The Children’s Health Insurance Program in Rural PA

It has been a decade since Pennsylvania took on a national leadership role in providing health care coverage for uninsured children. Through the Children’s Health Insurance Program (CHIP), Pennsylvania has been providing free or low-cost health insurance to children whose families earn too much to qualify for Medicaid but who cannot afford private insurance.

A recent study sponsored by the Center for Rural Pennsylvania to learn more about outreach and enrollment efforts aimed at rural children has found several factors that positively enhanced or influenced enrollment in CHIP. Referrals from other human services agencies and outreach personnel’s sensitivity to individuals’ religious beliefs are just two of the factors that have a positive influence on enrollment.

The study also found several factors that negatively impact enrollment, including the lack of support from local school systems and the CHIP application process.

CHIP basics
CHIP’s health benefits and services are provided through state contracts with private insurers, who are limited to specific geographic areas of the state. As of September 2003, 133,462 Pennsylvania children were receiving health care coverage through CHIP, according to the Pennsylvania Insurance Department. That’s a huge improvement over the 50,000 children that were receiving coverage more than five years earlier in 1998.

And while it is difficult to determine with certainty the actual number of uninsured children living in the Commonwealth, CHIP staff estimate that there are approximately 28,300 children eligible for but not enrolled in CHIP as of October 2003.

CHIP provides both free and subsidized benefits for children, dependent upon income. The subsidized program especially may be underused as estimates suggest that about 25 percent of children are eligible for the subsidized program and only 7 percent are enrolled.

To generate information for policy makers and insurers seeking to improve the health of rural children insured through CHIP, the Center for Rural Pennsylvania awarded a research grant in 2001 to Dr. Marie Twal and Dr. Elizabeth Palmer of Indiana University of Pennsylvania. The researchers focused on outreach activities, acceptance of and access to the program, and use patterns. They also set out to understand CHIP’s impact on the five stages of childhood, and to gain insights into the discrepancy between enrollment in the free and reduced premium arms of CHIP.

Study setting
The study focused on four rural Pennsylvania counties: Indiana, Perry, Potter, and Wayne. The counties were selected because of their rural composition and varied geographic location. Also, Potter and Wayne are two of six counties identified by the CHIP program as experiencing a low rate of CHIP participation. Perry County is one of six rural counties in which there are two established CHIP insurance contractors. Indiana County was selected to represent western Pennsylvania.

The researchers interviewed personnel involved in CHIP outreach activities in each of the four counties and compiled a list of the activities conducted over the past 12 months. The interviews produced a list of perceived barriers to access. An analysis of this data identified common themes.

To identify patterns for children insured through CHIP, the researchers gathered use data from each of the insurance contractors in the study counties. Contractors were asked to provide demographic and service use information for children enrolled in their program from July 1, 2000, to September 30, 2001.

Findings on outreach
The survey respondents identified the following factors as having positively enhanced or influenced enrollment in CHIP:

• referrals from other human services agencies;
• sensitivity to individuals’ religious beliefs;
• recognition of possible negative feelings associated with government “hand-out” programs;
• outreach to agencies who have contact with potential clients; and
• help with the application process and paper work.

Conditions that negatively affect the implementation and effectiveness of outreach activities are:

• lack of support from local school systems;
• education;
• application process;
• enrollment guidelines;
• stigma of a government program;
• religion; and
• confidentiality.

Strategies that work
The need for public education about the benefits offered through CHIP and the development of a trusting relationship between individuals in the community and those participating in outreach activities emerged as themes in the discussion of outreach strategies. The development of trust was an especially crucial element for many respondents.

Respondents identified school nurses as valuable partners in the outreach efforts since they have special access to school-aged children.

Perceived barriers
The perceived barriers to adequate health care for CHIP enrollees were dental care, transportation, and the lack of providers. Dental care, or the lack of providers, was the most frequently mentioned problem, followed by transportation.

Seven of the respondents identified transportation as a significant problem for some families. One stated that “people can find a way if they really have to, but it can be costly.” Respondent concerns ranged from poor road systems to having to travel out of the county for specialized services or even basic services not provided in the county.

Conclusions
The research yielded other useful insights into the CHIP program in rural Pennsylvania concerning evaluation activities; outreach strategies; the need for additional methods to reduce the stigma of government programs; improving access to health care, namely dental care; and use strategies.

For a copy of the report, Analysis of the Children’s Health Insurance Program in Rural Pennsylvania, call the Center for Rural Pennsylvania at (717) 787-9555 or email info@ruralpa.org.

