Copyright 2000 Federal News Service, Inc.
Federal News Service
May 16, 2000, Tuesday
SECTION: PREPARED TESTIMONY
LENGTH: 2682 words
HEADLINE:
PREPARED TESTIMONY OF KATHLEEN GIFFORD ASSISTANT SECRETARY OFFICE OF MEDICAID
POLICY AND PLANNING INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION
BEFORE THE HOUSE WAYS & MEANS COMMITTEE SUBCOMMITTEE ON
HUMAN RESOURCES
SUBJECT - HEALTH COVERAGE FOR
FAMILIES LEAVING WELFARE
BODY:
(NOTE: GRAPHS
NOT TRANSMITTABLE)
Madame Chairman and Members of the Subcommittee:
Thank you for inviting me to speak to you today about the importance of
health insurance in the post-welfare reform environment. The
coordinated efforts of Congress, the Executive Branch and the states have
brought critical attention and resources to the issue of ensuring the good
health of our children and your efforts are greatly
appreciated.
Indiana has achieved strong early successes both welfare
reform and access to health care. Former Governor and current
Senator Evan Bayh initiated Indiana's welfare reforms during the summer of 1995
with a series of Aid to Families with Dependent Children (AFDC) waivers very
similar to the federal legislation that followed in 1996. Governor Frank
O'Bannon has continued this welfare reform effort and has seen the State of
Indiana cited as first in the nation in Temporary Assistance for Needy Families
(TANF) job placements and sixth in success in the workforce, the highest overall
rating of any state. Indiana's success in welfare reform also has led to
significant caseload declines, almost 60% since 1994. However, these caseload
declines were accompanied by smaller declines in enrollment of families in
Medicaid and Food Stamps. At O'Bannon's direction, the State of Indiana has
dramatically reversed the downward trend in Medicaid enrollment and has begun an
effort to increase access and education regarding Food Stamps. In fact, Indiana
was recently highlighted in a report of Medicaid Enrollment in 21 States,
released by the Kaiser Commission on Medicaid and the
Uninsured, as the state with the highest enrollment increases
since 1998.i These enrollment increases were a result of the Governor's
commitment to families and children; teamwork within the Indiana Family and
Social Services Administration at the state and local levels; a strong central
policy with local implementation; and Indiana's commitment to family-friendly
services, prevention and, if necessary, early intervention. MEDICAID OUTREACH IN
INDIANA
In the post welfare reform era, it became apparent that to
encourage Medicaid enrollment the perception of the program would have to change
from welfare to health care. Accessibility of enrollment sites
and complexity of application procedures were also a concern. For these reasons,
Indiana felt it was vitally important to develop and implement outreach as a key
focal point in increasing Medicaid enrollments.
Governor Frank O'Bannon
and the state legislature first expanded Medicaid eligibility to Indiana
children in the summer of 1997. Later that year, Congress passed the Balanced
Budget Act of 1997 and brought the nation's attention to the troubling issue of
uninsured children among the poor and working poor in the U.S.
In July of 1998, Indiana expanded Medicaid eligibility for a second time and was
able to use the Children's Health Insurance Program (CHIP)
funding for both expansions of eligibility. At the same time, O'Bannon issued a
statewide directive that 91,000 uninsured children would be
targeted in an aggressive outreach campaign over the next 18 months. The
campaign encompassed three major components: de-stigmatize Medicaid and CHIP
services; reach out to local communities to find all uninsured
children who are eligible for Medicaid and CHIP; and simplify enrollment
processes.
De-stigmatization of Medicaid
The de-stigmatization
of Medicaid and CHIP was a priority for the State. Medicaid was to be converted
from a "welfare program" to a program of health care coverage
for persons in need of help in obtaining such coverage. In short, Medicaid was
made to look as much like private coverage as possible. Several strategies
addressed this priority: Medicaid and CHIP became known to the public as
"Hoosier Healthwise," the name formerly used only for the Medicaid managed care
program; Hoosier Healthwise was advertised with a friendly mascot, Dr. Whoosier,
an owl that would appear in parades, on frisbees and sipper cups and in public
appearances with Governor O'Bannon; and The customer's Medicaid card became a
Hoosier Health Card, similar to that used by
health plans across the state.
Outreach at the Local
Level
Another vital element of increased enrollment is outreach into
local communities. A key element to this outreach was extending outreach beyond
state facilities and staff. Prior to 1998, a family had to visit a Local Office
of Family and Children to apply for Hoosier Healthwise. An active effort was
initiated to identify and recruit alternative locations for enrollment. Soon
after the outreach campaign began, this effort had resulted in over 500
community enrollment centers that volunteered to accept Hoosier Healthwise
applications across the state, including hospitals, health
clinics, child care centers and social service providers. At the same time, new
mail-in applications were available to families through a widely advertised
toll-free number.
