Regrettably, many families don’t realize that they may be eligible for government-sponsored health coverage for their children. Medicaid is the largest publicly financed program of health services for children. It provides free coverage to low-income kids. In August 1997, Congress expanded coverage with the passage of the State Children’s Health Insurance Program. SCHIP enables families whose income exceeds the Medicaid limit to sign up their children for health insurance. The states administer the SCHIP program and have some leeway in setting eligibility standards. In about one-third of the states, parents who earn 200 percent of the poverty level (the federal poverty level in 2002 was $18,100 for a family of four) can enroll their children for free or low-cost coverage; some states exceed these income levels and others fall below them. Under both Medicaid and SCHIP, the state governments share the costs with Washington.

Health reformers hailed SCHIP as a godsend for the many working families that couldn’t afford private coverage but earned too much to qualify for Medicaid. These parents either don’t get family insurance coverage at their jobs or can’t afford their share of the monthly premiums. Still, despite the existence of generous government coverage programs, 8.5 million children—11.6 percent of all kids—were not covered by health insurance in 2000, according to the U.S. Census Bureau.² Most of them live in a family where at least one parent is working. Even more troubling, more than half of these uninsured children were eligible for SCHIP or Medicaid but had not signed up for coverage.

For years before Congress passed SCHIP, The Robert Wood Johnson Foundation had been concerned about lackluster enrollment among Medicaid-eligible children. Since the failure of President Clinton’s health reform plan in 1994, the Foundation had been seeking ways to increase enrollment of eligible children who were not participating in Medicaid. Foundation staff members reasoned that community leaders should go into the neighborhoods, find eligible youngsters, and sign them up. In July 1997, the Foundation approved a new program to do just that. Covering Kids: A National Health Access Initiative for Low-Income, Uninsured Children authorized $13 million for community-based coalitions of health care advocates and government officials in fifteen states and local communities. The Foundation chose the Southern Institute on Children and Families, a public policy organization based in Columbia, South Carolina, as the National Program Office. Sarah C. Shuptrine, the institute’s president, was named to head the program office.

Only a month after Covering Kids was approved, Congress passed SCHIP. Recognizing the potential of Covering Kids to help many more youngsters than first envisioned, in July 1998 the Foundation expanded the program to cover the entire country. The expansion added another $34 million to create coalitions in all fifty states, 170 communities, and the District of Columbia. The program was to cover a three-year period, from 1998 to 2001. (In April 2001, the Foundation, building on Covering Kids, approved a four-year, $68 million initiative called Covering Kids and Families.)

Covering Kids sought to attack the enrollment problem from three angles. First, the coalitions that the states and localities created would reach out and enroll eligible children at schools and other community-based organizations. Second, the coalitions would tackle the complex application process to make it easier for an eligible family to sign up. To this end, the coalitions would help the states remove burdensome and unnecessary questions and tasks (such as a face-to-face interview) not required for determining eligibility, thus significantly shortening the application form and process. Third, the initiative would prod states to coordinate SCHIP and Medicaid. In many states, the two programs had separate offices, applications, and requirements; without coordination, a child rejected by one program was not automatically considered for the other.

Even as the coalitions’ activities grew, The Robert Wood Johnson Foundation remained concerned that the federal government was not actively publicizing SCHIP and Medicaid, and that the states had not touched millions of available federal dollars targeted for children’s health care. Foundation staff members were convinced that a nationally coordinated advertising effort, coupled with grassroots and outreach activities that generated information and messages backed by high-level market research, would work. If the right message were created, they believed, low-income parents could be persuaded to take the first step: calling the hotline. In January 2000, the Foundation decided to “raise the ante,” as Stuart Schear, a senior communications officer at the Foundation who spearheaded the effort, described it. It authorized $26 million for an aggressive communications campaign to increase the visibility of the government programs. In effect, the Foundation was trying to fill a gap left by the federal government.

To run the communications campaign, the Foundation contracted with Greer, Margolis, Mitchell, Burns, & Associates, or GMMB, which creates media campaigns for political candidates and also specializes in public-awareness campaigns, such as the Air Bag and Seat Belt Safety Campaign.

