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How Policy ChangesImpact Enrollment: A Look at Three County Efforts

May 2004

How Policy ChangesImpact Enrollment: A Look at Three County Efforts

Prepared for CALIFORNIA HEALTHCARE FOUNDATION

by The Lewin Group

AuthorsLisa ChimentoJoanne JeePooja Shukla

May 2004

Acknowledgments

This report would not have been possible without the followingcounty agency and health plan administrators who generouslycontributed their time and input to describe the history anddevelopment of their county policy initiatives.

From Alameda County: Hannia Casaw, Joyce Kennedy, PaulReeves, and Jo Robinson, Social Services Agency; Jose Carvajal,Vana Chavez, and Patricia Lebron, Health Care ServicesAgency; Renee Shiota, Alameda Alliance for Health.

From San Mateo County: Glen Brooks, Elsa Dawson, LorenaGonzalez, Arlette Hess, Angela Romero, and Michel Vasquez,San Mateo County Human Services Agency; Marmi Bermudez,Toby Douglas, and Claudia Lopez, San Mateo County HealthServices Agency; Ellen-Dunn Malhotra, Health Plan of SanMateo; Rob Fucilla, Lupe Gutierrez, and Carolyn Thon, SanMateo Medical Center.

From Santa Clara County: Mary Cardenas, Cliff O’Connor,Hector Garza, and Dorothy Smith, Santa Clara County SocialServices Agency; Margo Maida and Robin Roche, Santa ClaraCounty Health and Hospital Systems; Janie Tyre, Santa ClaraFamily Health Plan.

In addition, eligibility supervisors, eligibility workers, outreachcoordinators, and other specialized enrollment staff in eachcounty provided valuable insights into the specialized eligibilityand enrollment processes in their respective counties.

About the Foundation

The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improvingCalifornia’s healthcare delivery and financing systems. Formedin 1996, our goal is to ensure that all Californians have accessto affordable, quality health care.

For more information, visit us online at www.chcf.org.

ISBN 1-932064-65-6©2004 California HealthCare Foundation

http://www.chcf.org/

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’sHealth 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

4 | CALIFORNIA HEALTHCARE FOUNDATION

THE GROWING NUMBER OF PERSONS WITHOUThealth insurance continues to be a policy concern nationwideand in California. Across the country 41 million people —almost 17 percent of the population — lack insurance. Theproblem of the uninsured is especially acute in California,where more than 20 percent of the state’s residents are withoutcoverage. This critical policy issue is currently being explored at many levels in California. One recent statewide initiative toimprove California’s health insurance rates is the CaliforniaHealth Insurance Act of 2003 (Senate Bill 2), a “pay or play”measure, which was signed by Governor Davis in October 2003.1

California counties also have been proactive in addressing thecontinuing concern about the state’s uninsured population. Anumber of counties have been at the forefront of implement-ing initiatives to expand public health insurance coverage andto improve access to coverage for families. Three counties —Alameda, San Mateo, and Santa Clara — have gone beyondstate requirements,2 not only in expanding eligibility for cover-age, but also in creating a more seamless process for enrollmentin county programs, Medi-Cal, and Healthy Families. Thesegains were only possible through a series of policy changes andwith the concerted efforts of county collaboratives to identifypossible 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 HealthCareFoundation to prepare this report to share the experiences ofAlameda, San Mateo, and Santa Clara Counties with otherCalifornia counties. The report explores the policy, operational,and other considerations of implementing partnerships amongcounty agencies, health plans, and other community stakehold-ers to change and improve the process for enrolling familiesinto public health care programs.

The Lewin Group conducted site visits to each of the threecounties to learn about their enrollment initiatives. Lewin staffinterviewed key individuals at the counties’ health and socialservices agencies to understand the steps taken to develop andlaunch the outreach and enrollment initiatives. Lewin staff alsointerviewed county eligibility and outreach workers during sitevisits to understand how “application processing” changed asthe counties centralized their eligibility screening processes and

Three counties — Alameda,

San Mateo, and Santa

Clara — have gone beyond

state requirements, not only

in expanding eligibility for

coverage, but also in creating

a more seamless process

for enrollment in county

programs, Medi-Cal, and

Healthy Families.

I. Introduction

ways in which future efforts to automate enroll-ment will impact their day-to-day tasks. Finally,Lewin staff interviewed representatives from thelocal health plans involved in the developmentand implementation of the expansion and enroll-ment initiatives to gain perspective on theirsuccesses and challenges faced.

While each county took a different approachtoward increasing enrollment in public healthcare programs, the following lessons werelearned:

■ Strong leadership drove initiative development.In each county, one or more champions of theinitiatives brought stakeholders to the table,gaining their commitment and support. Thisleadership made initiative development andimplementation possible.

■ Intra-county collaboration made the initiativesviable. County agencies, health plans, andother community stakeholders shared commongoals. By working in partnership, agenciesbenefited from each others efforts. Collabora-tion among initiative partners previously hadbeen inconsistent, but became the norm withimplementation of county initiatives.

■ Broad stakeholder support was critical to thesuccess of the initiatives. To advance initia-tives, county collaboratives considered theneeds of and input from various stakeholders,such as eligibility workers, other agency line staff, health plans, community-basedorganizations, hospitals, and schools.Stakeholder involvement began early in theinitiatives and secured ongoing support.

■ County stakeholders acknowledged the financial interdependencies that exist betweeneach county’s organizations. The financialfuture of initiative partners is interwoven.Partners across agencies within each countyrecognized that their upfront financial commitments would not only bring themcloser to reaching their policy goals, but that

their actions would also benefit their county’soverall fiscal situation.

