The application for California's Healthy Families program is bursting with warm fuzzies: Multicolored hearts, outstretched hands and stars are sprinkled throughout the 27-page form.
But the graphics don't obscure the fact that completing the application requires a calculator, copies of records from the Internal Revenue Service and Immigration and Naturalization Service, utility bills and pay stubs. Green-tinted text boxes warn that the form will be returned if certain questions are unanswered.
The form's complexity, along with myriad other bureaucratic issues, is among the reasons many observers believe California's insurance program for children from low-income families will not meet expectations.
Healthy Families is California's answer to the federal Child Health Insurance Program mandate contained in the Balanced Budget Act of 1997. CHIP gives states more leeway in spending Medicaid funds, establishing new programs or a combination of both to provide insurance coverage for the estimated 11.3 million people under age 19 who don't have it.
Under CHIP, 20 states are expanding Medicaid, 14 are starting new insurance programs, and 15 are developing dual systems, according to the Center for Studying Health System Change.
California's new program covers children from households that earn no more than double the federal poverty level, which is $27,300 for a family of three. Officials with the two state agencies that oversee the program, the Department of Health Services and the Managed Risk Medical Insurance Board, say 400,000 children will be enrolled by the end of 1999 and more than 500,000 will enroll by the end of 2000.
But as of Aug. 3 -- more than a month after the state launched Healthy Families and the accompanying $21 million media blitz -- only 5,000 children had enrolled in a state with more than 30 million residents.
L.A. Care, a Medi-Cal HMO for Los Angeles County residents, has a modest projection of 5,000 enrollees for the Healthy Families program this year. But with only 18 enrollees from the state's most populous county by the end of July, "it certainly is an enthusiastic goal," said L.A. Care spokesman Keith Malone.
"Those numbers are just appalling when you consider the number of uninsured families in L.A. County," said Carmela Castellano, chief executive officer of the California Primary Care Association, a trade group that represents more than 275 community clinics statewide.
"It's a program that needs to be a lot more user-friendly.*.*.*.*They need to be able to bring children in from the ground up," said E. Richard Brown, a professor at the UCLA Center for Health Policy Research. Brown is a co-author of a recent enrollment study by the center that concludes Healthy Families will actually enroll no more than 400,000 children.
Lynn Kersey, executive director of Maternal and Child Access, a Los Angeles-based community group that promotes coverage for low-income families, noted that other states' CHIP applications, such as South Carolina's, are as short as four pages.
Along with the complexity of California's application, Brown, Kersey and others have criticized the premiums charged, lack of assurances available to immigrant families about how the information on the forms will be used and whether glitches in the state's outreach program can be quickly addressed.
Despite the widespread skepticism, officials at the Department of Health Services and the Managed Risk Medical Insurance Board have not wavered from their year-end enrollment projections of 200,000.
Health Services Director S. Kimberly Belshe conceded that the first-year enrollment estimate is ambitious but insisted it is doable. While she acknowledged the application is long, she insisted much of the information requested is required by federal law. Belshe also cited the $17 million outreach program the state has launched to train members of various community groups to help applicants fill out the forms. The groups are paid $25 for every child they help enroll.
However, Castellano said the training sessions the state provides through a private firm have been spotty.
"The trainers were unable to fill out the applications themselves and often unable to answer basic questions," Castellano said.
Belshe confirmed Castellano's complaints but said they had been ironed out. "You can't expect a program of this scope to get off the ground flawlessly," she added.
Cost is another concern. Although premiums were not required under the federal CHIP guidelines, Belshe said they were added as part of the decision that Healthy Families should mimic employer-based insurance. Premiums range from $4 per child per month to $27 to cover a large family. There are also $5 copayments for medical office visits, capped at $250 per year. Although the out-of-pocket costs are low compared with similar employer-based coverage, the first three months of premiums must be sent with the application.
"These families have incomes that fluctuate a lot, and they're not used to buying insurance to cover future healthcare needs," said UCLA's Brown.
But again, Belshe waxed enthusiastic about Healthy Families, citing the extensive focus group research conducted before its launch.
"One of the consistent findings is that many people believe the program is too good to be true, that they can't believe the government would provide such low-cost options," she said.
Much of that research has been used to carefully craft an extensive marketing and advertising campaign that includes print ads on buses and spots on radio and television. Observers admit that the campaign was carefully orchestrated and would probably boost enrollment.