The Covering Kids Communications Campaign had three fundamental strategies. The first was to complement the existing Covering Kids coalitions’ outreach effort with a media blitz that would encourage viewers or listeners to call a toll-free government hotline for enrollment assistance (although it was not actively publicizing SCHIP and Medicaid, the Department of Health and Human Services allowed Covering Kids to use its toll-free hotline in its marketing efforts). Four- or five-week media blitzes would be timed to run with high-visibility grassroots enrollment activities organized by the Covering Kids coalitions of health care professionals, business leaders, churches, government officials, schools, and child advocates.

The second strategy was to enlist as partners dozens of national organizations and major corporations, which would encourage their local members and stores to get the word out about government health insurance programs for children. The third strategy was to train local Covering Kids coalition members to develop long-term relations with the press and to deliver research-tested information to their community. The communications professionals would send senior Covering Kids officials to meet with journalists, train local coalition members to reach out to local news organizations, hold press conferences in Washington and in target markets, and advise local outreach workers on how to distribute information to community organizers and eligible families.

In effect, the Covering Kids communications campaign was to operate much like a political campaign, bombarding communities with information from many sources. Annie Burns, a partner in GMMB, described the premise of this saturation strategy: “When parents go to work, they hear a story on the radio, and at night they see the advertising on TV. When they go into a store, they see a poster, and when they go to a back-to-school meeting, the school nurse tells them about Medicaid and SCHIP. When you hit people every place they live their lives, then you increase the likelihood that they will take the step that will bring them closer to getting health insurance for their children.”

As in most social marketing campaigns, the Covering Kids communications team uses techniques from the world of corporate marketing. But the Foundation’s initiative differs from other campaigns in several ways, chief among them its extensive use of in-depth market research to study the motivations of low-income populations.

The Foundation signed on Wirthlin Worldwide, a firm that conducts research and creates advertising messages for General Motors, McDonald’s, Boeing, and many other large corporations. Wirthlin was directed to conduct the research and help come up with a set of message concepts that would become the framework for the advertising and for other facets of the communications campaign. “We performed the same level of analysis that we perform for any of our Fortune 100 clients,” said Maury Giles, a senior research executive at Wirthlin, who handles the $1 million-plus Covering Kids account.

But marketing cars or hamburgers is different from selling the idea of health coverage to low-income parents. In creating the message framework, Wirthlin knew that a parent’s relationship with a child strikes a deep emotional chord, especially for a family where financial survival and responsible parenthood are often competing priorities. With this in mind, the firm recognized that the communications strategy needed to link the tangible benefits of health coverage with the personal values that would motivate these parents to take action.

In the spring of 2000, Wirthlin conducted two-hour, one-on-one interviews in five cities with 114 adults whose children either were enrolled in Medicaid or SCHIP or were likely to be eligible. The interviews targeted four ethnic groups: Caucasian, African American, Latino, and Native American. The firm used a proprietary research methodology that links rational considerations with emotional ones—in this case, the attributes of coverage with the emotions parents have about their role as protector. The insights from the interviews led to the communications framework: all of the ads and materials had to show that being a good parent meant raising successful, healthy children, and enrolling in a program offering low-cost or free health care was a smart choice. This in turn would reduce stress and bring peace of mind.

The conclusion would seem like a given. But the value of the market research, according to Giles, was in eliminating many other possible messages that, on the surface, would seem equally logical. For instance, the researchers had considered a message that would show parents how much healthier their kids would be if they signed up for health coverage. The assumption was that low-income parents didn’t see the value of heath care. But, Giles noted, “The parents saw great value in taking their kids to the doctor.” They simply couldn’t afford it.

The researchers had also been considering a message aimed at overcoming parents’ negative feelings about government programs. During June, two focus groups of social service caseworkers told researchers that many families wouldn’t sign up because of the social stigma associated with public programs. That’s not what low-income families told researchers, though. During the same month, Wirthlin conducted telephone interviews with nearly three thousand parents of eligible children. Seventy-five percent said they believed government health programs based on financial need were “a good thing to help people take care of their families.” Only 25 percent said these programs were a “public symbol that I cannot make it on my own.” However, they feared that front-office staff at the doctors’ offices would treat them rudely.

