTIES PROVIDE HEALTH COVERAGE to a variety of populations through local health insurance expansion programs and have designed these initiatives to address their local needs (see Table 1). The counties financed their expansion programs with combined funding from Proposition 10 through local First 5 Commissions, county and municipal funds, local health plans, and hospital and health care districts. They also solicited and obtained one-time and some ongoing grant dollars from foundations and local Tobacco Settlement Funds. Table 1. Overview of Local Health Insurance Expansion Programs, by County Program Population Implementation COUNTY Name Covered Date Alameda Alliance Uninsured adults and July 2000 Family Care children between 250– 300% of the federal poverty level (FPL). Santa Clara Healthy Uninsured children January 2001 Kids under age 19 and below 300% of the FPL. San Mateo Healthy Uninsured children January 2003 Kids under age 19 and below 400% of the FPL. In operationalizing their expansion programs, these three counties implemented innovative approaches to eligibility determination and enrollment, “changing the way they do business” in order to improve and streamline the process for families. One of the biggest barriers faced by counties was organizational. Within these counties, the health agency is distinct from the human services agency. Each has its own budget, staff, and programs that are developed and adminis- tered with little, if any, consultation with other agencies in the county. In general, the health agency is responsible for provid- ing public health care services and programs such as behavioral health, environmental health, and some indigent care programs; while the human services agency is responsible for public social service programs such as general assistance, food stamps, and Medi-Cal. The independent structure of county agencies contributes to infrequent collaboration and limited awareness of each other’s 6 | CALIFORNIA HEALTHCARE FOUNDATION missions and the interdependencies (e.g., finan- cial and health insurance coverage goals) that exist. Front line eligibility and enrollment staff in each agency hold specialized roles and only focus on enrolling clients into the specific programs within their agency’s purview. For example, a family coming to a county clinic in need of serv- ices might find that the adults could be enrolled at the clinic in a county-sponsored program, while the children would be referred to two other programs — Medi-Cal and Healthy Families — depending on their ages. To enroll the children, the family would be required to go to two sepa- rate entities, often in two separate locations, to apply for coverage. Due to the policy decisions made in Alameda, Santa Clara, and San Mateo Counties, however, health and human services agencies, health plans, and community based organizations work together to enroll families in the most appropri- ate health insurance program available. The county eligibility workers, other front line staff, health plan staff, and other community based organization staff now assist families in the application and enrollment processes for several programs — Medi-Cal, Healthy Families, Healthy Kids and other county health care programs — regardless of their specific agency affiliation. Families, the agencies, health plans, and other community stakeholders have benefited from the new partnerships. How Policy Changes Impact Enrollment: A Look at Three County Efforts | 7 III. Overview of County Initiatives EACH O F T H E T H R E E P I L OT C O U N T I E S — Alameda, San Mateo, and Santa Clara — has taken a different approach to increasing access to public health insurance programs for children and families. The initiatives in place in each county are examined below, and the approach and neces- sary action steps identified by the county health and human services agencies, health plans, and stakeholder groups to create a seamless enrollment process are discussed. The information presented below was obtained during county site visits and interviews with county agency and health plan staff, unless otherwise noted. For more detailed information about coun- ties’ outreach and enrollment strategies, see “County Profiles” at www.chcf.org/topics/view.efm?itemID=102216. Alameda County’s SCHIP Project and “No Wrong Door” Pilot Until fall 2001, Alameda County’s Medi-Cal intake process typically required clients to come to the county’s Social Services Agency (SSA) one or more times to meet with a Social Services intake worker, complete the Medi-Cal application, and provide all required supporting documentation. The Social Services intake worker would review all the information and determine eligibility. In the event a client was deemed ineligible for Medi-Cal (which could take up to 45 days to determine), the applicant would be denied coverage under Medi-Cal and would be informed of alternative coverage options (i.e., Healthy Families), but received little additional assistance in applying for the programs. Alameda County experimented with two pilot projects, the SCHIP project and the No Wrong Door pilot, in an attempt to make the overall application process more timely and efficient, not only for the applicant but also for county staff and other stakeholder groups. SCHIP Project In an effort to maximize enrollment in available public health insurance programs, the Alameda County Health Care Services Agency (HCSA), in collaboration with SSA, implemented a Medi-Cal, Healthy Families, County Medically Indigent Services Plan,3 and Alameda Alliance Family Care4 pilot project (referred to as “the SCHIP project”) in October 2001. A major objective of the project was to implement the recommendations 8 | CALIFORNIA HEALTHCARE FOUNDATION of the Alameda County Children and Families Families due to improved pre-screening and Health Insurance Task Force, which was convened coordination between HCSA and SSA. The by County Supervisor Alice Lai-Bitker to increase total number of people served by the SCHIP public health