Case Study: Health Insurance Coverage for U.S. Children

Problem to solve

We focused on achieving this goal first at a state level, since states have direct authority over Medicaid and SCHIP implementation.   We started in California, home to one in eight children in the U.S., including 700,000 eligible but uninsured children.  We determined that creating a successful model in one state would lead other states to adopt an approach that has been tested and proven. 

Proposed Solution

Since data show that such a significant number of the children we are trying to reach have already qualified for another public program, why not use that same information already provided and accepted to “express” them through the health insurance process?  Moreover, because so many of the kids are already in schools or community programs, we hoped to efficiently target large numbers of uninsured children.

Thus, The Children’s Partnership, in collaboration with our National Advisors, developed Express Lane Eligibility (ELE), a common sense strategy that uses information already provided by parents to successfully qualify for one program,  to also qualify their child for health insurance. In California, The Children's Partnership helped develop the policy and provide assistance to implementing ELE  through school lunch and food stamps. Now, the parents of children enrolled in these programs and participating in ELE can ask for “express enrollment” in health insurance. Their application is moved forward rapidly, with all eligibility checks along the way instituted, and as a result, the child can receive health insurance within a few days.  The parents also provide permission for their information to be shared.

Core questions

Could our change model deliver a direct and tangible service to significant numbers of children?   
This change model had the potential to make sure that millions of underserved children without access to health insurance would be enrolled in needed coverage.  This program could result in significant and substantial improvements for thousands of individual children and families.

Could our change model be taken to scale so that children throughout California and throughout the nation would ultimately benefit?
Yes, if we can accomplish express enrolling children in California, we should be able to continue to increase enrollment through additional Express Lane programs both in California and in other states.  In addition, lessons learned from programs in California can help identify needed policy changes at the state and federal levels.

Will our model leverage a change in the way systems work to be more responsive (and hence effective) from the family point of view?   
Yes, because it begins the process of encouraging large public systems, as well as other community entities that serve families, such as departments of education and departments of health, to work together.

For example, a key component of making Express Lane Eligibility work is the use of computer systems to allow the public programs that provide school lunch and ones that provide health insurance, to communicate and share data (as allowed by law).  Developing a computer system to accomplish this became part of the Express Lane project. Technical expertise was provided by Deloitte Consulting, with funding from The California Endowment.  This new element provided momentum to the project and helped involve various parties (who had not worked together before) in working out the solution.  It also helped overcome a barrier to the success of Express Lane Eligibility: time consuming comparisons of family eligibility records by hand.  By making this core and lasting improvement to the system, Express Lane helped institutionalize positive changes toward increasing children’s enrollment in health insurance.

As we build the infrastructure that helps systems cooperate, it becomes more and more part of the institutional culture to cooperate.  Moreover, this project was the first time for many in senior positions in various agencies to actually meet and work with their counterparts in other human service agencies. Through Express Lane, these workers have now found common ground and are engaged in working together to better serve kids, a collaboration we hope to continue to foster.

Is our model sustainable? 
Opinion research repeatedly and firmly demonstrates that the public supports covering all children with health insurance. A recent California survey by The California Endowment showed that 78% of voters in the state support a plan to "ensure that every child in California has health insurance." Express Lane is a way to demonstrate that this desired public goal is achievable and in a way that is practical and politically acceptable.  We feel that matching the public will with a workable solution, especially in one of the largest states in the country, will help build a lasting solution to covering all uninsured children.

Is this change model a new contribution, providing additional tools to advance the cause of seeing all children have health insurance?   
Express Lane has added many new tools to local, state and national efforts to cover all kids. These new tools can become building blocks that under-gird substantial and lasting change in enrolling hard-to-reach children into public health insurance programs.  These tools include developing a vastly simplified enrollment form that makes it easier for parents to apply for health insurance for their children.  We also made numerous other changes to the enrollment system that helps families get enrolled. For example, as part of ELE through school lunch, California allowed parents to self certify their income instead of submitting various documents. Back-end verification is maintained to ensure program integrity.

All of these system improvements, as well as sample documents and lessons learned, are available on The Children’s Partnership sponsored Web site, www.expresslaneinfo.org.

Will this model help develop new, influential constituencies that could help serve the long-term goal of health insurance for all children (and possibly beyond)? 
One of the most significant successes that has evolved from the California Express Lane experience over several years is the expansion of constituencies actively advocating for health insurance coverage for uninsured children. Some of the new allies include: teachers, unions, health plans, faith-based grassroots groups, and business interests, such as chambers of commerce and small business groups. The development of this new “army” has been very helpful in developing forceful advocacy for the political push to cover all children in California.  In fact, such a campaign, with associated legislation, was launched in February, 2005. See the 100% Campaign Web site.

Finally, the state-level Express Lane experience has revealed certain barriers to covering children that are caused by federal policies.  The Children’s Partnership is currently researching how changes in federal policy can allow for even more effective “express’ enrollment programs.

Does this change model help build public will to invest confidently in health care and other needed resources for children? 
We believe that Express Eligibility has had a significant impact on building awareness of the need to cover uninsured children, as well as the fact that covering all kids is within our reach. The ongoing work over six years has helped keep the subject in front of policymakers and the public; the periodic successes have helped build the perception – and reality – that it is feasible to cover all children in California, and the development of new partners has added momentum to the cause of health insurance for all children.