Following are some highlights from the focus groups with uninsured, low-income parents about enrolling in Medicaid and SCHIP:
Many parents seem "hardened" by past experiences with public assistance programs. They are suspicious of messages that present the Medicaid or SCHIP enrollment process as "easy" or "simple" because, based on their experiences, they perceive this process as burdensome and requiring too much documentation.
Most parents feel they know a lot about Medicaid, even though most of their information is old and outdated. They know much less about SCHIP. A number of parents have been enrolled in Medicaid in the past and this experience shapes their current opinions. Their comments revealed, however, that their knowledge of Medicaid is old and perhaps outdated. Some still associate the program with welfare. They know much less about SCHIP, with some parents only knowing the program's name and very little about the program's details.
Most of these parents face significant barriers to enrolling in Medicaid. The primary barrier is their perception that they earn too much to qualify for Medicaid, although they admitted they do not know the actual income eligibility level. Indeed, some have been told in the past that they do not qualify, and they think this still applies. Many do not seem to understand that a change in family circumstances could affect their eligibility.
Many have a negative perception of the Medicaid enrollment process. Most parents have either personally experienced this process or have friends or family members who have. They cited long waits, poor treatment by eligibility workers, intrusive questions, and too much paperwork as reasons why enrolling is unpleasant.
Despite this, most parents still express interest in enrolling in Medicaid. They appreciate that the program is free and enables them to gain access to many different health services.
Some parents are still unfamiliar with SCHIP, even though their children are potentially eligible. While many said that they have seen ads for SCHIP on trains and elsewhere, many of these parents have not contacted the program to learn more about it. When asked why, they said they need more information about the program before they would call.
Parents lack a sense of urgency about acquiring coverage for themselves and perceive coverage as unaffordable. Parents are much more concerned about their children's health coverage than they are about going without it themselves. Their emphasis on getting their kids enrolled may increase the likelihood that they may miss opportunities to sign up for coverage for themselves. While these adults know they need coverage--they discussed preventive care as an important reason--they also assume it is financially out of reach.
Language barriers stop some Hispanic parents from enrolling. Many Spanish-speaking adults said that they avoid calling the program for information because they do not speak English.
There are numerous challenges to communicating with low-income parents about enrolling in Medicaid and SCHIP. Because many parents do not think they qualify for coverage, they do not pay attention to messages urging them to enroll. Also, many parents are wary of Medicaid and do not believe messages that say the enrollment process for Medicaid has been "simplified" or that it is now "easy to enroll." Furthermore, parents may be paying attention to information about coverage for their children but not for themselves, since they are not focused on coverage for themselves. Finally, in the context of all of their financial concerns, they just do not place a high priority on health coverage for themselves. While they may understand the importance of health care coverage and want it, they believe it is out of reach.
As part of this project, we tested messages that the research team thought would encourage parents to enroll in Medicaid or SCHIP. Insights from this process include the following:
Some messages do appear to break through. Messages about "low-cost or free" health coverage for "working families" that covers doctor visits, medicines and emergency room care seem to work well with these parents. The idea that "parents need coverage for themselves to better care for their own children" was appealing as well as the statement that health coverage should be available to "everybody" (not just the wealthy). It seems that messages that combine factual information and an emotional pull score the best.
Income eligibility information is key to crafting effective messages. Because most parents believe they earn too much to qualify for Medicaid, they may need to see actual income eligibility figures before they pursue enrollment. In the focus groups, parents responded best to annual income figures for Medicaid and SCHIP. They did not seem bothered that these figures were only estimates. Rather, the main reaction was one of relief because the figures were higher than expected--even the $18,000 annual income figure cited for Medicaid. Other ways to discuss income eligibility were not as effective, including hourly wage amounts, such as $11, $12 or $13 an hour, or descriptions such as "even families earning over minimum wage can qualify." Messages for adults would be most effective if they included a specific, credible, annual income figure to help eligible parents understand that these programs apply to them.
Since most parents think of their uninsured children first, messages urging parents to enroll should still include information about enrolling children. Most parents in this study said they find "whole family coverage" to be appealing. For this reason, messages about adult coverage should not just target parents but should talk about coverage for the entire family.
Low-income parents see themselves as "working families" and like to be referred to as such in messages. In a similar finding, many parents in the focus groups responded positively to the statement, "You are working as hard as you canů" indicating that they like this fact to be acknowledged.
Learning about "low-cost or free health coverage" is important to parents. Participants cited cost as the number one barrier to obtaining health care coverage. Leading with the words "low-cost" as opposed to "free" coverage would be most effective, since participants suggested that many parents perceive low-cost coverage to be better quality than free health coverage.
Many parents believe that health coverage for themselves is important because they need to remain healthy for their children. Participants responded strongly to messages that acknowledged that it is hard to fulfill parental responsibilities, especially if parents are often sick and cannot see a doctor or obtain medication.
Many parents do not believe messages that say, "Enrolling in SCHIP and Medicaid is easier than ever." These parents have had negative experiences in the past trying to enroll in government programs and have not heard of any recent improvements to the Medicaid enrollment process. Their negative perceptions about the enrollment process are so strong that they may not even believe it when states cite specific examples of how they have simplified the process.
Most parents want to hear about the specific health services that SCHIP and Medicaid will cover. Parents are particularly interested in hearing about coverage for doctor visits, medication and emergencies.
Some parents in this study feel that they have "nothing to lose" financially, and so messages that talk about financial ruin and bankruptcy because of unpaid medical bills do not work as well as they might with families with more income and assets. A number of parents revealed they currently have large medical bills or have already ruined their credit by not paying bills. Thus, messages about how health insurance can protect their financial security do not resonate.
Many parents said they do not like direct references to other government programs, particularly welfare/TANF and food stamps. Because many of these parents have negative associations with government programs, they may ignore messages that mention them. This makes it challenging to inform families who no longer qualify for TANF that they can still qualify for Medicaid.
For more information about these and other findings from these focus groups, please download the full Reaching Uninsured Parents report.