insurance enrollment, retention, Project totaled about 2,650. The project also and utilization. The project was funded by a yielded policy and operational recommendations $600,000 pilot grant from the State Children’s to develop a coordinated and comprehensive Health Insurance Program (SCHIP)5 and enrollment system that could be implemented $210,000 in required matching funds from the throughout Alameda County. Increased collabo- county. Alameda County estimates that actual ration between HCSA and SSA is a lasting effect project expenditures totaled $1.2 million.6 of the SCHIP project. The two agencies, along with volunteers from a dozen community-based Through the SCHIP project, the county made organizations,7 and state officials from DHS and several enhancements to the existing outreach MRMIB, coordinated in a way not previously and enrollment process, including conducting experienced to develop and staff enrollment ten community-wide enrollment events; using a events. computer-based application on laptop computers to improve timeliness, efficiency and accuracy “No Wrong Door” Pilot of applications; developing marketing materials; and creating a call center to provide information Continued collaboration enabled HCSA and about enrollment events. Approximately 24 SSA to implement the “No Wrong Door” pilot, Medi-Cal eligibility technicians (ETs) were an extension of the SCHIP project, to further its co-located with an equal number of Healthy policy and operational recommendations in July Families certified application assistants (CAAs) 2002. The “No Wrong Door” pilot, this time at the enrollment events. HCSA recruited and under the leadership of SSA and in conjunction trained CAAs from a pool of 54 volunteers. with HCSA, aimed to increase access and Together, teams of ETs and CAAs conducted approval rates for its health insurance and other initial eligibility determinations and pre-screened public assistance programs, improve efficiency applicants for the most appropriate form of of application processing, and increase program health insurance coverage. For the SCHIP pilot, retention. In addition to Medi-Cal and Healthy the Managed Risk Medical Insurance Board Families, other county-only expansion programs (MRMIB), the governing agency of the Healthy were included in the pilot, such as Alliance Families program, approved a request from Family Care and the County Medically Indigent HCSA that allowed eligibility workers to use the Services Program. joint Medi-Cal and Healthy Families application The “No Wrong Door” pilot also tested another for Healthy Families enrollment as long as eligi- key policy change — allowing Social Services staff bility workers confirmed that the applicant was to accept and process Healthy Families applica- indeed ineligible for Medi-Cal. In the SCHIP tions.8 During the pilot, Medi-Cal and Healthy pilot, the time required to complete the eligibility Families determinations were run concurrently determination in the application process was with three Social Services and two HCSA eligi- reduced because of the joint processing system bility workers designated to serve as Social in place. Services application assistors (SSAAs), a position The SCHIP project resulted in a higher rate of created specifically for the pilot. To identify the Medi-Cal eligibility approval and increased eligibility staff that would participate in the pilot, enrollment in both Medi-Cal and Healthy the county solicited volunteers from existing eligibility staff. During the pilot, every fourth How Policy Changes Impact Enrollment: A Look at Three County Efforts | 9 applicant who entered the Social Services office take advantage of the new enrollment process. In seeking Medi-Cal coverage was designated for the nine months following pilot implementation, processing via the pilot and met with an SSAA. more than 2,400 individuals were screened and All staff were trained using a training module the number of county offices participating in the developed jointly by HCSA and SSA. pilot expanded to five. Two additional satellite sites opened in December 2003.9 During the pilot, when clients walked in to a Medi-Cal office, they first met with an SSAA who conducted an initial assessment and assisted San Mateo County’s One Stop Model the client in completing the appropriate program and the Children’s Health Initiative application. If the client was pre-screened for Medi-Cal eligibility, the client would meet with One-Stop Model a Social Services eligibility technician to complete Between 1995 and 1996, San Mateo County processing of the application. If pre-screened and unveiled one-stops — single enrollment locations ineligible for Medi-Cal, the SSAA completed the where clients accessed a broad range of public appropriate application documents and forward- services. The one-stops were part of the county’s ed the client’s application to the appropriate move to adopt a model of integrated delivery of health coverage program (Healthy Families, county services whereby a family could access Alliance Family Care, or the County Medically multiple Human Services Agency (HSA) pro- Indigent Services Program) for processing. grams (e.g., Medi-Cal, employment training, CalWORKs, food stamps, general assistance, The county’s new referral system deviated from etc.) at a single entry point or location.10 the traditional Medi-Cal application process in that clients in the pilot walked away enrolled in Before the one-stops were implemented, programs Medi-Cal or with the application forwarded to were isolated from each other, requiring families another health coverage agency. In the traditional to complete a separate application process for Medi-Cal application process, referrals to other each program, often at different office locations programs sometimes occurred, but pended or around the county. Under the one-stop model, denied applications often would fall through the families could go to any of the county’s one-stop cracks over time or the applicant would refuse, offices and were screened