Over Enrollment not a Problem
On May 12, 1994, the program begins, ceremoniously, at the Southeast Neighborhood Partnership Center. Physicians have been recruited, eligibility defined, staff hired, case management initiated, legal status arranged, target area identified, intake assessment formulated, and discharge procedures established.

The partners in the project are Memorial Hospital, PARTNERS Health Plan, Michiana Medical Associates, Family & Children's Services, and South East Quality of Life (SEQL) neighborhood association. Balloons, punch, cake, coffee, guests, buttons, refreshments, brochures, handshakes, name tags, and smiling speakers launch the CHP.

Enrollment begins at the opening ceremony and the number of members rises throughout the first year, but not at the rate that had been expected. The fear of over enrollment was, according to Mark Chambers, "woefully exaggerated."

The program struggles the first year with problems endemic to any start-up venture: office managers don't get the word about billing; members are unable to afford the agreed-upon co-payment; the phone lines that had been put in don't work. Less predictable is a more significant problem: having flung the doors open, having offered $10,000 dollars worth of virtually free coverage, the program discovers that it has relatively few applicants.

A Matter of Trust
Janine Chambers: "The neighborhood representatives saw the problem as one of trust. The southeast side has not had positive experiences with large institutions, and we had this new idea. Plus during the intake we ask personal questions, and the experience of some people is that being too honest can lead to trouble. And people tend to cling to old patterns of behavior, like delaying treatment or seeking care in the ER.

Mike Mather: "I went and talked to [Publisher] Jack [McGann] at the [South Bend] Tribune about the articles they'd run on the way the slow enrollment for the free health coverage. I asked him what he thought the message was when you write about a community that isn't taking free health care? The message is that the people in the community are stupid. And that ignores the fact that people in this neighborhood are used to being ripped off not so much by robberies, but by people showing up and offering a deal that's too good to be true. How are people supposed to know right away that this isn't another one of those rip-off deals?"

By Year's End
In the fall following the kickoff event in the southeast neighborhood, CHP begins an aggressive attempt to "sell" the program: flyers are distributed, TV and radio coverage solicited, presentations made in neighborhood schools, and volunteers - including the CEO of Memorial Hospital - work the neighborhood door-to-door.

The results are disappointing. Enrollment still lags behind expectations. A program that has been set up to serve 300 people is, by October of 1994, serving only 70.

From October 1994 to January 1995, the program pays neighborhood residents to go door-to-door. Bonuses are awarded for sign-ups and for following up with phone calls.

By January, enrollment has risen to 135. After the first of the year, mass mailings and promotions are added to the mix. Enrollments continue to increase, and by the end of the program's first year, 215 people are being served.

Janine Chambers: "When you're looking at populations in need, certain segments are totally disenfranchised. They can find food and shelter - they can survive, but they don't often have the skills to make the transition to permanent insurance. They weren't the population that we originally envisioned, but during the first year we wanted members and were often signing up the most needy instead of those who had the greatest chance for success.

"By the end of the first year we were beginning to have an unacceptable level of noncompliance. Too many members weren't showing up for meetings with the case manager. Too many members weren't meeting the agreed-upon conditions.

"We began to realize that if we wanted to serve the population that we were getting, the population most in need, we would have to change our model. We would have to put case workers into homes and provide transportation and intensive counseling.

"But even if we had the resources to switch over to that model, two years wasn't long enough for real changes to take place. The model we had originally chosen was designed for a population that valued health coverage - the working poor, and we weren't getting as many of those enrolled as we had expected."

In August of 1995, a year after the program had begun, outreach efforts are suspended. The CHP operations group plans to shift the focus of enrollment from mailings and promotions to school-based educational programs. The enrollments over the next few months come in slowly, almost solely from direct referrals.