■ A common set of actions helped to build and strengthen the initiatives’ underlyingfoundations. Action steps often were takenconcurrently and required the participation of each initiative partner. The actions stepsresulted in real progress toward counties’ goals, strengthening their partnerships.

Additional information about each county’senrollment initiatives, as well as a more detaileddiscussion of the lessons learned, are presentedbelow.

How Policy Changes Impact Enrollment: A Look at Three County Efforts | 5


ALL THREE COUNTIES PROVIDE HEALTH COVERAGEto a variety of populations through local health insuranceexpansion programs and have designed these initiatives toaddress their local needs (see Table 1). The counties financedtheir expansion programs with combined funding fromProposition 10 through local First 5 Commissions, county and municipal funds, local health plans, and hospital andhealth care districts. They also solicited and obtained one-timeand some ongoing grant dollars from foundations and localTobacco Settlement Funds.

In operationalizing their expansion programs, these threecounties implemented innovative approaches to eligibilitydetermination and enrollment, “changing the way they dobusiness” in order to improve and streamline the process forfamilies. One of the biggest barriers faced by counties wasorganizational. Within these counties, the health agency is distinct from the human services agency. Each has its ownbudget, staff, and programs that are developed and adminis-tered with little, if any, consultation with other agencies in thecounty. In general, the health agency is responsible for provid-ing public health care services and programs such as behavioralhealth, environmental health, and some indigent care programs;while the human services agency is responsible for public socialservice programs such as general assistance, food stamps, andMedi-Cal.

The independent structure of county agencies contributes toinfrequent collaboration and limited awareness of each other’s

II. Background

Table 1. Overview of Local Health Insurance Expansion

Programs, by County

Population

C O U N T Y Covered

Alameda Alliance Uninsured adults and July 2000Family Care children between 250–

300% of the federal poverty level (FPL).

Santa Clara Healthy Uninsured children January 2001Kids under age 19 and below

300% of the FPL.

San Mateo Healthy Uninsured children January 2003Kids under age 19 and below

400% of the FPL.

Program

Name

Implementation

Date

missions and the interdependencies (e.g., finan-cial and health insurance coverage goals) thatexist. Front line eligibility and enrollment staff ineach agency hold specialized roles and only focuson enrolling clients into the specific programswithin their agency’s purview. For example, afamily coming to a county clinic in need of serv-ices might find that the adults could be enrolledat the clinic in a county-sponsored program,while the children would be referred to two otherprograms — 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, toapply 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 worktogether to enroll families in the most appropri-ate health insurance program available. Thecounty eligibility workers, other front line staff,health plan staff, and other community basedorganization staff now assist families in the application and enrollment processes for severalprograms — Medi-Cal, Healthy Families,Healthy Kids and other county health care programs — regardless of their specific agencyaffiliation. Families, the agencies, health plans,and other community stakeholders have benefitedfrom the new partnerships.



EACH OF THE THREE PILOT COUNTIES —Alameda, San Mateo, and Santa Clara — has taken a differentapproach to increasing access to public health insurance programs for children and families. The initiatives in place ineach county are examined below, and the approach and neces-sary action steps identified by the county health and humanservices agencies, health plans, and stakeholder groups to createa seamless enrollment process are discussed. The informationpresented below was obtained during county site visits andinterviews with county agency and health plan staff, unlessotherwise 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 processtypically required clients to come to the county’s SocialServices Agency (SSA) one or more times to meet with a SocialServices intake worker, complete the Medi-Cal application,and provide all required supporting documentation. The SocialServices intake worker would review all the information anddetermine eligibility. In the event a client was deemed ineligiblefor Medi-Cal (which could take up to 45 days to determine),the applicant would be denied coverage under Medi-Cal andwould be informed of alternative coverage options (i.e., HealthyFamilies), but received little additional assistance in applyingfor the programs. Alameda County experimented with twopilot projects, the SCHIP project and the No Wrong Doorpilot, in an attempt to make the overall application processmore timely and efficient, not only for the applicant but alsofor county staff and other stakeholder groups.

SCHIP ProjectIn an effort to maximize enrollment in available public healthinsurance programs, the Alameda County Health Care ServicesAgency (HCSA), in collaboration with SSA, implemented aMedi-Cal, Healthy Families, County Medically IndigentServices Plan,3 and Alameda Alliance Family Care4 pilot project(referred to as “the SCHIP project”) in October 2001. A majorobjective of the project was to implement the recommendations

III. Overview of County Initiatives


http://www.chcf.org/topics/view.efm?itemID=102216

of the Alameda County Children and FamiliesHealth Insurance Task Force, which was convenedby County Supervisor Alice Lai-Bitker to increasepublic health insurance enrollment, retention,and utilization. The project was funded by a$600,000 pilot grant from the State Children’sHealth Insurance Program (SCHIP)5 and$210,000 in required matching funds from thecounty. Alameda County estimates that actualproject expenditures totaled $1.2 million.6

Through the SCHIP project, the county madeseveral enhancements to the existing outreachand enrollment process, including conductingten community-wide enrollment events; using acomputer-based application on laptop computersto improve timeliness, efficiency and accuracy of applications; developing marketing materials; and creating a call center to provide informationabout enrollment events. Approximately 24Medi-Cal eligibility technicians (ETs) were co-located with an equal number of HealthyFamilies certified application assistants (CAAs) at the enrollment events. HCSA recruited andtrained CAAs from a pool of 54 volunteers.Together, teams of ETs and CAAs conducted initial eligibility determinations and pre-screenedapplicants for the most appropriate form ofhealth insurance coverage. For the SCHIP pilot,the Managed Risk Medical Insurance Board(MRMIB), the governing agency of the HealthyFamilies program, approved a request fromHCSA that allowed eligibility workers to use thejoint Medi-Cal and Healthy Families applicationfor Healthy Families enrollment as long as eligi-bility workers confirmed that the applicant wasindeed ineligible for Medi-Cal. In the SCHIPpilot, the time required to complete the eligibilitydetermination in the application process wasreduced because of the joint processing system in place.