by one eligibility worker or fail, to follow up with other coverage options. for multiple HSA programs. Building upon HSA’s one-stop model, in 2002, HSA and the Similar to the SCHIP project, under the “No Health Services Agency (Health) implemented Wrong Door” pilot, SSA and HCSA conducted similar strategies to create a more seamless enroll- enrollment events where ETs and application ment process for and to maximize enrollment in assistors used laptop computers with an electron- Medi-Cal and Healthy Families, working collab- ic application template developed by the county oratively to conduct outreach and enrollment to help families complete applications. Families events throughout San Mateo County. applying for health insurance coverage at these events left enrollment events either enrolled in Health Services established a new application Medi-Cal or with an application for Healthy assistant position, Community Health Advocate Families or Alliance Family Care referred to the (CHA), to assist families to complete applications appropriate agencies. As word about these enroll- for Medi-Cal, Healthy Families, and the county’s ment events and the “No Wrong Door” pilot Section 17000 program, Wellness Education spread, families from areas outside of those served Low-cost Linkage (WELL), in clinic sites.11 Prior by the pilot sites would attend enrollment fairs to to the creation of the CHA position, San Mateo 10 | CALIFORNIA HEALTHCARE FOUNDATION County Health Services Agency staff believed Santa Clara County’s Children’s that there were individuals enrolled in WELL Health Initiative who might be eligible for Medi-Cal, but were not In January 2001, the Children’s Health Initiative enrolled due to scarce clinic resources devoted to (CHI) was launched in Santa Clara County as a enrollment assistance and insufficient time before partnership between the Social Services Agency the actual clinic visit itself to complete the lengthy (SSA), Health and Hospital Systems (HHS), the process for Medi-Cal. Because the county was Santa Clara Family Health Plan (SCFHP), and not leveraging Medi-Cal dollars, it was draining other community-based organizations. The vision its own local resources at an even higher rate of the county-wide initiative is that 100 percent than necessary. For the first time, HSA benefits of the children residing in Santa Clara County analysts and Health Services CHAs were co- with incomes at or below 300 percent of the FPL located at clinic sites, community family resource shall have access to quality health care through centers, and staff enrollment events to ensure comprehensive health insurance. CHI serves as families were enrolled or referred to the appropri- an umbrella for Medi-Cal, Healthy Families, and ate program in a timely manner and without the Healthy Kids program.13 To increase access for requiring families to make multiple trips to sepa- children, the CHI’s goals are to educate families rate application centers. Also, from 2000–2002, about use of their health benefits, improve enroll- HSA increased outstationed benefits analysts at ment and retention, and create a single point of community clinic locations from seven to 14. access to any of the three CHI programs. Children’s Health Initiative During the summer of 2001, Santa Clara County Continuing its commitment to ensuring health implemented a pilot project to cross-train eligi- insurance coverage for San Mateo County resi- bility workers and CAAs to use a more holistic dents and to a seamless health insurance approach to enrolling children and families in the application process, San Mateo County rolled county’s public health insurance programs. With out its Children’s Health Initiative (CHI) in this goal in mind, new eligibility processes were January 2003. The cornerstone of CHI is the designed for CAAs and SSA eligibility workers Healthy Kids program, which provides coverage located in clinics and county SSA district offices. to children under age 19 in families with incomes In settings where eligibility workers were co- below 400 percent of the FPL. Eligibility for located with HHS financial counselors (who Healthy Kids is conducted using the one-stop determine eligibility for HHS-administered HSA-Health method of enrollment. While programs, such as the Child Health Disability Healthy Kids eligibility is determined by specialized and Prevention Program and Family Planning, HSA benefits analysts (BAs), all BAs and CHAs Access, Care and Treatment), processes were can assist families in completing applications for jointly developed to facilitate workflow and any form of health coverage in the county. Under eliminate duplication of services between these CHI, BAs and CHAs assess whether children programs and those under CHI. In Santa Clara, appear to be eligible for Medi-Cal, Healthy financial counselors (FCs) have traditionally been Families, and Healthy Kids — in that order — trained as Healthy Families CAAs as well. With and assist families in completing the appropriate the implementation of the CHI, the FCs also application. San Mateo County also actively acquired responsibilities for enrolling children pursued ways to use automation to support the in the Healthy Kids program, and HHS was One Stop program and is now implementing authorized to hire additional FCs to assist with Health-e-App on a countywide basis.12 enrollment as part of the CHI. Representatives How Policy Changes Impact Enrollment: A Look at Three County Efforts | 11 from HHS, SSA, and SCFHP participated in public forums around the county to increase their visibility and presence. County agency staff engaged in joint trainings and launched a cam- paign to shift the public’s perception of their agencies from unwelcoming to welcoming. Approximately 26 application assistors14 and 11 FCs initially participated in the initiative, and now more than 500 eligibility workers have been trained to assist with joint Medi-Cal, Healthy Families, and Healthy Kids application intake and processing. Santa Clara sought and