The biggest obstacle to enrollment, the parents said, was that most of them didn’t realize their kids were eligible. Only 22 percent of these parents had ever heard of SCHIP, and most of those aware of the program didn’t realize they could qualify. “We went into the market research having listened to the professionals talk about social stigma as being a major barrier to signing up,” said Elaine Arkin, a communications consultant retained by the Foundation. “We came out of the research with a different understanding: the biggest barrier was that these families didn’t believe they were eligible. Some of these parents work two or three jobs, and they don’t assume the government will provide something for them.”

By mid-2000, GMMB and Wirthlin were developing the ads. The close relationship between the research and creative teams is unusual in the worlds of both social and corporate marketing. Researchers often leave the scene once they deliver their findings. Agency executives often toss out the research if it slows the flow of their creative juices. But the Foundation would not tolerate such turf battles. It insisted that the creative people work with the research team, and that both of them collaborate with the Covering Kids National Program Office, the grantees, and the national organizations that were carrying out the marketing work.

GMMB produced nine thirty-second television ads for about $450,000, and radio and print ads for $50,000 more. Those production figures did not include the costs of buying air time and newspaper ad space. GMMB wanted high-quality spots that could run alongside product advertising and not turn off prospective “consumers.” So it used film instead of videotape and hired professional actors. Persons of all targeted ethnic groups played patients, physicians, and office staff. Because parents in focus groups were concerned about how they would be treated in the waiting rooms, “office personnel” in the spots appeared friendly and cheerful. Some of the ads had a version with Spanish audio and written screen information. The voiceovers for all of the ads could be changed to provide information aimed at audiences in specific states. Public service announcement versions that could run anywhere were also created.

Before airing the advertisements, Wirthlin and GMMB convened four groups of parents of eligible children to view them. Even after viewing the ads many times, the parents didn’t realize they were the target audience. The communications team was surprised. “After we mentioned that they could apply, they said, ‘No, no, I’m not eligible because I’m working,’” Burns of GMMB recalled. “We told them that from the information they gave us they were eligible. They found it hard to believe.” When told they could apply, they started writing down the hotline number. This convinced GMMB and Wirthlin to use an income figure in the voiceovers. In Maryland, for instance, viewers would be told that “even families earning up to $30,000 or more” could get free coverage.

The decision sparked a firestorm. Though Idaho had agreed to become a target market, state officials there worried that the generous income limits would attract too many costly enrollees. Sarah Shuptrine, head of the National Program Office, believed a specific dollar figure would be misleading, since income limits differ by family size. Only a family of four would qualify on the basis of the income figure used in Maryland’s ad. A mother with one child would be eligible only if she earned less than $23,000. Shuptrine worried that a mother earning slightly more would feel duped if she applied and was rejected.

Wirthlin convened a second round of focus groups to retest the language. Viewers noted they wouldn’t be angry if they were rejected. Shuptrine is still not convinced. “In the focus groups, just using the words ‘working families’ was very effective,” she said.

The four-week wave of coordinated advertising and outreach efforts, known as Back-to-School 2000, started in mid-August in six media markets. The Foundation wanted the ads tested in these six markets before it would decide whether to expand. It also demanded measurable proof of the strategy’s effectiveness—in this case, an increase in the number of calls to the hotline. The strategists chose medium-sized markets where advertising costs were reasonable. Targets were also selected on the basis of ethnic and geographical characteristics: Albuquerque, New Mexico, and Fresno, California, for Latinos; Baltimore and Greenville, North Carolina, for African Americans; and Springfield, Illinois, and Boise, Idaho, for Caucasians. In addition, the strategists chose only those states that were simplifying enrollment procedures. “The last thing we wanted was to go out with a pizzazzy media campaign only to have families turned off by the application process,” Shuptrine said.

Though many social marketing campaigns depend on free public service announcements, the Foundation could afford paid advertising. “If you are looking to have a certain impact within a certain time frame with a certain audience, paid advertising gives you more control,” GMMB partner Burns said. GMMB bought time during radio and television shows popular with target ethnic groups between the ages of eighteen and thirty-four. The agency made enough buys so parents would see the spots thirty-five times over four weeks. “We weren’t just trying to promote awareness, but to actually get people to pick up a phone,” said David A. Smith, another GMMB partner. “We wanted to have enough frequency to ensure that our target audience would see it and be motivated to make a call.”