The Hoosier Healthwise enrollment process was
significantly simplified to assist families, further de-stigmatize services, and
encourage participation of local enrollment sites. A fairly complex automated
eligibility process conducted in a Local Office of Family and Children became a
single, double-sided sheet for children and pregnant women that could be
completed in an enrollment center or mailed into the DFC. Income verifications
were simplified and self-declaration was used more frequently. Although
enrollment has been simplified and enrollment centers are handling part of the
application process, the integrity of eligibility determination has been
important to the State. The DFC received HCFA approval to evaluate the quality
of the enrollment center application process to further improvement in this
area.
The outreach effort also included specific strategies to increase
enrollment among ethnic minorities. The DFC contracted with three statewide
organizations - the Wishard Hispanic Health Project, Indiana
Black Expo and Indiana Minority Health Coalition. Posters,
brochures and applications were translated into Spanish to address the needs of
the largest non-English-speaking population in the state. Additionally, the
Indiana Primary Healthcare Association participated in monthly meetings with the
other statewide organizations to ensure services in the community were
coordinated among all the partners.
Outreach funds were provided
directly to the 92 counties' Local Offices of Family and Children to implement
the Governor's enrollment directive in a way that addressed the unique needs and
interests of each local community. Communities used remarkable creativity in
spreading the word about Hoosier Healthwise enrollment: appearing in parades,
visiting local schools and health providers, and sponsoring
special events. This local direction and coordination was vital to the State's
success.
Results
The outreach campaign was, and continues to be,
extremely successful. Indiana's enrollment of children in Hoosier Healthwise has
increased by almost 60% since the outreach began in July of 1998, from 210,000
to over 330,000. Over 100,000 additional children without insurance were
enrolled in Hoosier Healthwise, which eclipsed Governor O'Bannon's target of
91,000.
Data Concerns
I would like to express Indiana's concerns
with the data and methodologies used to measure the uninsured
population and allocate federal resources to serve the
uninsured. The increase in enrollment of over 100,000
uninsured children during the first eighteen months exceeded
Governor O'Bannon's original expectations. This was due in part to the lack of
precision of the Current Population Survey (CPS) data that provide the only
state-level estimates of uninsured children by poverty level.
The CPS data indicated a 35% drop in the number of children under 200% of
poverty between the 1995 and 1998 three-year averages for the State of Indiana.
This trend seems too extreme to reflect reality in any meaningful way,
especially when compared to other economic indicators.
The Census
Bureau's most recent estimate of uninsured children under 200%
of poverty for Indiana is 123,000. However, the Census Bureau's large margin of
error acknowledges the fact that their point estimates are questionable.
Congress has appropriated more funds to enlarge the survey. Still, these point
estimates currently are being used to determine the CHIP allotments for states.
These seemingly inaccurate estimates compounded with the precipitous decline in
the number of children under 200% of poverty in Indiana's CPS data have resulted
in a projected 10% decrease in CHIP funding for the State in 2000. Since Indiana
is enrolling many more children than the CPS data projected, a decrease in
funding this time could be quite detrimental to efforts to improve working
families access to health care. Because of the current
inaccuracy of the CPS data at the state level, we have commissioned a survey of
10,000 families in Indiana to generate our estimates. Preliminary results from
the survey will be available in June 2000. We would appreciate any flexibility
Congress could build into the allocation formula to adjust for situations such
as these.
In addition, Indiana is one of only 13 states that have or are
expected to have expended its 1998 CHIP allotment. There is debate regarding the
prospect of re-allocating the unused funds. States with successful enrollment
initiatives should not be penalized by delaying re-allocations until other
states exhaust their allotments. The funds should be used by the states that are
providing health coverage to children now to promote further
expansions in enrollment across the country. The combined effect of inaccurate
CPS figures and declining funds at just the time Indiana needs them would be
hugely detrimental to Hoosier Healthwise.