obtained approval from MRMIB to allow the county to have lead trainers who could train other Medi-Cal and Healthy Families eligibility workers to be CAAs for the Healthy Kids program. Since its inception in January 2001, more than 76,000 eligible children applied for health insurance through the CHI. The Santa Clara County Board of Supervisors and the San Jose City Council played a key role in advancing the initiative. Tobacco settlement funds, SCFHP, FIRST 5 grants, and several foundations15 provided financial support for health care premiums and seed money for various aspects of the initiative, including outreach and enrollment. SCFHP was a key partner from the initial conception of the CHI, acts as the administrator of the Healthy Kids program, and continues to perform many operational and financial duties for the initiative, including mar- keting, organizing public relations campaigns, conducting outreach, and training. In 2000, the SCFHP formed the Santa Clara Family Health Foundation, which is the primary fundraiser for Healthy Kids. Santa Clara County’s CHI efforts continue with ongoing planning and policy-making by the CHI Policy Group, whose membership includes SSA, Health and Hospital Systems, SCFHP, People Acting in Community Together (PACT),16 and Working Partnerships USA.17 12 | CALIFORNIA HEALTHCARE FOUNDATION IV. Lessons Learned and Remaining Challenges “Running a pilot project takes S EVERAL CONSIDERATIONS RELATED TO THE development and implementation of enrollment initiatives leadership—people with a emerged during interviews with county staff and stakeholders. risk-taking attitude and These lessons learned were critical to the success of the three people that are good at counties’ enrollment initiatives. The key lessons learned by the initiatives are described below, followed by the specific action consensus building.” steps that the counties took to move their initiatives from — Alameda Alliance for Health concept to reality. representative Leadership Drove Initiative Development In each county, the leadership and dedication of individuals and community-based organizations drove the ultimate plan- ning and implementation of new county enrollment initiatives, including their decisions to modify the roles and responsibilities of eligibility workers. At the same time, the impetus for change in each county was unique. Individuals who were interviewed stressed the importance of identifying one or more initiative champions to move the initiative from concept to implementa- tion. The champion in each pilot county helped convene the necessary players, ensure commitment of resources, and win overall support for the initiative. In San Mateo County, managers from both the Health Services and Human Services Agencies brought the agencies together to implement the county’s one-stop model. In Alameda, the “No Wrong Door” pilot grew from one elected official’s leadership in convening a task force of community- based organizations, providers, and county agencies to increase enrollment and retention, and to better utilize exist- ing public health coverage programs. Santa Clara benefited from a strong partnership between county management and staff, SCFHP, and labor leaders who were dedicated to improving access to health coverage for children. How Policy Changes Impact Enrollment: A Look at Three County Efforts | 13 Collaboration Made Initiatives Viable traditional role of gatekeeper, but faced the chal- lenge of increasingly tight budget constraints. “Instead of being perceived as gatekeep- After gaining each other’s perspective, initiative ers, we are now perceived as doormen.” partners understood that actions that helped the — San Mateo Human Services Agency mission of other agencies or organizations also administrator benefited their own. Newly recommitted to their shared goals, staff from county agencies, health “Most benefit analysts, child health plans, and other initiative partners continued meeting to implement their enrollment initia- advocates and eligibility technicians no tives. County and health plan staff and eligibility longer have misunderstood or negative workers acknowledged that having fresh goals and a shared outlook built the momentum neces- images of each other. The common focus sary to institute change. is the client, so cooperation among all In each county, the local health plan (i.e., the of us is made easier.” Alameda Alliance for Health, Health Plan of San Mateo, and Santa Clara Family Health Plan) was — San Mateo Health Services Agency eligibility worker involved in the development and implementation of the health care initiative to varying degrees. The countywide organizational collaboration These health plans not only funded part or all required to successfully implement new outreach of county-based health care programs, but have and enrollment initiatives cannot be underesti- also participated in planning and brought their mated. The new enrollment approaches took capabilities to assist with activities such as out- hold once leaders from county agencies, health reach and retention. plans, and other community stakeholders recog- nized that they shared common goals. By collaborating with groups in their counties, in Through establishment of the Children’s Health Initiative, Santa Clara County Social Services some cases the local health plan and in other Agency and Health and Human Services cases the County Board of Supervisors, leaders Agency now cross-train workers to have a from the county agencies realized tangible working knowledge of several county adminis- progress could be achieved by bringing together tered programs; conduct joint staff trainings; stakeholders to discuss and develop a shared and conduct joint enrollment events for the vision around outreach and enrollment. Medi-Cal, Healthy Families, and Healthy Kids programs. Traditionally, administrative staff and eligibility workers did not interact with their counterparts at other agencies. Agencies also grappled with the natural tensions that existed in their