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Chipping Away

'Walkers and talkers' from Health Care For All go door to door through this city's poorest neighborhoods looking for uninsured residents and kids. Recently, they've been joined from people from across the country who hope to repeat their success.

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The old man didn't want to tell them out loud the amount of his retirement income. Even though they were sitting inside his apartment, filling out his Medicaid form. "He wrote it on a piece of paper," Catrina Trumble-Corey says. "He thought his neighbors might be listening."

Trumble-Corey supervises a five-person team of "walkers and talkers" -- outreach workers for the program Health Care For All. Outfitted in their usual khaki shorts and maroon polo shirts, the team had just spent a few hours knocking on doors in the B.W. Cooper (Calliope) housing project. If anyone is uninsured, the Health Care For All team can -- on the spot -- complete an application, either for Medicaid, the public-health plan for low-income people, or for LaCHIP, the health-care plan for children.

The walkers and talkers use handheld scanners to scan in documents like birth certificates, medical bills and social-security cards. If anyone lacks these documents, the outreach team secures the paperwork through the local Social Security office or the vital statistics offices in any state.

Unless the temperatures get too high or turf wars turn too violent, walkers and talkers spend nearly every workday in B.W. Cooper. They've done so since April. Before that, they door-knocked in the now-demolished St. Thomas project and then in the working-poor area around St. Thomas.

This day is not unusual as far as the work they're doing. But today, visitors from San Diego are here, watching the team make its rounds. Afterward, everyone returns to the Kingsley House, where Health Care For All is based. The San Diego visitors give a full report, starting with Trumble-Corey and the elderly man.

The man had allowed Trumble-Corey to bring one visitor into his apartment, and she has plenty to say about the experience. "We had a real character," she says. "What impressed me was that, no matter what curve he threw, Catrina was patient." At one point, the old man had mentioned that he had a shotgun in the house. No reaction from Trumble-Corey. Then the man was hesitant about handing over his Social Security number. She told him, "That's fine -- they'll mail back something telling you what they need."

Program Manager Tammi Fleming listens and nods her head. "With the elders, we won't push that much. Because if they receive something in the mail, they'll send it back. It's the young ladies with the children that we try to follow through on -- because sometimes something else might come up and they might not follow through on their own."

Welcome to the world of Health Care For All, where Fleming and her staff of seven are honing health-care outreach into a fine art. They've been so successful that, in the past few months, several teams of outreach workers -- including the current visitors from San Diego -- have flown in from other cities to watch them at work.

Dr. Marcia Bayne-Smith explains that the high visibility, door-to-door approach used by Health Care For All relies on neighbors talking to each other. A professor of urban studies at Queens College in New York and a consultant for the Baltimore-based Annie E. Casey Foundation, which partly funds Health Care For All, Bayne-Smith is helping to facilitate the visit from San Diego, using observations from B.W. Cooper as a lesson.

The idea, says Bayne-Smith, is that when you sign up one resident for LaCHIP or Medicaid, she will knock on her friends' doors and tell them "you need to get health insurance for your child." It uses what Bayne-Smith calls "social glue, that network of families and neighbors found in poor neighborhoods. These relationships help people in ways that no government programs can do."

A member of the San Diego team weighs in on that point. "We only got as far as the stoop," she says. "Pam had enrolled two out of three women, and the third was very eager to sign up." While they were outside, she notes, several other people came up to say hi or ask for information.

The success they've witnessed today is the result of smart recruitment, intensive training and hard work, emphasizes Bayne-Smith. "None of what you've identified came by accident," she says.

Fleming tells the San Diego group that when she hires, she looks for raw communication skills -- the ability to converse about any subject with any person. "You can say, 'What about this cold drink?' to Pam [Dixon] and she can give you three hours on a cold drink," she says.

Walkers and talkers start out with an intensive month-long training period, during which they polish communication skills and role-play different scenarios. Fleming demonstrates the role-playing by calling on Dixon. "Pam -- act like a person who doesn't want to be bothered," she says, and Dixon acts expertly like a young woman with an attitude who "really doesn't feel like filling out any forms today."

Everyone laughs. But Fleming points out that people have reason to be wary, even hostile. "Folks like us have been knocking on those doors and not been honest." She recalls that 15 people were evicted from St. Thomas after one group conducted a survey and weren't forthright about how they were going to share their information.

