Emergency Departments and Uninsured Children: An Enrollment Opportunity☆

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Abstract 

[Nedza SM, Mulligan-Smith D, Harris R. Emergency departments and uninsured children: an enrollment opportunity. Ann Emerg Med. September 2000;36:240-242.]

Even though America’s economic health has never been better, an uninsured population that is growing at an alarming rate jeopardizes its physical health. The call from citizens, providers, and elected officials for solutions to this problem and to provide access to care continues to grow. Coverage for the uninsured is critically important to emergency departments, as the only site required by law to screen and stabilize all who seek emergency care under the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986.¹

As the one site where uninsured individuals are guaranteed access to the health care system under this statute, EDs play a vital role as part of the safety net by caring for uninsured children and their families. This is substantiated by the fact that EDs provided care to 16,388,736 individuals without health care coverage from a total of 97 million visits in 1996.² As the percentage of uninsured ED visits increases, what is an appropriate role for emergency medicine in addressing this complex issue?

Should EDs solely be limited to complying with the EMTALA legal mandate to provide emergency care? Or should the role be expanded to seeking collaborative enrollment solutions and access to primary care for these individuals? Ultimately, are EDs part of the problem (expensive sites of care that are to be avoided at all cost), or are they part of a comprehensive solution?

We postulate that these departments have a unique opportunity to join patient enrollment programs that are seeking to improve access to care for the uninsured. The most promising opportunity is through efforts to enroll children in the State Children’s Health Insurance Program (SCHIP). This program is one of the most significant health care reforms for children since the enactment of Medicaid in 1965. Under Title XXI, the federal government allocated to the states more than $24 billion between 1998 and 2002, and nearly $40 billion over the 10-year life of the legislation, to provide health insurance for previously uninsured children. States were given broad latitude to create a program that specifically addressed the needs within that state. To receive funding, each state plan was required to maintain the Medicaid eligibility in place on April 15, 1997, and maintain the same level of state spending on child health programs that was expended in 1996.

Initially, few states developed comprehensive plans. Most elected to participate by implementing Medicaid expansions while they continued to work on a more comprehensive plan. To assist in this effort, the federal government passed several modifications to Medicaid law, allowing for a more streamlined eligibility and enrollment process.

During 1999, more and more states went beyond Medicaid expansion and began to develop comprehensive SCHIP programs. By mid-1999, every state and territory had an approved plan operating within its jurisdiction. However, new program development constraints slowed enrollment in SCHIP during the first 6 to 9 months after enactment and prompted some to criticize the program and call for its repeal. However, during the last half of 1998, the new systems began to have an impact, resulting in health care coverage for 1 million previously uninsured children. Efforts to seek new strategies to increase enrollment are accelerating, although access and enrollment problems continue.

These problems were reflected in a recent report, “The Kaiser Commission on Medicaid and the Uninsured,”³ that recognized 2 significant barriers to the success of this program. The first is that families with no previous connection to the welfare system must be informed about the SCHIP program and that their children may be eligible. The second is that the enrollment systems must be instituted with minimal administrative burden.

The Kaiser report also supports efforts to distribute outreach materials widely so that they reach all segments of the targeted population. These outreach strategies need to be community-based, and in many cases one-on-one. It is in this area that EDs can play a vital role in ensuring the success of these efforts. We suggest that an effort that is currently under way in New Jersey could provide a method for other EDs to follow and to refine.

The New Jersey Chapter of the American College of Emergency Physicians is the 550-member specialty association representing physicians practicing in the state’s EDs. They have successfully partnered with NJ Kidcare⁴ to undertake enrollment strategies. The program began with an educational piece that was distributed to all member physicians within the state. Information about the plan was also highlighted in the chapter newsletter. To support enrollment, the chapter disseminated materials describing the program and eligibility EDs throughout the state.

This information is available in both Spanish and English. The brochures also carefully address the issue of the eligibility of the children of undocumented aliens.

In addition, a toll-free (800) telephone number for information is also posted in the waiting rooms. Further collaboration occurred when the NJ KidCare staff also established enrollment sites on evenings and weekends in targeted EDs. The heightened awareness of the program led to an additional benefit as registration personnel also began encouraging families to enroll their children. A concerted effort was made to maintain communication among the chapter, NJ KidCare, medical staffs, and hospital administrations. The chapter also encouraged that state administrators be kept informed on changes in the program.

Initially, New Jersey officials estimated that 350,000 children were without health insurance within the state. Since the program began, they have successfully enrolled 60,000 of the 154,00 children eligible for SCHIP. How much of this success has been directly linked to EDs? Although outreach materials continue to be disseminated through these sites, there is currently no tracking mechanism to directly measure the number of new enrollees attributable to this project. Clearly, this needs to be monitored as the effort continues and should be included in any other state efforts.

This lack of definitive data does not diminish the potential of using these locations as a point of access to target eligible families and children for SCHIPS enrollment. One of the hurdles to implementing this type of effort is the great variability of resources from institution to institution. No single model will be successful. Institutions can seek customized solutions ranging from the simple placement of basic information in waiting rooms to the active use of social workers to facilitate enrollment of children. Institutions may also consider other enrollment strategies such as using discharge information in their efforts. Finally, including information in bills sent to patients who identify themselves as self-payers may be the appropriate incentive needed to encourage enrollment. As the states move toward models of presumed eligibility, we postulate that ED outreach in the area of enrollment will also become easier.

EDs have a vital role in providing care and access to the health care system in every community. EDs are also uniquely positioned to undertake this effort. It has been estimated that a patient spends 147 minutes in an ED during the average visit. Of this time, only 28 minutes is direct care time.⁵ On a fundamental level, this should be considered a unique teachable moment. This non–direct care time provides a window of opportunity to reach this group with the message of available coverage options such as SCHIPS or Medicaid.

Will this effort work? The US Department of Health and Human Services actively promotes the importance of having health insurance and recognizes that a regular source of continuing care leads to healthier outcomes.⁶ It might be argued that improving access to insurance is only a small part of the work necessary to improve the health of the population. It remains to be seen if this program or others like it actually lead to better health.

More specifically, it is impossible to say whether enrollment in the SCHIPS program will decrease ED utilization for nonurgent care or increase reimbursement. Until these questions can be answered, emergency medicine can look on this as an opportunity to define itself as an important voice and potential partner in efforts to incrementally increase access to health care. Hopefully, we will then be perceived as part of the solution to the problem of the uninsured and not excluded from policy initiatives as part of the problem.

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References 

1. Health Care Financing Administration . The Emergency Medical Treatment and Active Labor Act, as established under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 USC 1395 dd). Federal Register. 1994;59:32086–32127
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2. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 Emergency Department Summary. NCHS Advance Data No. 293, Center for Disease Control, National Center for Health Statistics Hyattsville, MD: National Center for Health Statistics; December 1997;
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3. Making Child Health Coverage a Reality: Lessons From Case Studies of Medicaid and CHIP Outreach and Enrollment Strategies. Kaiser Commission on Medicaid and the Uninsured. Menlo Park, CA: Henry J. Kaiser Family Foundation; September 1999;
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4. NJ Kidcare FAQ. Available at http://www.njkidcare.orgJuly 11, 2000.; Accessed
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5. Emergency Care Reform, Executive Briefing for Clinical Leaders. Washington, DC: Clinical Initiatives Center, the Advisory Board Company; 1998;
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6. Simpson G, Bloom B. Access to Health Care Part 1: Children, Vital and Health Statistics, Series 10 (National Health Survey No. 196). Hyattsville, MD: National Center for Health Statistics; 1997;
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