The demographic analysis in this report, however, focuses on the group of children for whom coverage is mandated. Illegal aliens are eligible only for emergency services under Medicaid. Medicaid-Eligible Children Who Are Uninsured Have Characteristics That Can Be Used to Target Outreach Efforts

Uninsured Medicaid-eligible children differ somewhat from those currently enrolled in Medicaid, and these differences can be used by states to focus their outreach and enrollment efforts. Overall, about 23 percent—or 3.4 million—of the 15 million children who were eligible for Medicaid were uninsured in 1996. 1.) They are disproportionately children of the working poor, Hispanic, and U.S.-born children of foreign-born parents or foreign-born, and they are more likely to live in the West and the South. Hispanics, U.S.-Born Children of Foreign-Born Parents, and Immigrant Children Are More Likely to Be Uninsured

Among racial and ethnic groups, the proportion of uninsured Medicaid-eligible children, as well as the proportion enrolled in Medicaid, varies by racial and ethnic group. 2.) Over 70 percent of children in immigrant families are Hispanic, suggesting that outreach efforts be targeted to the Hispanic community as well as use Spanish-language outreach materials and applications. 3.) Even families who know about the program may not realize that they could be eligible. With the long-standing link between Medicaid and AFDC, many families—both those who have never received welfare and those who have—assume that if they are not receiving cash assistance, they are not eligible for Medicaid. Two types of families tend to be unaware of their eligibility: working families who assume that Medicaid eligibility is tied to welfare eligibility and families who were previously on welfare and believe that, because of welfare reform, they are no longer eligible for Medicaid. Families May Not Perceive a Need for Medicaid Due to Good Health and Alternative Sources of Care

Several state officials, providers, and one expert told us that some families do not become concerned about health care access until their children become sick and, therefore, do not enroll them in Medicaid—especially if the children are relatively healthy. State officials, beneficiary advocates, and other experts told us that lengthy enrollment forms and the associated documentation requirements create a barrier for families. In addition to length, enrollment forms often require extensive documentation. A valid and reliable eligibility determination process is important to state officials to ensure program integrity. Some States Use Innovative Strategies to Target Outreach and Encourage Enrollment

To enroll eligible children in Medicaid, some states are using innovative strategies that are intended to increase knowledge and awareness of the program and its benefits, minimize the perceived social stigma, and simplify and streamline the eligibility process. To improve the enrollment process, some states have adopted strategies to assist immigrant families or have simplified and streamlined the eligibility process by shortening forms and accepting applications at many new sites, as well as mail-in applications. They generally agreed that a successful education and outreach program should target outreach to low-income working families with children, using nontraditional methods and locations, and work in collaboration with community groups, schools, providers, and advocates. In addition, states have advertised the program as one that is intended for working families, while some have included policies to avoid displacing private health insurance. 4.) 1.) 8, 1997).
Why GAO Did This Study

Pursuant to a congressional request, GAO reported on children who are eligible for Medicaid but are not enrolled, focusing on: (1) the demographic and socioeconomic characteristics of children who qualify for Medicaid, and identifying groups in which uninsured children are concentrated and to whom outreach efforts might be expected; (2) the reasons these children are not enrolled in Medicaid; and (3) strategies that states and communities are using to increase employment.

What GAO Found

GAO noted that: (1) the demographic and socioeconomic characteristics of uninsured Medicaid-eligible children suggest that outreach strategies could be targeted to specific groups; (2) in 1996, 3.4 million Medicaid-eligible children--23 percent of those eligible under the federal mandate--were uninsured; (3) the majority were children of working poor or near poor, and their parents were often employed by small firms and were themselves uninsured; (4) uninsured children who are eligible for Medicaid are more likely to be in working families, Hispanic, and either U.S.-born to foreign-born parents or foreign born; (5) state officials, beneficiary advocates, and health care providers whom GAO contacted cited several reasons that families do not enroll their children in Medicaid; (6) lower income working families may not realize that their children qualify for Medicaid, or they may think their children do not need coverage if they are not currently sick; (7) under welfare reform, the delinking of Medicaid and cash assistance may cause some confusion for families, although GAO found that states were making efforts to retain a single application and eligibility determination process to avoid this problem; (8) in addition, many low-income families believe that Medicaid carries the same negative image of dependency that they attach to welfare; (9) immigrant families, many of whom are Hispanic, face additional barriers, including language and cultural separateness, fear of dealing with the government, and changing eligibility rules; (10) the enrollment process for Medicaid can involve long forms and extensive documentation, which are intended to ensure program integrity but often are a major deterrent to enrollment; (11) recognizing these impediments, some states have undertaken education and outreach initiatives and have tried to change the image of the program and simplify enrollment to acquire only necessary information; (12) these efforts include mass media campaigns and coordination of effort with community organizations and provider groups; (13) some states have made the enrollment process more accessible for working families, using mail-in applications or enrollment at sites chosen for their convenience; (14) several states have changed the name of the program to minimize its identification with welfare and other assistance programs; (15) many states provide Spanish-language applications and some are working with community groups; and (16) some states have also simplified the enrollment procedure by shortening the enrollment form and reducing the documentation requirements.