The advertising wave coincided with 268 high-visibility Covering Kids enrollment activities in the six target markets as well as in twenty other states. The enrollment activities included health fairs that distributed goody bags with prizes and information; sign-up tables at churches, businesses, festivals, and hospitals; and free immunizations and physicals at community events. To intensify the impact of the ads and the enrollment events, the strategists sought to generate extensive news coverage by releasing some of Wirthlin’s research findings. Covering Kids unveiled its communications campaign at press conferences in Washington and in the six markets. The hook that grabbed press attention was the Wirthlin findings that had guided the communications strategy: six out of ten parents of eligible children didn’t realize their kids were eligible for government health insurance programs, and 82 percent said they would apply if they knew they would qualify. Covering Kids counted more than fifteen thousand television, radio, and print news stories, which reached about 78.8 million Americans. This included forty TV stories in the target markets, coverage on national networks, and articles in newsmagazines and top newspapers.

From the first, the Foundation sought ways to assess whether the communications strategy was working. News coverage was one measurement. The triple punch of ads, outreach, and news coverage delivered the audience impact the communications strategists sought. Calls to local hotlines in each of the six test markets rose significantly. Because of the extensive national media coverage, calls to the national hotline soared as well, to fifty-eight thousand during August, up from fifteen thousand a month before the campaign. In September, the calls remained high, at thirty-three thousand, which the White House attributed to Covering Kids and its communications campaign. In two control markets—Idaho Falls, Idaho, and Wilmington, North Carolina, where the campaign ran no ads—the number of calls rose very little in comparison. For instance, average weekly calls to the North Carolina hotline from Wilmington rose to 27 during the campaign period, up from a weekly average of 13 calls before the campaign. Meanwhile, calls from Greenville, a target market, rose to 246 during the campaign, up from 33 calls before.

Even during the advertising wave, Wirthlin was evaluating the impact. It interviewed 503 hotline callers in Albuquerque and Greenville to find out what had motivated them to call. Advertising was the main cause; more than 80 percent said they had learned of the telephone number from the ads, and most of the callers said they intended to apply. Fewer than 10 percent of the callers learned from the telephone operators that they were not eligible. Once the advertising wave was over, Wirthlin surveyed three thousand parents in test and comparison markets and found that 58 percent in the test markets had seen the ads, and that one out of four who had seen the ads made a call.

For the next phase, the strategists returned to the same markets (except for Greenville). Starting in March, during a flu season enrollment drive, the campaign aired the same ads but did not hold press events or release new research. Depending on the market, ads ran five or six weeks. Calls to the national hotline and to hotlines in target markets rose, but the numbers were less than half of what they were the first time around. “It was harder to go back to the same markets and get the coverage again,” GMMB’s Burns said.

During that phase, Covering Kids expanded to Miami and New Orleans with radio ads only. The campaign wanted to see if radio alone could generate similar results at lower cost. Though hotline calls rose, the increase was not as dramatic as a combined television and radio blitz in the previous phase. Covering Kids had increased its ad spending in this phase, to $1.9 million, but the press coverage reached an audience of only four million. This compared with the $1.8 million spent in the first campaign, which generated national news coverage reaching nearly eighty million Americans.

Seeking a bigger impact in the next phase, the communications team decided to enter new markets for a Back-to-School 2001 campaign. This time, GMMB asked the states to apply to become target markets, expecting that a contest of sorts would attract the most committed grantees. GMMB eventually chose Miami; Tucson; Hartford, Connecticut; Brownsville, Texas; and the District of Columbia.

The Foundation didn’t have the resources for an intensive ad campaign nationwide, but the strategists thought they could boost enrollments in nontarget states with a modest national buy. Beyond the money spent in the target markets, the Foundation spent more than $500,000 to buy ad time in thirty-six states on ABC Radio and the Univision Television Network. GMMB believed that such ads in nontarget states could help Covering Kids grassroots organizers generate additional interest in the government health programs. GMMB’s Smith recalled, “Organizations conducting news events would have some level of advertising that they could point to. As in the target markets, people would be hearing the messages wherever they went—on the radio and in their doctor’s offices.”