roles both as service provider and “gatekeeper,” where their responsibility is to ensure that only those persons who meet all program requirements and submit necessary documentation are enrolled in the program. Agencies were enthusiastic about increasing enrollment and retention, demonstrat- ing a significant philosophical change from their 14 | CALIFORNIA HEALTHCARE FOUNDATION Initiatives Needed Broad their clients, by seeking staff input on aspects of Stakeholder Buy-in the enrollment process that needed improve- ment, conducting staff training, and identifying “One of the lessons learned in launching strategies to facilitate the enrollment process. county initiatives is recognizing the Counties also published internal newsletters to keep staff informed on the progress of initiatives benefits of having a health plan that is and to solicit their feedback. In some cases, eligi- connected to the county — it creates a bility worker positions were elevated or salaries were adjusted to recognize their modified respon- vehicle to make things easier and to sibilities. In Alameda County, the eligibility make things happen faster.” workers who originally volunteered to participate in the “No Wrong Door” pilot were so enthusias- — Alameda Alliance for Health representative tic about the new enrollment process that the pilot gained popularity among other eligibility “Staff were very open to the initiative workers in the county and additional eligibility workers requested to participate in the pilot. and liked being able to offer families Agencies also engaged boards of supervisors by other programs [if they were determined including them in planning meetings, presenting updates at board meetings, and hosting initiative- ineligible for another program]. related events to recognize the contributions of Eligibility workers embraced the county staff and the board members themselves. initiative.” Clients themselves are key stakeholders in coun- ties’ enrollment initiatives. County staff noted — Santa Clara Health and Hospital Systems representative that clients were generally eager and enthusiastic about participating in county pilots, especially In shaping and implementing their enrollment when they experienced a more efficient applica- initiatives, initiative partners garnered support tion process. Clients also especially appreciated from various stakeholder groups, including eligi- receiving a preliminary eligibility determination bility workers and other agency line staff, health from one eligibility worker, rather than having to plans, community-based organizations, hospitals, submit separate applications to different eligibili- clinics, schools, and county board members. To ty workers at multiple sites. advance their initiatives and limit potential hur- dles, the counties built collaborative relationships Financial Interdependencies and identified common goals with these and Were Recognized other stakeholder groups early on and throughout the planning process. The counties acknowledged In addition to the policy goals that factored into that several factors — including stakeholder inter- the counties’ decisions, financial considerations ests and cooperation, the political climate, and also played a significant role. The county social county demographics — could all shape the services and health agencies and the local health direction of an enrollment initiative. plans recognized that their budgetary futures were interwoven. For example, shortfalls in County agencies won the support of their staffs, health agency budgets have repercussions for which were open to innovative enrollment tech- social services (and other county agency) budgets. niques that would enhance their ability to assist Likewise, these county social services agencies How Policy Changes Impact Enrollment: A Look at Three County Efforts | 15 knew that their processing times and approval not only with their own coverage goals, but also rates directly affected the revenues of their county with their business needs. health agencies and health plans. All of the enti- ties also realized that Medi-Cal and Healthy Action Steps Made a Difference Families coverage provides federal and state matching funds, saving local dollars for local pro- “We had a deliberate campaign [within grams. In this way, dedicating county and health plan resources to eligibility and enrollment was the Social Services Agency] to change seen as a benefit to all county entities; therefore, the view of the initiative as a pilot to there were recognized benefits in the need for reallocation of budgetary resources across agencies county-wide adoption. Health and or in achieving savings through more efficient Hospital Systems and the Social Services eligibility processing. Their initial investments in Agency were in it together. We did cross-training of eligibility workers were made in an effort to enhance caseworker efficiency, which trainings together and we still meet has ensured a quicker application process, reduced monthly to talk about the issues.” the number of eligible but uninsured individuals, and assisted in creating healthier communities. — Santa Clara County Social Services Agency representative In practice, leaders from the county agencies and health plans recognized that implementing their The initiative partners took specific steps to build policy decisions required initial and ongoing and strengthen the foundation of county enroll- financial commitment. In Santa Clara County, ment initiatives. Many of these activities occurred for example, the SSA struggled with financial concurrently and all were equally important. hardships in its Medi-Cal program while the Counties made the following operational and county’s HHS (the county’s largest department financial decisions to develop and implement the fiscally) remained financially viable. When leaders enrollment initiatives that not only improved from both agencies and the health plan convened, access to health coverage, but also made them all parties recognized that