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Chairman’s Message

The holiday season is just around the corner as I write this Chairman’s Message. As the days grow shorter, it is important that we give thanks for the blessings we take for granted during our hectic daily routines throughout the year. We need to be especially grateful for the fruits of the farmer’s hard labor whenever we sit down to a table filled with the delicacies that have become traditional fare as we celebrate during the final two months of the year.

I always look forward to this time of year, when Mother Nature forces us to slow our pace just a bit after spending the growing and harvest seasons working round the clock, or so it seems. This is a perfect time to reflect on what went well during the previous 10 months and what we might do better in the coming year.

Analyzing what is being done well and what might need improvement is a good exercise for government, as well as for farmers and other business enterprises. The Center for Rural Pennsylvania recently funded a study that looked at a state-administered health insurance program. Dr. Marie Twal and Dr. Elizabeth Palmer of Indiana University of Pennsylvania performed this “check up” of the Children’s Health Insurance Program (CHIP). They found that referrals from other human service agencies and CHIP outreach personnel’s sensitivity to individuals’ religious beliefs are just two of the factors that are having a positive influence on the program’s enrollment. They also found that there was room for improvement in a number of areas to build on this program's successful track record. State government, for example, needs to analyze the CHIP application process to determine what can be changed to make enrollment less of an obstacle.

The General Assembly is benefiting from another chapter in the work of Dr. E.L. Shafer and Youngsoo Choi of Penn State University on nature-based tourism activities and their popularity in Pennsylvania. The researchers’ recently released report is featured on page 2. In this study, the researchers surveyed public and private agency staff, who in turn provided a number of recommendations that address specific barriers or opportunities related to the funding, development, and management of sustainable nature-based tourism for rural Pennsylvania.

In this issue of Rural Perspectives, we continue our Trends in Rural Pennsylvania series with this month’s focus on water, woods, and energy. We also welcome two new board members, Steve Crawford and William Sturges, whose biographies appear on page 6.

As you prepare your New Year’s resolutions and make plans for the coming months, be sure to check out the information on 2004 conferences on page 7. The Center for Rural Pennsylvania will once again be participating at the annual Pennsylvania Farm Show beginning January 10th. Please stop by and visit our booth when you come to Harrisburg. If you haven't visited our bigger and better Farm Show Complex yet, you are in for a treat. And don't forget to save room for all those mouth-watering foods that make Farm Show famous - like baked potatoes, milk shakes, pork and beef sandwiches, and lamb stew. (Be sure any New Year’s resolutions to lose weight start in February!) We'll see you there.

On behalf of the board and staff, I wish you happy holidays and a happy, healthy and prosperous New Year.

Representative Sheila Miller

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Research Provides Nature-Based Tourism Policy Recommendations

Bird watching, hiking, and skiing are just some of the nature-based tourism activities that have witnessed skyrocketing participation rates nationwide over the past five years. Rural Pennsylvania, which is the obvious destination for most of these activities, has a unique opportunity to capitalize on the growing national, and even international, interest in nature-based tourism (NBT).

To learn more about this growing tourism trend, the Center for Rural Pennsylvania sponsored a research project in 2002 to specifically look at current programs supported in Pennsylvania that promote and develop NBT. The project, which was conducted by Dr. E.L. Shafer and Youngsoo Choi of Penn State University, also documented NBT-related policy issues of 17 other states that have major NBT activities, and identified current NBT issues, initiatives and related programs that need to be addressed in the state.

The research included a survey of public and private agency staff and provides a number of recommendations that address specific barriers or opportunities related to the funding, development, and management of sustainable NBT for rural Pennsylvania. Each of the recommendations fall within one of the following areas: resource allocation and management; state agency planning and coordination; partnership with stakeholders; communications between state agencies and the public; knowledge base and the role of science; and information and data management.

The survey respondents also provided recommendations for 14 specific NBT policies.
For a copy of the report, Nature-Based Tourism Policy, call the Center for Rural Pennsylvania at (717) 787-9555 or email info@ruralpa.org.

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Trends in Rural Pennsylvania: The Environment and Natural Resources

Pennsylvania has a diverse environment and numerous natural resources, most of which can be found in the state’s rural counties. For a closer look at these assets, the Center for Rural Pennsylvania examined a range of land cover, mineral, and environmental protection databases created and maintained by various state and federal agencies.

Water
Although Census data show that open water, excluding Lake Erie, covers just 1 percent of Pennsylvania’s total area, the lakes and streams in the Commonwealth play an important part in rural life. The Commonwealth’s extensive network of more than 80,000 miles of streams divides the state into 104 watersheds. Watershed management also includes wetlands, of which there are currently about 404,000 acres, found throughout the Commonwealth.