The SCHIP project resulted in a higher rate ofMedi-Cal eligibility approval and increasedenrollment in both Medi-Cal and Healthy

Families due to improved pre-screening andcoordination between HCSA and SSA. The total number of people served by the SCHIPProject totaled about 2,650. The project alsoyielded policy and operational recommendationsto develop a coordinated and comprehensiveenrollment system that could be implementedthroughout Alameda County. Increased collabo-ration between HCSA and SSA is a lasting effectof the SCHIP project. The two agencies, alongwith volunteers from a dozen community-basedorganizations,7 and state officials from DHS andMRMIB, coordinated in a way not previouslyexperienced to develop and staff enrollmentevents.

“No Wrong Door” PilotContinued collaboration enabled HCSA andSSA to implement the “No Wrong Door” pilot,an extension of the SCHIP project, to further itspolicy and operational recommendations in July2002. The “No Wrong Door” pilot, this timeunder the leadership of SSA and in conjunctionwith HCSA, aimed to increase access andapproval rates for its health insurance and otherpublic assistance programs, improve efficiency of application processing, and increase programretention. In addition to Medi-Cal and HealthyFamilies, other county-only expansion programswere included in the pilot, such as AllianceFamily Care and the County Medically IndigentServices Program.

The “No Wrong Door” pilot also tested anotherkey policy change — allowing Social Services staffto accept and process Healthy Families applica-tions.8 During the pilot, Medi-Cal and HealthyFamilies determinations were run concurrentlywith three Social Services and two HCSA eligi-bility workers designated to serve as SocialServices application assistors (SSAAs), a positioncreated specifically for the pilot. To identify theeligibility staff that would participate in the pilot,the county solicited volunteers from existing eligibility staff. During the pilot, every fourth


applicant who entered the Social Services officeseeking Medi-Cal coverage was designated forprocessing via the pilot and met with an SSAA.All staff were trained using a training moduledeveloped jointly by HCSA and SSA.

During the pilot, when clients walked in to aMedi-Cal office, they first met with an SSAAwho conducted an initial assessment and assistedthe client in completing the appropriate programapplication. If the client was pre-screened forMedi-Cal eligibility, the client would meet with a Social Services eligibility technician to completeprocessing of the application. If pre-screened andineligible for Medi-Cal, the SSAA completed theappropriate application documents and forward-ed the client’s application to the appropriatehealth coverage program (Healthy Families,Alliance Family Care, or the County MedicallyIndigent Services Program) for processing.

The county’s new referral system deviated fromthe traditional Medi-Cal application process inthat clients in the pilot walked away enrolled inMedi-Cal or with the application forwarded toanother health coverage agency. In the traditionalMedi-Cal application process, referrals to otherprograms sometimes occurred, but pended ordenied applications often would fall through thecracks over time or the applicant would refuse, or fail, to follow up with other coverage options.

Similar to the SCHIP project, under the “NoWrong Door” pilot, SSA and HCSA conductedenrollment events where ETs and applicationassistors used laptop computers with an electron-ic application template developed by the countyto help families complete applications. Familiesapplying for health insurance coverage at theseevents left enrollment events either enrolled inMedi-Cal or with an application for HealthyFamilies or Alliance Family Care referred to theappropriate agencies. As word about these enroll-ment events and the “No Wrong Door” pilotspread, families from areas outside of those servedby the pilot sites would attend enrollment fairs to

take advantage of the new enrollment process. Inthe nine months following pilot implementation,more than 2,400 individuals were screened andthe number of county offices participating in thepilot expanded to five. Two additional satellitesites opened in December 2003.9

San Mateo County’s One Stop Model

and the Children’s Health Initiative

One-Stop ModelBetween 1995 and 1996, San Mateo Countyunveiled one-stops — single enrollment locationswhere clients accessed a broad range of publicservices. The one-stops were part of the county’smove to adopt a model of integrated delivery ofcounty services whereby a family could accessmultiple Human Services Agency (HSA) pro-grams (e.g., Medi-Cal, employment training,CalWORKs, food stamps, general assistance,etc.) at a single entry point or location.10

Before the one-stops were implemented, programswere isolated from each other, requiring familiesto complete a separate application process foreach program, often at different office locationsaround the county. Under the one-stop model,families could go to any of the county’s one-stopoffices and were screened by one eligibility workerfor multiple HSA programs. Building uponHSA’s one-stop model, in 2002, HSA and theHealth Services Agency (Health) implementedsimilar strategies to create a more seamless enroll-ment process for and to maximize enrollment inMedi-Cal and Healthy Families, working collab-oratively to conduct outreach and enrollmentevents throughout San Mateo County.

