Rural Kids

From "Why is Rural Important? Enrolling Rural Children in CHIP and Medicaid," by the federal Rural Work Group of the Interagency Task Force on Children's Health Insurance Outreach (the complete and detailed report with specific outreach recommendations is a www.nal.usda.gov/orhp/chip2.htm) (Summarized by Mr. Tim Size, Rural Wisconsin Health Cooperative, RWHC April 1999.)

Rural Areas Are Not Just Small Urban Enclaves

"Some populations of American children are receiving greater attention in our outreach efforts due to higher rates of poverty and lower rates of insurance, specific barriers that make mainstream outreach efforts less effective, and disenfranchisement from the health care system in general. Rural and frontier populations are often left out of conversations of specially targeted populations. rural children are more likely to be uninsured than their urban counter part--21% of rural children are without insurance, versus 14% of children in urban areas."

"Rural areas are not just small urban enclaves in which mainstream outreach efforts can be ownsized and effectively implemented without translation. The rural context, while containing some of the same elements as the urban context, is different and warrants focused attention. While rural areas are extremely diverse, there are some generalizations that can be made about rural demographics and infrastructure that help to place outreach in rural areas in the appropriate context."

"Rural areas have higher rates of poverty than urban areas. In 1997, non-metro counties had a 15.9% poverty rate compared to 12.6% for metro counties. This higher rate of poverty can partially be attributed to a higher reliance on minimum wage jobs and service sector employment in rural areas."

"While rural economies are no longer exclusively dependent on farming, rural areas still have a higher percentage of small business economies than urban areas. Low wages and smaller business size in rural areas also mean that rural residents have lower rates of employer sponsored health insurance coverage. 51.7% of rural employees are covered by employer health plans compared to 60.4% coverage in urban areas. Lower rates of employee sponsored insurance contributes greatly to the lower rate of insurance for rural children. Therefore, partnering with small rural businesses may prove an effective outreach strategy."

"The characteristics of rural communities also may suggest subtle differences in outreach strategies. For example, rural welfare recipients are more likely to be employed and married than urban recipients. Rural communities are smaller communities in which residents are more familiar with each other than in urban areas. This familiarity is often coupled with a distrust of outsiders and newcomers. Many rural communities also have strong religious values and have strong connections with their local churches. Rural areas also have a large elderly population. These respected elders provide much of the childcare in rural areas, and may serve as a special target for rural outreach."

Enrolling Rural Children for Health Insurance

"It is this rural context that outreach efforts need to focus on reaching rural children. A United States General Accounting Office report in March 1998 discussed general reasons why children may not be enrolled in Medicaid or CHIP. The working poor may not realize they are eligible. The delinking of Medicaid and cash assistance also has created confusion for families and service providers. Outreach efforts will also have to deal with cultural misunderstanding, language barriers, and the negative perception of dependency. Efforts will also have to be made to simplify and explain the cumbersome enrollment process and health system."

"These factors, compounded by sparse rural populations and less health infrastructure, suggest that outreach efforts in rural areas may require more effort, more time, and a higher initial investment. While it is too early in the CHIP implementation process for a complete evaluation of rural outreach efforts, there are lessons that can be learned from 'rural' states that have had some success in reaching children. We also can learn from efforts in Medicaid outreach that proceeded CHIP. There are also lessons from CHIP outreach success stories in rural communities."

"In Balsam Lake, Wisconsin, ABC for Health Inc. developed an outreach model that has been successful in increasing Medicaid enrollment. Since 1988, the project has used family health benefit counselors at local health departments to assist clients in enrolling in public assistance on a family-by-family basis. In 1998, the project began to focus on children's health insurance programs, and has since expanded to 17 counties in northwestern Wisconsin. The counties share information on available programs, rules, and regulations. These counselors do not just enroll children; they also review applications, assist clients when they have been denied coverage, and provide guidance for hearings and appeals. Public health nurses refer families to the counselors, and a small team of public interest lawyers and law students provides technical assistance to the counselors and families."

"The program's success is linked to the dedication of resources by health clinics and health departments. Health clinics have found that the program is only beneficial when they can dedicate enough staff support to the effort. After eighteen months, one clinic found a 46% increase in third-party payment. Project Director Michael Rust says 'the clinic administrators told us that we gave them a new outlook on working with the community.' They said 'We'll do anything we can because we discovered it's to the family's benefit and it's to the clinic's financial benefit.' "

"Rural communities often have few choices when it comes to primary care providers. For the enrollment of children in CHIP and Medicaid to lead to improved health outcomes, the health professionals that currently reside in rural areas will need to participate. With many states turning to managed care as a way of increasing eligibility, it is important that these managed care programs include rural providers. It will not help a child to be insured if the only doctor that can treat him or her is 50 miles away."

"Rural families will also need help accessing the health care system. Basic assumptions made by the health care system may not be true in some rural areas. For example, some poor rural families do not have phones. Transportation problems in rural areas are severe because of a lack of public transportation and farther distances to travel to get to a medical facility. Training outreach workers in rural communities that can help families enroll children in programs, and then work with families to help them access the system, can help to alleviate some of these problems."

"Although a strong case can be made for the need to focus on rural communities, the rural context is not completely unique and distinct from the urban setting. To the contrary, the similarities between the two settings are striking and a lot will be gained by sharing experiences between both settings. Rural areas and urban areas face many of the same problems, but many times rural communities experience these problems in different degrees or with a different spin."