Pennsylvania’s water resources provide water not only for drinking and washing but also for various recreational opportunities such as fishing and boating. According to 2002 Fish and Boat Commission statistics, there were nearly 150,000 boats registered in rural Pennsylvania, which account for more than 40 percent of total registrations in the state. Fishing is practiced by 14 percent of all residents in Pennsylvania’s rural counties - nearly 480,000 rural residents purchased fishing licenses in 2002.

Forests
According to the U.S. Geological Survey, deciduous, evergreen, and mixed forests covered 65 percent of Pennsylvania’s total land area in 1992.1 Seventy-one percent of land area in Pennsylvania’s rural counties is forested, which amounts to five forested acres in every seven.

According to the Census Bureau’s County Business Patterns, the forestry industry employed more than 1,000 rural Pennsylvanians and was the work of about 340 business establishments in 2001. Ten years earlier in 1991, forestry’s 275 rural establishments employed about 1,300 people.2

To take advantage of the natural beauty of the state’s environmental resources such as water and forests, there are more than 100 state parks in the Commonwealth, which hosted nearly 36 million visitors in 2002. Parks in rural and urban counties each attract approximately the same number of visitors although rural parks account for 75 percent of state park land.

Energy Resources
Pennsylvania is among the top five states for production of coal and is home to nearly all of the anthracite (hard) coal reserves in the United States. Bituminous (soft) coal is found primarily in the southwest and anthracite in the northeast portions of the state. In the early 20th century, Pennsylvania coal production accounted for nearly two-thirds of the total in the United States, and it still accounts for nearly one-tenth. DEP data for 2001 shows nearly 450 operating coal mines, 95 percent of which are located in rural counties.

Our Commonwealth also produces and contains large quantities of oil and natural gas, particularly in the northwest. In fact, Titusville, Crawford County is the site of the first oil well in the country.

Although it has decreased over time, the mining industry is important to the rural economy. Mining employed more than 10,000 rural residents in about 650 establishments in 2001. Ten years earlier in 1991, mining’s 850 rural establishments employed more than 19,000.3

Waste and Recycling
A critical link in conserving and preserving natural resources is the recycling of products made with natural resources. While there are no available data specific to rural areas for the recycling industry, in Pennsylvania as a whole there are 3,247 recycling and reuse establishments, which employ 81,322 people. This includes those involved in collection and processing, recycling manufacturing, and reuse and remanufacturing.

Rural Pennsylvania produced nearly 3 million tons of municipal solid waste and recycled 28 percent of it in 2001. Recycling in rural areas appears to be growing rapidly both in total tons recycled and in terms of rate per ton of trash generated.

1 This survey is to be updated for release in 2004.
2 Between these two years, data collection was changed from SIC to NAICS industry classifications. This affects comparability to some extent.
3 Again, between these two years, data collection was changed from SIC to NAICS industry classifications. This affects comparability to some extent.

NOTE: In this analysis, rural is defined as counties whose population density, according to the 2000 Census, is less than the statewide figure of 274 persons per square mile.

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Center Welcomes Newest Board Members

The Center for Rural Pennsylvania welcomes its newest board members, Steve Crawford and William Sturges, who were appointed by Governor Edward G. Rendell.

Mr. Crawford is the secretary of legislative affairs for Governor Rendell. He was appointed in January 2003, and is responsible for representing the governor before the members of the General Assembly. Prior to this appointment, he worked for the House of Representatives as a leadership executive director and the senior caucus advisor for the Agriculture and Rural Affairs Committee. Mr. Crawford also served as deputy secretary of agriculture under Governor Robert P. Casey and as a lobbyist for the Pennsylvania Farm Bureau. Mr. Crawford has a bachelor’s degree in Political Science from Mansfield University and is a board member of Mansfield University’s Alumni Board and the Nicholas Wolff Foundation.

Mr. Sturges is the executive director of the Pennsylvania Rural Development Council, an agency within the Governor's Executive Offices charged with convening, representing, educating and advocating on behalf of the citizens of rural Pennsylvania. Governor Rendell appointed Mr. Sturges to the position in July 2003.

Prior to this appointment, Mr. Sturges worked in commercial real estate, was the executive director of a statewide agricultural trade association, and was a dairy farmer in Pennsylvania’s Northern Tier.

Mr. Sturges currently serves as a board member of the Pennsylvania Public Utility Council on Electric Choice, the Pennsylvania Hardwoods Development Council, the Pennsylvania Health Department, and the State Health Improvement Planning Committee, and as a member of the Governor’s Interagency Team and the Governor’s Policy Office.