Health Services established a new applicationassistant position, Community Health Advocate(CHA), to assist families to complete applicationsfor Medi-Cal, Healthy Families, and the county’sSection 17000 program, Wellness EducationLow-cost Linkage (WELL), in clinic sites.11 Priorto the creation of the CHA position, San Mateo


County Health Services Agency staff believedthat there were individuals enrolled in WELLwho might be eligible for Medi-Cal, but were notenrolled due to scarce clinic resources devoted toenrollment assistance and insufficient time beforethe actual clinic visit itself to complete the lengthyprocess for Medi-Cal. Because the county wasnot leveraging Medi-Cal dollars, it was drainingits own local resources at an even higher ratethan necessary. For the first time, HSA benefitsanalysts and Health Services CHAs were co-located at clinic sites, community family resourcecenters, and staff enrollment events to ensurefamilies were enrolled or referred to the appropri-ate program in a timely manner and withoutrequiring families to make multiple trips to sepa-rate application centers. Also, from 2000–2002,HSA increased outstationed benefits analysts atcommunity clinic locations from seven to 14.

Children’s Health InitiativeContinuing its commitment to ensuring healthinsurance coverage for San Mateo County resi-dents and to a seamless health insuranceapplication process, San Mateo County rolledout its Children’s Health Initiative (CHI) inJanuary 2003. The cornerstone of CHI is theHealthy Kids program, which provides coverageto children under age 19 in families with incomesbelow 400 percent of the FPL. Eligibility forHealthy Kids is conducted using the one-stopHSA-Health method of enrollment. WhileHealthy Kids eligibility is determined by specializedHSA benefits analysts (BAs), all BAs and CHAscan assist families in completing applications forany form of health coverage in the county. UnderCHI, BAs and CHAs assess whether childrenappear to be eligible for Medi-Cal, HealthyFamilies, and Healthy Kids — in that order —and assist families in completing the appropriateapplication. San Mateo County also actively pursued ways to use automation to support theOne Stop program and is now implementingHealth-e-App on a countywide basis.12

Santa Clara County’s Children’s

Health Initiative

In January 2001, the Children’s Health Initiative(CHI) was launched in Santa Clara County as apartnership between the Social Services Agency(SSA), Health and Hospital Systems (HHS), theSanta Clara Family Health Plan (SCFHP), andother community-based organizations. The visionof the county-wide initiative is that 100 percentof the children residing in Santa Clara Countywith incomes at or below 300 percent of the FPLshall have access to quality health care throughcomprehensive health insurance. CHI serves asan umbrella for Medi-Cal, Healthy Families, andthe Healthy Kids program.13 To increase access forchildren, the CHI’s goals are to educate familiesabout use of their health benefits, improve enroll-ment and retention, and create a single point ofaccess to any of the three CHI programs.

During the summer of 2001, Santa Clara Countyimplemented a pilot project to cross-train eligi-bility workers and CAAs to use a more holisticapproach to enrolling children and families in thecounty’s public health insurance programs. Withthis goal in mind, new eligibility processes weredesigned for CAAs and SSA eligibility workerslocated in clinics and county SSA district offices.In settings where eligibility workers were co-located with HHS financial counselors (whodetermine eligibility for HHS-administered programs, such as the Child Health Disabilityand Prevention Program and Family Planning,Access, Care and Treatment), processes werejointly developed to facilitate workflow and eliminate duplication of services between theseprograms and those under CHI. In Santa Clara,financial counselors (FCs) have traditionally beentrained as Healthy Families CAAs as well. Withthe implementation of the CHI, the FCs alsoacquired responsibilities for enrolling children in the Healthy Kids program, and HHS wasauthorized to hire additional FCs to assist withenrollment as part of the CHI. Representatives


from HHS, SSA, and SCFHP participated inpublic forums around the county to increasetheir visibility and presence. County agency staffengaged in joint trainings and launched a cam-paign to shift the public’s perception of theiragencies from unwelcoming to welcoming.

Approximately 26 application assistors14 and 11FCs initially participated in the initiative, andnow more than 500 eligibility workers have beentrained to assist with joint Medi-Cal, HealthyFamilies, and Healthy Kids application intakeand processing. Santa Clara sought and obtainedapproval from MRMIB to allow the county tohave lead trainers who could train other Medi-Caland Healthy Families eligibility workers to beCAAs for the Healthy Kids program. Since itsinception in January 2001, more than 76,000 eligible children applied for health insurancethrough the CHI.

The Santa Clara County Board of Supervisorsand the San Jose City Council played a key rolein advancing the initiative. Tobacco settlementfunds, SCFHP, FIRST 5 grants, and severalfoundations15 provided financial support forhealth care premiums and seed money for variousaspects of the initiative, including outreach andenrollment. SCFHP was a key partner from the initial conception of the CHI, acts as theadministrator of the Healthy Kids program, andcontinues to perform many operational andfinancial duties for the initiative, including mar-keting, organizing public relations campaigns,conducting outreach, and training. In 2000, theSCFHP formed the Santa Clara Family HealthFoundation, which is the primary fundraiser for Healthy Kids. Santa Clara County’s CHIefforts continue with ongoing planning and policy-making by the CHI Policy Group, whosemembership includes SSA, Health and HospitalSystems, SCFHP, People Acting in CommunityTogether (PACT),16 and Working PartnershipsUSA.17



SEVERAL CONSIDERATIONS RELATED TO THEdevelopment and implementation of enrollment initiativesemerged during interviews with county staff and stakeholders.These lessons learned were critical to the success of the threecounties’ enrollment initiatives. The key lessons learned by theinitiatives are described below, followed by the specific actionsteps that the counties took to move their initiatives from concept to reality.