collaboration and uniquely positioned to launch future initiatives. dedication of HHS and health plan resources to outreach, eligibility, and enrollment would not Conduct a Preliminary Assessment only bring to fruition many of their shared goals, Before designing its enrollment initiative, each but also provide a return on their investments in county reviewed its current enrollment process the form of increased revenue. and assessed needed improvements. Assessments could be formal, as in San Mateo County, where Financial considerations also bolstered health a report on findings from an evaluation of the plans’ support of county initiatives. From the county’s outreach and enrollment activities health plan perspective, increased enrollment of identified obstacles to enrollment and made eligible families into appropriate public insurance recommendations for improvement. Other programs also meant an increase in the plan’s counties’ assessments were more informal, with enrollment and revenues. Of course, the quicker stakeholders meeting to identify challenges and and more efficient eligibility determination discuss ways to increase access to health coverage. process only furthered the financial benefit to the The resulting findings and recommendations plans. For the health plans, supporting counties’ were the basis upon which initiatives were efforts to facilitate enrollment was in alignment developed. 16 | CALIFORNIA HEALTHCARE FOUNDATION Counties also assessed what resources might be working groups that focus on particular issues, available to support their initiatives and also such as outreach, retention, and training, meet looked at the political landscape. Identification regularly to address the issues affecting initiatives. of the barriers and opportunities before the The county partners also met with boards of initiatives helped proponents develop their supervisors. Meeting participants typically implementation strategy. included staff from the counties’ health plans, as well as from the county agencies. In one county, Make Cultural and Attitudinal Changes staff from the human services and health agencies Both health and social services agencies experi- participated in a day-long strategy retreat. These enced a cultural and attitudinal change around meetings serve multiple purposes. Meetings are eligibility, outreach, and enrolling children and an effective way of keeping stakeholders up to adults into public insurance programs. Where date on the progress of initiatives to maintain agencies previously worked independently of their support, without which the initiatives each other, a new, collaborative relationship would face substantial hurdles. Additionally, was built among agencies to frame enrollment meetings encourage the ongoing participation initiatives and work at outreach events to enroll of county organizations and their continued families in public health insurance programs. collaboration. County agencies came to see themselves as partners, rather than independent entities. Address Management and Staff Concerns Understanding the needs and concerns of all While the counties had previously acted as gate- stakeholders, and working with them to address keeper, directing eligibility workers to prevent those needs early in the development process, families from enrolling in publicly funded health helped ensure timely progress of county initiatives. care programs, counties had gradually changed to County agencies consulted, and continue to con- encourage workers to enroll as many families as sult, management representatives to work through possible. Enrollee retention also became a priority. productivity and staffing issues as they arise. By In Santa Clara County, continuing eligibility providing training and reviewing initiative goals workers, who redetermine eligibility for established with staff, agencies overcame staff concerns or cases, also were trained to provide application hesitancy to adopt the operational protocols of assistance for Healthy Families and Healthy Kids. initiatives. For example, some eligibility workers The county agencies coupled these attitudinal initially were unfamiliar or uncomfortable using changes with business process changes, namely a technology to determine eligibility. Counties have shift to customer service, follow-up, and use of demonstrated that while challenges may arise, automation. The Alameda County Social Services by working as partners and thinking creatively, Agency, for example, became less rule-oriented the needs of all stakeholders, including county and more service-oriented. agencies and management, can be met. Meet and Provide Regular Updates Conduct External and Internal Marketing County health and social services agencies, health Counties marketed their initiatives to their stake- plans, and other stakeholders met regularly holder groups, including staff and clients, to throughout the planning and implementation obtain initial and ongoing support. Alameda of their enrollment initiatives and continue to County published successes of their pilot program do so. During meetings, agency staff and other in newsletters and through local media and also stakeholders provide updates on progress and held recognition events for eligibility workers and next steps for the initiatives. Subcommittees or How Policy Changes Impact Enrollment: A Look at Three County Efforts | 17 Healthy Families CAAs employed by both agen- Staffing and Productivity Issues cies. Santa Clara County hosts learning sessions Are Complex over lunch for eligibility workers and publishes Defining the roles and responsibilities of eligibility newsletters that are disseminated to county health workers in county initiatives was a challenge that and social services staff. The learning sessions stakeholders addressed early on in the planning and newsletters are avenues for sharing initiative processes for county enrollment initiatives. The updates, encouraging staff participation, and initiatives brought with them significant changes for training. Santa