Whoever thought teens' obsession with their looks could play a role in the nation's healthcare debate?
But posters promising clear skin - plastered all over the walls of schools in North Carolina's mountains - are proving a surprisingly effective recruitment tool. Along with simple two-page enrollment sheets, the ads are part of a campaign to sign up children whose parents can't afford health insurance.
Helping low-income families care for their children has been a sensitive topic for years, with almost as many approaches suggested as there are parents. But recently, North Carolina has outstripped the rest of the country by enrolling about three-quarters of its uninsured children - offering lessons closely watched by other states as they seek to aid America's 11 million uninsured kids.
"This is one of the best things that could have happened to children's healthcare," says Olsen Huff, former president of the North Carolina Pediatric Association.
In 1997, Congress set aside $24 billion over five years for states to care for a new class of "working poor." The legislation, an "enhancement" of the Medicaid program, puts free or low-cost healthcare in reach of families making less than $32,000 a year. Quietly, often with county social workers as the pitch men, the Children's Health Insurance Program (CHIP) is spreading from Long Beach, Calif., to Bar Harbor, Maine. Nationwide, some 2 million out of perhaps 7 million eligible children have been enrolled.
The program has an aura of the universal healthcare system President Clinton proposed in 1993, because it caters to people who run small businesses or those who simply can't afford hundreds of dollars a month to insure a family.
Indeed, conservative critics have balked at what they say is a new "middle-class welfare" program. "I don't think we ought to be desperately begging middle-income families to enroll in a welfare program," says John Hood of the John Locke Foundation, a Raleigh think tank.
But Charlotte social worker Luis Tejera is grateful his son and daughter are among the newly insured. "It came at a great time, like falling from the sky," says Mr. Tejera, who says he had no idea, on a $25,000 salary, where to find an extra $200 a month to insure his kids.
States differ widely in implementing Medicaid programs, and so far, North Carolina has taken the boldest approach toward covering its estimated 71,000 "working poor" children.
Among the 12 states with the most uninsured children, North Carolina has picked up the highest percentage at the fastest rate, says a study by Families USA, a healthcare advocacy group. "It's no one thing, but a bunch of things we did correctly," says healthcare advocate Adam Searing in Raleigh.
After a partisan squabble, state lawmakers surprised critics by concocting a dizzyingly simple approach: year-round coverage, a two-page, bilingual enrollment form, and even a mail-in enrollment option. Unlike some states, North Carolina does not require an "asset test" or a check into what model car you drive.
Legislators kept the program simple by piggybacking the plan on the existing program for state employees. "We had just one goal: to find out how much they make and whether their children have health insurance," says June Milby, one of a small staff of state coordinators. "We didn't want to have any unnecessary requirements."
Still, conservative lawmakers almost killed the plan, concerned about who would be left holding the $108 million annual tab if the program evaporated.
"I just don't see any way the federal government would discontinue it, I really don't," says Dr. Huff, citing the early successes in North Carolina and elsewhere.
Indeed, Mr. Clinton (and, subsequently, presidential candidate Al Gore) is now seeking to extend CHIP to parents as well as children.
Vice President Gore's plan, in addition, would raise the income ceiling to as high as $41,000 for a family of four, making millions more Americans eligible.
But Mr. Searing sees a "dark side" to the CHIP program: its failure to cover a rising number of uninsured.
Although not part of the historic 1996 welfare-reform package, CHIP gained bipartisan support partly because it catered to families coming off welfare rolls, observers say.Yet there are more uninsured today than in 1996, ethicists complain.And one big reason is that only about half of those eligible in most states have signed up.
One problem, says Farber, is some states have shown little enthusiasm for CHIP - and their asset tests often complicate the process. Further, in states such as Indiana, many doctors are rebelling, claiming poor reimbursement. And border states such as Texas and California face cultural and geographic barriers to reaching the uninsured.
Even in North Carolina, with its door-to-door enrollment drives, the response has not been as strong as hoped. Although most states have tried to "destigmatize" the offering, it seems many handout-wary Americans are still reticent.
Tejera, however, had few qualms about signing up. "In the Anglo-American culture, I think there's more of a worry about it being seen as welfare," he says from his office here in Charlotte. "In our Hispanic culture, if we need something and there's a way to get it legally, we go get it."
(c) Copyright 2000. The Christian Science Publishing Society