Leadership Drove Initiative Development

In each county, the leadership and dedication of individualsand community-based organizations drove the ultimate plan-ning and implementation of new county enrollment initiatives,including their decisions to modify the roles and responsibilitiesof eligibility workers. At the same time, the impetus for changein each county was unique. Individuals who were interviewedstressed the importance of identifying one or more initiativechampions to move the initiative from concept to implementa-tion. The champion in each pilot county helped convene thenecessary players, ensure commitment of resources, and winoverall support for the initiative.

“Running a pilot project takes

leadership—people with a

risk-taking attitude and

people that are good at

consensus building.”

— Alameda Alliance for Health representative

IV. Lessons Learned andRemaining Challenges

In San Mateo County, managers from both the HealthServices and Human Services Agencies brought the agenciestogether to implement the county’s one-stop model. InAlameda, the “No Wrong Door” pilot grew from one electedofficial’s leadership in convening a task force of community-based organizations, providers, and county agencies toincrease enrollment and retention, and to better utilize exist-ing public health coverage programs. Santa Clara benefitedfrom a strong partnership between county management andstaff, SCFHP, and labor leaders who were dedicated toimproving access to health coverage for children.

Collaboration Made Initiatives Viable

“Instead of being perceived as gatekeep-

ers, we are now perceived as doormen.”

— San Mateo Human Services Agency administrator

“Most benefit analysts, child health

advocates and eligibility technicians no

longer have misunderstood or negative

images of each other. The common focus

is the client, so cooperation among all

of us is made easier.”

— San Mateo Health Services Agency eligibility worker

The countywide organizational collaborationrequired to successfully implement new outreachand enrollment initiatives cannot be underesti-mated. The new enrollment approaches tookhold once leaders from county agencies, healthplans, and other community stakeholders recog-nized that they shared common goals. Bycollaborating with groups in their counties, insome cases the local health plan and in othercases the County Board of Supervisors, leadersfrom the county agencies realized tangibleprogress could be achieved by bringing togetherstakeholders to discuss and develop a sharedvision around outreach and enrollment.Traditionally, administrative staff and eligibilityworkers did not interact with their counterpartsat other agencies. Agencies also grappled with the natural tensions that existed in their rolesboth as service provider and “gatekeeper,” wheretheir responsibility is to ensure that only thosepersons who meet all program requirements andsubmit necessary documentation are enrolled inthe program. Agencies were enthusiastic aboutincreasing enrollment and retention, demonstrat-ing a significant philosophical change from their

traditional role of gatekeeper, but faced the chal-lenge of increasingly tight budget constraints.

After gaining each other’s perspective, initiativepartners understood that actions that helped themission of other agencies or organizations alsobenefited their own. Newly recommitted to theirshared goals, staff from county agencies, healthplans, and other initiative partners continuedmeeting to implement their enrollment initia-tives. County and health plan staff and eligibilityworkers acknowledged that having fresh goalsand a shared outlook built the momentum neces-sary to institute change.

In each county, the local health plan (i.e., theAlameda Alliance for Health, Health Plan of SanMateo, and Santa Clara Family Health Plan) wasinvolved in the development and implementationof the health care initiative to varying degrees.These health plans not only funded part or all of county-based health care programs, but havealso participated in planning and brought theircapabilities to assist with activities such as out-reach and retention.


Through establishment of the Children’s HealthInitiative, Santa Clara County Social ServicesAgency and Health and Human ServicesAgency now cross-train workers to have aworking knowledge of several county adminis-tered programs; conduct joint staff trainings;and conduct joint enrollment events for theMedi-Cal, Healthy Families, and Healthy Kidsprograms.

Initiatives Needed Broad

Stakeholder Buy-in

“One of the lessons learned in launching

county initiatives is recognizing the

benefits of having a health plan that is

connected to the county — it creates a

vehicle to make things easier and to

make things happen faster.”

— Alameda Alliance for Healthrepresentative

“Staff were very open to the initiative

and liked being able to offer families

other programs [if they were determined

ineligible for another program].

Eligibility workers embraced the

initiative.”

— Santa Clara Health and Hospital Systemsrepresentative

In shaping and implementing their enrollmentinitiatives, initiative partners garnered supportfrom various stakeholder groups, including eligi-bility workers and other agency line staff, healthplans, community-based organizations, hospitals,clinics, schools, and county board members. Toadvance their initiatives and limit potential hur-dles, the counties built collaborative relationshipsand identified common goals with these andother stakeholder groups early on and throughoutthe planning process. The counties acknowledgedthat several factors — including stakeholder inter-ests and cooperation, the political climate, andcounty demographics — could all shape thedirection of an enrollment initiative.

County agencies won the support of their staffs,which were open to innovative enrollment tech-niques that would enhance their ability to assist

their clients, by seeking staff input on aspects ofthe enrollment process that needed improve-ment, conducting staff training, and identifyingstrategies to facilitate the enrollment process.Counties also published internal newsletters tokeep staff informed on the progress of initiativesand to solicit their feedback. In some cases, eligi-bility worker positions were elevated or salarieswere adjusted to recognize their modified respon-sibilities. In Alameda County, the eligibilityworkers who originally volunteered to participatein the “No Wrong Door” pilot were so enthusias-tic about the new enrollment process that thepilot gained popularity among other eligibilityworkers in the county and additional eligibilityworkers requested to participate in the pilot.Agencies also engaged boards of supervisors byincluding them in planning meetings, presentingupdates at board meetings, and hosting initiative-related events to recognize the contributions ofcounty staff and the board members themselves.