Clara County’s CHI Public in how enrollment in Medi-Cal, Healthy Relations and Marketing group and the CHI Families, and county health insurance programs Outreach group, which includes SCFHP, the would occur, affecting eligibility workers’ duties. HHS, other CHI partner agencies, and labor Acceptable staffing and productivity strategies groups, meet monthly. These groups ensure con- were developed over time through the concerted sistency in marketing messages and coordinate and collaborative efforts of county staff and and maximize limited resources. The SCFHP management representatives. Strategies took into plays a key role in the external marketing of the consideration the experience of eligibility workers, county Children’s Health Initiative. SCFHP con- the complexity of assigned tasks, and the desire ducted a public relations campaign with local of staff to participate in the initiatives. County newspapers such as the San Jose Mercury News managers and management representatives con- to gain exposure for the initiative. SCFHP also tinue to work together to address other issues as called on its speakers bureau, including the high- they arise. est levels of SCFHP’s leadership, to present at meetings of community organizations like the Struggles with Success Arise Rotary Club and the Kiwanis Club. The agencies Counties are achieving their goal of linking fami- promoted the pilot programs to prospective lies to health insurance coverage. However, clients by establishing and advertising a toll-free counties also are struggling with their success. hotline through colorful posters and banners at Following the launch of their new marketing clinics, enrollment fairs, etc. Working with clients campaign and the enrollment fairs for the was important for building their trust in and Children’s Health Initiative, Santa Clara County understanding of the benefits of the counties’ witnessed a rise in applications, increasing staff new ways of doing business. workload and boosting the number of Medi-Cal, Healthy Families, and Healthy Kids enrollees. Many Challenges Overcome, Clients who heard through word of mouth about But Some Issues Remain Alameda County’s “No Wrong Door” pilot flocked to the three pilot sites from outlying For the three counties, planning and implement- regions to apply for coverage using the new, more ing their enrollment initiatives was not without efficient application process; long waiting times challenges. Some variation existed in the types ensued. In fact, enrollment in county expansion of issues encountered from county to county; programs has grown so rapidly that budgetary however, it is noteworthy that the counties and limits are being reached and, in Alameda and other stakeholder groups worked tirelessly to find Santa Clara Counties, enrollment caps have been workable solutions for each of the challenges met, requiring the counties to set-up waiting raised. Some of these challenges are ongoing and lists. In Alameda County, the Alliance Family new ones will arise as county initiatives continue. Care Program was not accepting new members as of early December 2003 because of the combined 18 | CALIFORNIA HEALTHCARE FOUNDATION effects of families’ need for health coverage, the state’s budget crisis, and the local effects of premium cuts. San Mateo expects to reach its Healthy Kids enrollment limit of 5,800 enrollees by the end of summer 2004.18 Some State Budget Constraints May Be Addressed Locally With increasing state and county budgetary constraints and the state imposed Medi-Cal cuts, the counties face tough decisions about how best to proceed in enrolling eligible but unenrolled populations into appropriate state and county administered programs. County staff from both health and social services agencies reiterated the benefits derived by the community as a whole when efforts are made to provide health coverage and other social services to both adults and chil- dren, as well as the increased need for such services during difficult economic times. County agencies looked to and are continuing to work together to gain financial support from alternate sources for financial support (e.g., foundations and corporations). Despite ongoing budget con- straints, Santa Clara HHS, in partnership with SCFHP, recently increased their investment in outreach activities to $1 million in FY 2001 and then contributed $750,000 in the following year. SCFHP continues its leadership in garnering financial support for the Healthy Kids program. The CHI Policy Group acknowledged the diffi- culty of the decision during a time of ongoing budget constraints, but in the end, stayed com- mitted to their critical role in advancing the goals of the Children’s Health Initiative. How Policy Changes Impact Enrollment: A Look at Three County Efforts | 19 V. Using Technology to Support County Enrollment Initiatives Implementing technology AS ALAMEDA, SAN MATEO, AND SANTA CLARA Counties continue to refine and implement their initiatives, solutions that will allow they look for new tools to implement their policy decisions counties to automatically effectively. Implementing technology solutions that will allow screen and enroll eligible counties to automatically screen and enroll eligible families in Medi-Cal, Healthy Families, or other local or state-based families in Medi-Cal, health insurance programs is the next step in advancing county Healthy Families, or other initiatives and policy goals. Automation allows eligibility staff to link families more effectively to the appropriate health care local or state-based health programs. Technology allows for screening for eligibility for insurance programs is the multiple programs quickly and efficiently, and enables a more efficient referral process to other agencies as appropriate. next step in advancing Technology also reduces the need for detailed training and county initiatives and knowledge of complex eligibility rules for every program, policy goals. which are subject to change. Further, automation can facilitate