Some residents may also be going through traumatic times, dealing with domestic violence or with the death or incarceration of a loved one. "So if they don't have a child sick, maybe they really don't have the time to deal with this right now. We are always quick to criticize. But I was a teen-age mom at the St. Thomas, outside playing cards."

"I met Tammi 13 years ago," recalls Bayne-Smith. "She was 17 years old, had a baby, was on welfare. She started as a volunteer for Plain Talk, our teen pregnancy prevention program. She wasn't even getting paid. But she went to school at night, got her GED, bachelor's, then master's in public health."

"It took us years to get Catrina off the porch," adds Fleming. "Some of your most reluctant people can become key messengers for your program."

When it comes to health care and social services, Louisiana is usually ranked 49th or 50th in the United States. Yet the state's efforts to enroll children in LaCHIP have been ranked at the top of the charts by several health-care advocacy groups. Currently, the state has, on its Medicaid and LaCHIP rolls, 553,000 children. Of those children, 238,000 -- 43 percent -- were uninsured when the state launched LaCHIP in 1998.

A high portion -- 79 percent -- of LaCHIP's medical costs are paid for by the federal government, through national legislation that in 1997 created the State Children's Health Insurance Plan (SCHIP). SCHIP was designed to help working families whose incomes were too high to qualify for Medicaid but too low to afford private insurance. State plans vary; children in Louisiana are eligible for LaCHIP if their household's income is up to twice the federal poverty level.

Louisiana's efforts have been lauded on a few fronts, including the application itself, which can be used for both LaCHIP and Medicaid kids (adults 19 years old and older have a separate six-page Medicaid form). "We shrunk it from what used to be 14 pages down to two pages, written in plain English," says David Hood, secretary of the state Department of Health and Hospitals (DHH).

Louisiana is also doing well with renewals, which must be completed every 12 months. "You have to be sure there's not a hole in the bucket, that you're not losing children faster than you're adding them," explains Ruth Kennedy, who as deputy medical director for DHH oversees the state's outreach efforts.

Still, even with those efforts, many children remain uninsured. In Louisiana, according to a recent Urban Institute report, 202,700 children -- or 17.6 percent of kids in the state -- currently lack insurance. Two-thirds of those children are eligible for LaCHIP or Medicaid.

Louisiana's situation is paralleled nationwide, says Sarah Shuptrine, president of the Southern Institute for Families and head of Covering Kids and Families, a $97 million Robert Wood Johnson Foundation initiative focusing on SCHIP and Medicaid outreach. "Many, many children below poverty are not enrolled in this program," says Shuptrine. "Often families with eligible children simply do not know about it or don't know how to enroll."

Dorthea Brimmer used to take her little girl to Charity Hospital. Her daughter, now 13, once had asthma, which she now seems to have outgrown. During the past two years, she's only been to the hospital once, when she got a piece of glass stuck in her foot.

"Knock on wood, she's been healthy," Brimmer says. "But I feel like she has more protection now. With her LaCHIP card, I can get an appointment for her either at the St. Thomas health clinic or at her own personal doctor." Brimmer enrolled her daughter in LaCHIP in 1999, when she lived in the now-demolished St. Thomas housing project, the first targeted by the Health Care For All team.

Children who lack health insurance are less likely to get the medical care they need, experts say. Parents of uninsured children are more likely to put off doctor visits. According to the American College of Physicians, uninsured kids are five times more likely to use the emergency room as a regular source of care. Uninsured children are more likely to be sick as newborns and less likely to be immunized as preschoolers. If a child is uninsured, readily treatable health conditions -- dental cavities, middle-ear infections, poor eyesight, and asthma -- are much more likely to go undetected. These conditions can increase school absences or make reading and learning more difficult.

When Brimmer started a new job, her daughter was knocked off of LaCHIP. "I had reported my job, but the computers made a mistake," she says. She talked to the Health Care For All team, and the approval papers were in the mailbox the next week, she says.

"You really become more of a caseworker for that person once you do that initial survey," says Fleming. Parents have one thing in common, she says. "Every mother, whether she's on crack, welfare, or has a million dollars, wants the best for her kids," she says.