Clients themselves are key stakeholders in coun-ties’ enrollment initiatives. County staff notedthat clients were generally eager and enthusiasticabout participating in county pilots, especiallywhen they experienced a more efficient applica-tion process. Clients also especially appreciatedreceiving a preliminary eligibility determinationfrom one eligibility worker, rather than having tosubmit separate applications to different eligibili-ty workers at multiple sites.

Financial Interdependencies

Were Recognized

In addition to the policy goals that factored intothe counties’ decisions, financial considerationsalso played a significant role. The county socialservices and health agencies and the local healthplans recognized that their budgetary futureswere interwoven. For example, shortfalls inhealth agency budgets have repercussions forsocial services (and other county agency) budgets.Likewise, these county social services agencies


knew that their processing times and approvalrates directly affected the revenues of their countyhealth agencies and health plans. All of the enti-ties also realized that Medi-Cal and HealthyFamilies coverage provides federal and statematching funds, saving local dollars for local pro-grams. In this way, dedicating county and healthplan resources to eligibility and enrollment wasseen as a benefit to all county entities; therefore,there were recognized benefits in the need forreallocation of budgetary resources across agenciesor in achieving savings through more efficient eligibility processing. Their initial investments incross-training of eligibility workers were made inan effort to enhance caseworker efficiency, whichhas ensured a quicker application process, reducedthe number of eligible but uninsured individuals,and assisted in creating healthier communities.

In practice, leaders from the county agencies andhealth plans recognized that implementing theirpolicy decisions required initial and ongoingfinancial commitment. In Santa Clara County,for example, the SSA struggled with financialhardships in its Medi-Cal program while thecounty’s HHS (the county’s largest departmentfiscally) remained financially viable. When leadersfrom both agencies and the health plan convened,all parties recognized that collaboration and dedication of HHS and health plan resources tooutreach, eligibility, and enrollment would notonly bring to fruition many of their shared goals,but also provide a return on their investments inthe form of increased revenue.

Financial considerations also bolstered healthplans’ support of county initiatives. From thehealth plan perspective, increased enrollment ofeligible families into appropriate public insuranceprograms also meant an increase in the plan’senrollment and revenues. Of course, the quickerand more efficient eligibility determinationprocess only furthered the financial benefit to theplans. For the health plans, supporting counties’efforts to facilitate enrollment was in alignment

not only with their own coverage goals, but alsowith their business needs.

Action Steps Made a Difference

“We had a deliberate campaign [within

the Social Services Agency] to change

the view of the initiative as a pilot to

county-wide adoption. Health and

Hospital Systems and the Social Services

Agency were in it together. We did

trainings together and we still meet

monthly to talk about the issues.”

— Santa Clara County Social Services Agencyrepresentative

The initiative partners took specific steps to buildand strengthen the foundation of county enroll-ment initiatives. Many of these activities occurredconcurrently and all were equally important.Counties made the following operational andfinancial decisions to develop and implement theenrollment initiatives that not only improvedaccess to health coverage, but also made themuniquely positioned to launch future initiatives.

Conduct a Preliminary Assessment Before designing its enrollment initiative, eachcounty reviewed its current enrollment processand assessed needed improvements. Assessmentscould be formal, as in San Mateo County, wherea report on findings from an evaluation of thecounty’s outreach and enrollment activities identified obstacles to enrollment and made recommendations for improvement. Other counties’ assessments were more informal, withstakeholders meeting to identify challenges anddiscuss ways to increase access to health coverage.The resulting findings and recommendationswere the basis upon which initiatives were developed.


Counties also assessed what resources might beavailable to support their initiatives and alsolooked at the political landscape. Identification of the barriers and opportunities before the initiatives helped proponents develop theirimplementation strategy.

Make Cultural and Attitudinal Changes Both health and social services agencies experi-enced a cultural and attitudinal change aroundeligibility, outreach, and enrolling children andadults into public insurance programs. Whereagencies previously worked independently ofeach other, a new, collaborative relationship was built among agencies to frame enrollmentinitiatives and work at outreach events to enrollfamilies in public health insurance programs.County agencies came to see themselves as partners, rather than independent entities.

While the counties had previously acted as gate-keeper, directing eligibility workers to preventfamilies from enrolling in publicly funded healthcare programs, counties had gradually changed toencourage workers to enroll as many families aspossible. Enrollee retention also became a priority.In Santa Clara County, continuing eligibilityworkers, who redetermine eligibility for establishedcases, also were trained to provide applicationassistance for Healthy Families and Healthy Kids.The county agencies coupled these attitudinalchanges with business process changes, namely ashift to customer service, follow-up, and use ofautomation. The Alameda County Social ServicesAgency, for example, became less rule-orientedand more service-oriented.

Meet and Provide Regular UpdatesCounty health and social services agencies, healthplans, and other stakeholders met regularlythroughout the planning and implementation of their enrollment initiatives and continue to do so. During meetings, agency staff and otherstakeholders provide updates on progress andnext steps for the initiatives. Subcommittees or

working groups that focus on particular issues,such as outreach, retention, and training, meetregularly to address the issues affecting initiatives.The county partners also met with boards ofsupervisors. Meeting participants typicallyincluded staff from the counties’ health plans, aswell as from the county agencies. In one county,staff from the human services and health agenciesparticipated in a day-long strategy retreat. Thesemeetings serve multiple purposes. Meetings arean effective way of keeping stakeholders up todate on the progress of initiatives to maintaintheir support, without which the initiativeswould face substantial hurdles. Additionally,meetings encourage the ongoing participation of county organizations and their continued collaboration.