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Religion in Rural Pennsylvania

One of the more noticeable features of Pennsylvania’s rural and small towns is the many houses of worship that dot the landscape. Data indicates that Pennsylvania’s rural counties have a broad diversity of religious denominations and more religious establishments, per capita, than urban areas.

To better understand the scope of rural religious establishments, the Center for Rural Pennsylvania analyzed data from the 2000 County Business Patterns, published by the U.S. Census Bureau, and the 2000 Religious Congregations and Membership, published by the Glenmary Research Center in Nashville, Tennessee.

To distinguish rural religious establishments from urban establishments, the Center used its definition of a rural county, which is any county that has a population density below the statewide density of 274 persons per square mile. All other counties were considered urban.

Religious Establishments
According to the U.S. Census Bureau, in 2000, there were 3,235 religious establishments in Pennsylvania’s rural counties, or 95 establishments for every 100,000 residents. In urban areas, there were 5,783 religious establishments, or 61 establishments for every 100,000 residents.

Nationally, in 2000, Pennsylvania ranked third in the total number of religious establishments. First-ranked Texas and second-ranked California each have more than 10,500 religious establishments.

Between 1991 and 2000, the number of religious establishments in both rural and urban Pennsylvania increased. Rural counties had a 10 percent increase, while urban areas had an 11 percent increase. The counties with the greatest increase in religious establishments were Forest, Fulton, and Sullivan. Each of these counties had an increase of more than 66 percent. Seven counties had either a decline or no change in religious establishments.

Religious establishments are an important rural employer. According to Census Bureau data, in 2000, religious establishments in rural areas employed more than 15,700 workers, or nearly 2 percent of the total rural workforce. In 2000, the average religious establishment employed nearly five workers with an average annual wage of nearly $9,890.

Types of Religious Establishments
According to the Glenmary Research Center, in 2000, Pennsylvania rural counties had a total of 91 different denominations and 5,816 congregations. On a per capita basis, this comes to 2.7 denominations for every 100,000 residents and 171.4 congregations for every 100,000 residents. Urban counties have fewer denominations and congregations per capita (0.9 denominations and 82.0 congregations per 100,000 residents.)

The religious establishments with the most congregations in Pennsylvania’s rural counties were the United Methodist Church, the Catholic Church, the Evangelical Lutheran Church in America, the Presbyterian Church, U.S.A., and the United Church of Christ. These same congregations were also the top five congregations in urban counties.

Nationally, Pennsylvania ranked fourth in the number of different types of denominations. The Midwestern states of Illinois, Michigan, and Ohio had the greatest array of denominations, while the New England states of Vermont, Rhode Island, and New Hampshire had the least, as did North Dakota and Wyoming.

Want more info?
For the fact sheet, Religious Establishments in Rural Pennsylvania, call the Center for Rural Pennsylvania at (717) 787-9555 or email info@ruralpa.org.

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Did You Know . . .

• A Center for Rural Pennsylvania study found that, in 1999, the cost of living in rural Pennsylvania was 2.4 percent lower than it was in urban Pennsylvania.
• During the 1990s, rural homeownership increased 11 percent while urban homeownership increased 6 percent.
  

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Just the Facts: Lead Poisoning

Lead poisoning affects all Pennsylvania children, both in rural and urban areas.

While it is likely this problem is under-reported in rural areas, there is a sizable number of children who are poisoned by lead each year. According to the most current data from the Pennsylvania Department of Health, in 1998, more than 750 rural children under the age of 6 were found to have elevated blood lead levels, or 3.3 children per 1,000 children. In urban areas outside of Philadelphia, the rate was 4.3 per 1,000 children.

This data was collected as part of the Department of Health's Childhood Lead Poisoning Prevention Program (CLPPP). Part of this program includes blood screening and referral for treatment and diagnostic services, investigations in lead hazards, technical assistance for educating residents about the hazards of lead paint, and educational services for the community, professionals, and parents.

For rural families, one of the limitations of the CLPPP is that it is primarily conducted in urban areas. As a result, rural parents may find it difficult to have their children tested for higher blood lead levels. Because of this, the number of rural cases may be underrepresented.

Lead poisoning has been shown to cause slower child growth and, in severe cases, impaired mental development or even death. To prevent lead poisoning, testing for high blood lead levels and refurbishing of areas of lead paint are required, both of which can be expensive for low-income rural families.

For more about the Pennsylvania Department of Health's Childhood Lead Poisoning Prevention Program, visit the department's website at www.dsf.health.state.pa.us/health and search for “lead poisoning.”