Health Care For All began in 1999, armed with data showing that local housing projects were fertile territory for health insurance outreach. Using income statistics, the Housing Authority of New Orleans (HANO) had projected that the city's nine housing developments held 30,000 eligible children. Families in the projects are often labeled hard-to-reach.

"Some would-be recipients," says DHH's Ruth Kennedy, "need the type of outreach that the walkers and talkers with Health Care For All provide, that one-on-one assistance in completing the application and conveying the message that this is something they really do qualify for."

In an economic downturn, outreach of any sort continues to be crucial, says Donna Cohen Ross, the director of outreach for the Center on Budget and Policy Priorities. "Families are less secure now," she says. "People are losing their jobs along with, perhaps, the employer-based health-insurance that came with it."

Indeed, economists for the Henry J. Kaiser Foundation estimated last year that for every percent point rise in the unemployment rate, 1.2 million people become uninsured. These newly unemployed people might not have listened to previous outreach efforts because they had health coverage, says Cohen Ross. "They could be considered an entirely new audience," she suggests.

Members of the Health Care for All team pour coffee into their cups and walk into the Kingsley House conference room for their Monday morning meeting. Program director Tammi Fleming sits at the head of the table, surrounded by the rest of her team. It's a close-knit group: secretary Hillary Lofton-Everidge, supervisor Catrina Trumble-Corey and the five walkers and talkers -- Pamela Dixon, Sandra Faulk, Shawana Morris, Letha Richardson and Marian Jordan.

Fleming reminds her staff to check their voice-mail messages regularly, that they "don't want people to say we have the same bureaucratic delays as the welfare office." They then discuss the previous day's fatal shooting in B.W. Cooper, on Thalia Street. Before they head out to the field today, they'll feel out the situation with the B.W. Cooper management office.

This summer's turf war has meant that the team can't make night visits to locate qualified residents who work during the day. "We're hoping the cooler weather will bring some calm to those communities so that we can do some evenings," says Fleming.

Next on the agenda is a report from Trumble-Corey. Within the first six months of 2002, she calculates, Health Care for All completed 509 applications. Their annual program goal is 600 enrollments per year; last year, says Fleming, they enrolled 850 total people, 40 percent over that goal. This year, they're on track to do even better than that.

To date, Trumble-Corey says, they have made contact with 56 percent of the 1498 units in B.W. Cooper. Once they have reached 80 percent, they will move on to another area, maybe to the Guste or St. Bernard housing projects or to the working-poor neighborhoods around B.W. Cooper.

Pamela Dixon walks down Galvez Street and knocks on a door emblazoned with five bumper stickers that say "My child is a New Orleans Public School scholar." A woman opens the inside door and speaks through the screen door. "Good morning, how are you doing?" says Dixon. "My name is Pamela, I work for Kingsley House. We have a contract with B.W. Cooper to go from door to door to find out if any kids or adults in your household need free health insurance."

First, the woman takes the Health Care For All household survey. She has two kids, she says; they're already covered by Medicaid. Dixon thanks her for her time and walks over to the next building. She marks her paperwork. "This was my eighth time to that house. I got lucky," she says.

After stopping at several more doors, Dixon heads off to meet her co-workers. Letha Richardson has stopped a little short of their scheduled rendezvous point. She's talking with a 19-year-old man named Ernest; on her clipboard is a Medicaid application indicating that he has a stack of recent medical bills. Richardson tells him that Medicaid will reimburse him for bills up to three months back.

Ernest says that he thought he didn't qualify because he isn't on welfare. It's a common misconception because, in the days before welfare reform, the programs used to be linked.

Richardson finishes up with Ernest and then walks toward the car with Dixon and Shawana Morris. Richardson points out that she wasn't simply completing Ernest's form. "I let him sit there and watch me fill it out," she says. "I was trying to teach him so that next time he could do it his own self."

As the team members stroll toward the B.W. Cooper management office, several other residents approach and ask questions about various policies and invoices. "That's what we took all this training for -- to educate our community," says Dixon. It's getting to be late afternoon. The three women pile into the hot car and head back to the Kingsley House.

Health Care for All's Pam Dixon, Hillary Lofton-Everidge, Catrina Trumble-Corey and Shawana Morris - TRACIE MORRIS/YOUNG STUDIO

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