Address Management and Staff ConcernsUnderstanding the needs and concerns of allstakeholders, and working with them to addressthose needs early in the development process,helped ensure timely progress of county initiatives.County agencies consulted, and continue to con-sult, management representatives to work throughproductivity and staffing issues as they arise. Byproviding training and reviewing initiative goalswith staff, agencies overcame staff concerns orhesitancy to adopt the operational protocols ofinitiatives. For example, some eligibility workersinitially were unfamiliar or uncomfortable usingtechnology to determine eligibility. Counties havedemonstrated that while challenges may arise, by working as partners and thinking creatively,the needs of all stakeholders, including countyagencies and management, can be met.

Conduct External and Internal Marketing Counties marketed their initiatives to their stake-holder groups, including staff and clients, toobtain initial and ongoing support. AlamedaCounty published successes of their pilot programin newsletters and through local media and alsoheld recognition events for eligibility workers and


Healthy Families CAAs employed by both agen-cies. Santa Clara County hosts learning sessionsover lunch for eligibility workers and publishesnewsletters that are disseminated to county healthand social services staff. The learning sessions and newsletters are avenues for sharing initiativeupdates, encouraging staff participation, and for training. Santa Clara County’s CHI PublicRelations and Marketing group and the CHIOutreach group, which includes SCFHP, theHHS, other CHI partner agencies, and laborgroups, meet monthly. These groups ensure con-sistency in marketing messages and coordinateand maximize limited resources. The SCFHPplays a key role in the external marketing of thecounty Children’s Health Initiative. SCFHP con-ducted a public relations campaign with localnewspapers such as the San Jose Mercury Newsto gain exposure for the initiative. SCFHP alsocalled on its speakers bureau, including the high-est levels of SCFHP’s leadership, to present atmeetings of community organizations like theRotary Club and the Kiwanis Club. The agenciespromoted the pilot programs to prospectiveclients by establishing and advertising a toll-freehotline through colorful posters and banners atclinics, enrollment fairs, etc. Working with clientswas important for building their trust in andunderstanding of the benefits of the counties’new ways of doing business.

Many Challenges Overcome,

But Some Issues Remain

For the three counties, planning and implement-ing their enrollment initiatives was not withoutchallenges. Some variation existed in the types of issues encountered from county to county;however, it is noteworthy that the counties andother stakeholder groups worked tirelessly to findworkable solutions for each of the challengesraised. Some of these challenges are ongoing andnew ones will arise as county initiatives continue.

Staffing and Productivity Issues Are ComplexDefining the roles and responsibilities of eligibilityworkers in county initiatives was a challenge thatstakeholders addressed early on in the planningprocesses for county enrollment initiatives. Theinitiatives brought with them significant changesin how enrollment in Medi-Cal, HealthyFamilies, and county health insurance programswould occur, affecting eligibility workers’ duties.Acceptable staffing and productivity strategieswere developed over time through the concertedand collaborative efforts of county staff and management representatives. Strategies took intoconsideration the experience of eligibility workers,the complexity of assigned tasks, and the desireof staff to participate in the initiatives. Countymanagers and management representatives con-tinue to work together to address other issues asthey arise.

Struggles with Success AriseCounties are achieving their goal of linking fami-lies to health insurance coverage. However,counties also are struggling with their success.Following the launch of their new marketingcampaign and the enrollment fairs for theChildren’s Health Initiative, Santa Clara Countywitnessed a rise in applications, increasing staffworkload and boosting the number of Medi-Cal,Healthy Families, and Healthy Kids enrollees.Clients who heard through word of mouth aboutAlameda County’s “No Wrong Door” pilotflocked to the three pilot sites from outlyingregions to apply for coverage using the new, moreefficient application process; long waiting timesensued. In fact, enrollment in county expansionprograms has grown so rapidly that budgetarylimits are being reached and, in Alameda andSanta Clara Counties, enrollment caps have beenmet, requiring the counties to set-up waitinglists. In Alameda County, the Alliance FamilyCare Program was not accepting new members asof early December 2003 because of the combined


effects of families’ need for health coverage, the state’s budget crisis, and the local effects ofpremium cuts. San Mateo expects to reach itsHealthy Kids enrollment limit of 5,800 enrolleesby the end of summer 2004.18

Some State Budget Constraints May BeAddressed LocallyWith increasing state and county budgetary constraints and the state imposed Medi-Cal cuts,the counties face tough decisions about how bestto proceed in enrolling eligible but unenrolledpopulations into appropriate state and countyadministered programs. County staff from bothhealth and social services agencies reiterated thebenefits derived by the community as a wholewhen efforts are made to provide health coverageand other social services to both adults and chil-dren, as well as the increased need for suchservices during difficult economic times. Countyagencies looked to and are continuing to worktogether to gain financial support from alternatesources for financial support (e.g., foundationsand corporations). Despite ongoing budget con-straints, Santa Clara HHS, in partnership withSCFHP, recently increased their investment inoutreach activities to $1 million in FY 2001 andthen contributed $750,000 in the following year.SCFHP continues its leadership in garneringfinancial support for the Healthy Kids program.The CHI Policy Group acknowledged the diffi-culty of the decision during a time of ongoingbudget constraints, but in the end, stayed com-mitted to their critical role in advancing the goalsof the Children’s Health Initiative.