ENROLLMENT OF LOW-INCOME
FAMILIES
Between 1995 and 1998, Indiana observed declines in low-income
families' enrollment in Medicaid, as did the nation. The steps we have taken to
de-stigmatize the program, reach out to local communities and simplify
enrollment also have had a dramatic effect on the enrollment of low-income
families. In fact, the Low-Income Families (1931) category of Medicaid has
increased by over 40% since May of 1998, when outreach began. And the rate of
increase for parents actually exceeded the rate of increase for children in that
category. Enrollment in Transitional Medicaid has quadrupled since the outreach
began. It is apparent that fewer families were being served by Medicaid before
1998, perhaps due to complexity or stigma; however, family coverage has
increased dramatically since steps to de-stigmatize the program and reach out to
communities were taken. Most observers in Indiana feel that these
de-stigmatization and outreach efforts were effective with parents who
voluntarily withdrew from Medicaid when they left TANF, possibly because it was
seen as another type of "welfare."
In 1998, the State also made many
administrative changes to support the de-linking of Medicaid eligibility from
TANF. Changes were made to the automated system to ensure that no family closed
a Medicaid case without being informed that they remained eligible. Extensive
training was conducted with local staff to ensure that families were told about
the availability and importance of Transitional Medicaid Assistance and Hoosier
Healthwise for Children. These efforts complemented the general outreach efforts
that impacted children and families across the state.Indiana shares the concern
of the Health Care Financing Authority (HCFA) that families who
are eligible for coverage must continue to receive it. And the State looks
forward to receiving the results of the technical assistance visits conducted by
HCFA last fall. However, the guidance that was issued in April does not take
into account any specific state's circumstances or progress since the de-linking
of Medicaid and TANF. States have not yet been informed of specific deficiencies
found in the site visits. FSSA supports corrective action where necessary to
remedy any inappropriate loss of Medicaid coverage; however, we believer that a
"one-size-fits-all" reinstatement approach could cause confusion and extreme
administrative burdens.
CURRENT INITIATIVES AND NEXT STEPS As an
increasing number of families enter the workplace, the role of supportive
services including access to quality health care has become
even more crucial. In addition to health care, Indiana has
focused on a variety of supportive services for working families. As stated
earlier, Indiana is committed to increasing the level of access and education
regarding the availability of Food Stamps to low-income families; however,
simplifying enrollment processes for Food Stamps may be more challenging due to
the strong focus on eliminating any potential eligibility and payment errors.
Much of the innovation in supportive services for families is made
possible by the flexibility of TANF block grant funds that support many services
for working families up to 250% of poverty. Funds available for child
care-vouchers have increased .from $17 million in 1992 to over
$200 million in 2000. Governor O'Bannon's commitment to early
childhood has allowed for increased funding for early intervention and
prevention services for children at risk of developmental disabilities, abuse or
neglect. Indiana has focused on the importance of noncustodial parents in
children's lives with increased child support collections and Access and
Visitation services that promote the emotional bond between non-custodial
parents and their children. Also, through the Fathers and Families Initiative,
Indiana continues to encourage and support locally driven fatherhood programs
throughout the state through the provision of grants and technical assistance.
Indiana is committed to vigorous evaluation of welfare reform's effects
on families and children. As part of the State Level Project on Child Outcomes
funded by HHS in five states, Indiana is currently surveying Indiana's children
in families affected by welfare reform to determine its effects. Past findings
of Indiana's experimental welfare reform evaluation found that former clients
were working at much higher levels; however, they were having trouble retaining
employment and increasing the family's net income. As a result, the State
implemented an Earned Income Credit for low-income working families, enhanced
job retention services, and soon will implement an income disregard for TANF
families in poverty.
The vast majority of these family services have
been expanded through the use of TANF federal and Maintenance of Effort funds
and have allowed the State of Indiana to provide a comprehensive set of supports
for working families seeking economic self-sufficiency. As one of seven states
selected by the National Governors' Association for their State Policy Academy,
"Expanding Opportunities for Low- Income Families to Advance in the New
Economy," Indiana is committed to a comprehensive approach to enhance the lives
of Hoosier families. Indiana's success in promoting access to
health care will be used as a model for improving access to all
of the critical supports available to working families.
Indiana is
investigating options for the possible expansion health
coverage to the parents of children eligible for Hoosier Healthwise. A committee
of stakeholders (businesses, labor and health care providers)
has been appointed to look into a wide variety of approaches.
We, in
Indiana, are proud of our successful efforts to provide coverage to children and
working families. We greatly appreciate the support provided to us in these
efforts by Congress and the Department of Health and Human
Services and look forward to working with you to assure the best in
health care for every American. Thank you again for this
opportunity to speak with you today.
Endnote:
i Medicaid
Enrollment in 21 States, The Kaiser Commission on Medicaid and the
Uninsured, April 2000.
END
LOAD-DATE: May 17, 2000 