automatic screening for multiple programs and also assist eligi- bility technicians with recertifications for continuing clients. The three counties have taken preliminary steps in automating and using technology to support their respective county initia- tives. For example, Alameda County provided a small number of computer-savvy outreach workers with laptop computers and a computer-based enrollment form for use at enrollment events. In San Mateo, some outreach and enrollment workers piloted Health-e-App, the Web-based application for enrolling children and pregnant mothers in Medi-Cal or Healthy Families. In the coming months, Alameda, San Mateo and Santa Clara will pilot One-e-App, a Web-based application that builds upon Health-e-App to include screening and enrollment in a wide range of additional health programs, and develop strategies for how their respective counties can effec- tively use such technology to achieve their goals and add value to their daily operations. 20 | CALIFORNIA HEALTHCARE FOUNDATION VI. Next Steps A LAMEDA , S AN M ATEO , AND S ANTA C LARA Counties have demonstrated leadership and commitment to improving the rates of health insurance coverage for their resi- dents. Each has already implemented outreach and enrollment initiatives and is working to enhance those initiatives, including the use of automated eligibility determination. The experiences of these three counties shows how others can work with stake- holders to develop and implement outreach and enrollment initiatives and work collaboratively with related agencies to address the challenges they might face. While the counties have made commendable progress in expanding access to health coverage for their residents, the challenge of serving the uninsured is ongoing. County health and human services agencies, health plans, and community stakeholders will need to continue their partnerships to address the challenges that may arise, including the need to re-examine current staffing and productivity levels and county and state fiscal constraints. All three counties expect to increase the number of families enrolled in Medi-Cal, Healthy Families, and other county-based health coverage programs and continue striving to improve the efficiency of the enrollment process. How Policy Changes Impact Enrollment: A Look at Three County Efforts | 21 Endnotes 1. SB 2 requires employers to provide health insur- 10. The model is referred to as Shared Understanding ance coverage to employees or pay a fee to the to Change the Community to Enable Self- state, which will provide health coverage to the Sufficiency model (SUCCESS) and was employers’ employees. The passage of this measure implemented as part of the county’s Section 17000 was controversial and subject to a November 2004 welfare reform obligations. voter referendum to overturn its passage. California HealthCare Foundation, Overview of 11. WELL provides needed health care services to SB 2, viewed on March 8, 2004. roughly 9,000 uninsured adults with incomes up to 200 percent of FPL. 2. Under CA law, counties are responsible for provid- ing county-funded assistance, including medical 12. Operated by the State, Health-e-App is a Web- care, to indigent residents. The medical care pro- based application for enrolling children and vided under Section 17000 of California’s Welfare pregnant mothers in Medi-Cal or Healthy and Institutions Code does not take the place of Families. Medi-Cal or other health care programs, although 13. Healthy Kids is a Santa Clara County initiative counties have broad flexibility in fulfilling their that provides children in families with income at Section 17000 obligations. or below 300 percent of the FPL who are ineligible 3. The County Medically Indigent Services Programs for Medi-Cal or Healthy Families with compre- covers adults at or below 200 percent of the federal hensive coverage under the SCFHP, regardless of poverty level and has reduced premium payments immigration status. and a sliding-fee discount for enrollees. 14. Some of these application assisters are certified 4. Alliance Family Care provides health insurance application assistants. through the county’s local health plan to families 15. Santa Clara sought and obtained grants from the up to 300 percent of the federal poverty level. David and Lucille Packard Foundation, the 5. The State of California received a portion of the California HealthCare Foundation, The California $500 million outreach fund established by the Endowment, and the Health Trust. federal Temporary Assistance for Needy Families 16. PACT is a community-based organization that (TANF) program. California counties were, in seeks to improve the health, education, safety, and turn, encouraged to submit proposals that general well-being of people living in San Jose. increased access to and enrollment in county health insurance programs. Alameda’s SCHIP 17. Working Partnerships USA is a research, policy pilot grant is an example of this. and advocacy institute with a focus on economic development and contingent work issues in the 6. Alameda County Health Care Services Agency, Silicon Valley/Greater San Jose area, initiated by Report of the SCHIP Project Results, October 1, the South Bay (California) Labor Council. 2002. 18. Personal communication with Toby Douglas from 7. Volunteers were primarily used to staff enrollment the San Mateo County Health Care Services events. These individuals came from agencies Administration on March 11, 2004. such as The Berkeley Mayor’s Task Force on the Uninsured, church-based groups, school-based organizations, and family resource centers. 8. By law, Social Services staff do not have the authority to accept and process Healthy Families applications, unless the county obtains a waiver from the State, which allows Medi-Cal eligibility staff to cross-train and enroll clients in other non-agency programs. 9. Personal communication with Joyce Kennedy of the Alameda County Social Services Agency on March 12, 2004. 22 | CALIFORNIA HEALTHCARE FOUNDATION