AS ALAMEDA, SAN MATEO, AND SANTA CLARACounties continue to refine and implement their initiatives,they look for new tools to implement their policy decisionseffectively. Implementing technology solutions that will allowcounties to automatically screen and enroll eligible families in Medi-Cal, Healthy Families, or other local or state-basedhealth insurance programs is the next step in advancing countyinitiatives and policy goals. Automation allows eligibility staffto link families more effectively to the appropriate health careprograms. Technology allows for screening for eligibility formultiple programs quickly and efficiently, and enables a moreefficient referral process to other agencies as appropriate.Technology also reduces the need for detailed training andknowledge of complex eligibility rules for every program,which are subject to change. Further, automation can facilitateautomatic screening for multiple programs and also assist eligi-bility technicians with recertifications for continuing clients.

The three counties have taken preliminary steps in automatingand using technology to support their respective county initia-tives. For example, Alameda County provided a small numberof computer-savvy outreach workers with laptop computersand a computer-based enrollment form for use at enrollmentevents. In San Mateo, some outreach and enrollment workerspiloted Health-e-App, the Web-based application for enrollingchildren and pregnant mothers in Medi-Cal or HealthyFamilies. In the coming months, Alameda, San Mateo andSanta Clara will pilot One-e-App, a Web-based applicationthat builds upon Health-e-App to include screening andenrollment in a wide range of additional health programs, anddevelop strategies for how their respective counties can effec-tively use such technology to achieve their goals and add valueto their daily operations.

Implementing technology

solutions that will allow

counties to automatically

screen and enroll eligible

families in Medi-Cal,

Healthy Families, or other

local or state-based health

insurance programs is the

next step in advancing

county initiatives and

policy goals.

V. Using Technology to SupportCounty Enrollment Initiatives


ALAMEDA, SAN MATEO, AND SANTA CLARACounties have demonstrated leadership and commitment toimproving the rates of health insurance coverage for their resi-dents. Each has already implemented outreach and enrollmentinitiatives and is working to enhance those initiatives, includingthe use of automated eligibility determination. The experiencesof these three counties shows how others can work with stake-holders to develop and implement outreach and enrollmentinitiatives and work collaboratively with related agencies toaddress the challenges they might face.

While the counties have made commendable progress inexpanding access to health coverage for their residents, thechallenge of serving the uninsured is ongoing. County healthand human services agencies, health plans, and communitystakeholders will need to continue their partnerships to addressthe challenges that may arise, including the need to re-examinecurrent staffing and productivity levels and county and statefiscal constraints. All three counties expect to increase thenumber of families enrolled in Medi-Cal, Healthy Families,and other county-based health coverage programs and continuestriving to improve the efficiency of the enrollment process.

VI. Next Steps

1. SB 2 requires employers to provide health insur-ance coverage to employees or pay a fee to thestate, which will provide health coverage to theemployers’ employees. The passage of this measurewas controversial and subject to a November 2004voter referendum to overturn its passage.California HealthCare Foundation, Overview ofSB 2, viewed on March 8, 2004.

2. Under CA law, counties are responsible for provid-ing county-funded assistance, including medicalcare, to indigent residents. The medical care pro-vided under Section 17000 of California’s Welfareand Institutions Code does not take the place ofMedi-Cal or other health care programs, althoughcounties have broad flexibility in fulfilling theirSection 17000 obligations.

3. The County Medically Indigent Services Programscovers adults at or below 200 percent of the federalpoverty level and has reduced premium paymentsand a sliding-fee discount for enrollees.

4. Alliance Family Care provides health insurancethrough the county’s local health plan to familiesup to 300 percent of the federal poverty level.

5. The State of California received a portion of the$500 million outreach fund established by the federal Temporary Assistance for Needy Families(TANF) program. California counties were, inturn, encouraged to submit proposals thatincreased access to and enrollment in countyhealth insurance programs. Alameda’s SCHIP pilot grant is an example of this.

6. Alameda County Health Care Services Agency,Report of the SCHIP Project Results, October 1,2002.

7. Volunteers were primarily used to staff enrollmentevents. These individuals came from agencies such as The Berkeley Mayor’s Task Force on theUninsured, church-based groups, school-basedorganizations, and family resource centers.

8. By law, Social Services staff do not have theauthority to accept and process Healthy Familiesapplications, unless the county obtains a waiverfrom the State, which allows Medi-Cal eligibilitystaff to cross-train and enroll clients in other non-agency programs.

9. Personal communication with Joyce Kennedy ofthe Alameda County Social Services Agency onMarch 12, 2004.

10. The model is referred to as Shared Understandingto Change the Community to Enable Self-Sufficiency model (SUCCESS) and wasimplemented as part of the county’s Section 17000welfare reform obligations.

11. WELL provides needed health care services toroughly 9,000 uninsured adults with incomes upto 200 percent of FPL.

12. Operated by the State, Health-e-App is a Web-based application for enrolling children andpregnant mothers in Medi-Cal or HealthyFamilies.

13. Healthy Kids is a Santa Clara County initiativethat provides children in families with income ator below 300 percent of the FPL who are ineligiblefor Medi-Cal or Healthy Families with compre-hensive coverage under the SCFHP, regardless ofimmigration status.

14. Some of these application assisters are certifiedapplication assistants.

15. Santa Clara sought and obtained grants from theDavid and Lucille Packard Foundation, theCalifornia HealthCare Foundation, The CaliforniaEndowment, and the Health Trust.

16. PACT is a community-based organization thatseeks to improve the health, education, safety, andgeneral well-being of people living in San Jose.

17. Working Partnerships USA is a research, policyand advocacy institute with a focus on economicdevelopment and contingent work issues in theSilicon Valley/Greater San Jose area, initiated bythe South Bay (California) Labor Council.

18. Personal communication with Toby Douglas fromthe San Mateo County Health Care ServicesAdministration on March 11, 2004.

Endnotes


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