As it did in Back-to-School 2000, Covering Kids conducted splashy news conferences in Washington and in target markets. Organized by the communications team, the Washington news conference featured Shuptrine, the mayor of the District of Columbia, the New York State health commissioner, the president of the National Association of Chain Drug Stores, and families from several states. Once again, the communications strategists decided that Covering Kids should release new data at the news conferences. Among the statistics that grabbed headlines: one in five parents of uninsured children delayed or skipped medical care for their children because they couldn’t pay for it. In part because of the national advertising on Univision and ABC Radio, the news coverage was even bigger this time around, reaching an audience of more than eighty-four million people.

Once again, calls to the national hotline soared, to 47,183 in August, and remained high, at 27,105, in September. Hotline calls in the target markets also rose from precampaign levels in those two months. In Hartford, average weekly calls rose by 166 percent, to 678 during the campaign, up from 255 before. Awareness of the programs rose, too: in 2001, some 54 percent of parents of eligible-but-uninsured children thought their kids were eligible, compared with 36 percent a year earlier.

The advertising was not the only factor that led to this increase in calls. The communications team helped the coalitions organize enrollment events for the Back-to-School campaigns. The grassroots activists distributed two million fliers, bookmarks, and other promotional materials with messages backed by market research. Indeed, although the advertising borrows a page from the book on corporate marketing, the grassroots operations have the look and feel of a political campaign, with local and state foot soldiers reinforcing the carefully created communications message.

The communications team works closely on the outreach effort with the National Program Office and the Covering Kids state and local grantees. With guidance from the program office, the states and the communities have developed coalitions among hospitals, social service agencies, schools, and other groups that seek out eligible children and enroll them in government insurance programs. Meanwhile, GMMB has provided extensive technical communications assistance to coalitions, which have had little experience running aggressive marketing and grassroots campaigns.

A case in point: in the Back-to-School 2001 Campaign Action Kit, GMMB offered coalitions a detailed timeline for planning a press conference, with instructions on what they should be doing in the six weeks leading up to the event. The kit included talking points, templates of news advisories and speaker invitations, tips for pitching stories to reporters, and advice on enlisting schools and businesses to get the word out.

The training paid off, with the kind of high-visibility press events that local activists had rarely tried. In Hartford, the Connecticut lieutenant governor kicked off Back-to-School 2001 at a press conference. Also speaking was Guadalupe Arroyo, whose eight-year-old daughter, Connie, suffers from tuberous sclerosis, a genetic condition that causes tumors to grow on the brain. Her husband is an exterminator, and though his employer’s health plan covers his two children, out-of-pocket costs for Connie’s care are enormous. Arroyo heard about Connecticut’s SCHIP program at a PTA meeting, and though she doubted her children would qualify, she applied and was accepted. “When I meet people who don’t have insurance, I tell them all about it,” Arroyo said several months later.

Besides recruiting Arroyo, the Children’s Health Council (the Connecticut grantee) helped organize more than one hundred enrollment and outreach events across the state. Volunteers offered application help at the Bridgeport Zoo. While registering for school, children enrolled in SCHIP. At a Wal-Mart reopening in Manchester, SCHIP organizers inside the store offered raffles. Judith Solomon, executive director of the state-funded council, said that in the past such events at stores and fairs had failed to attract much attention. This time, she said, people were asking questions. She believed the TV ads “legitimized the program,” and she has bought a number of ad tapes, which she is pitching to local cable access stations. She also said the technical assistance from GMMB was invaluable. “We never wrote a press release before,” she said. “We’ll do them from now on.”

In addition, GMMB produced fifty-page communications kits for reaching Latino and Native American families. In its Latino kit, the communications team offers advice on recruiting high school students as volunteers, making home visits, setting up enrollment tables at cultural festivals, and working with local businesses. The kit also offers tips on getting the local Immigration and Naturalization Service involved and recruiting promotoras (lay health workers).

In Doña Ana County in New Mexico, the Covering Kids pilot has enlisted the INS to encourage immigrants to enroll their U.S.-born children. The pilot there is using promotoras to meet with families in their homes. “These are trusted members of the community,” says Shelly Almaguer, the Covering Kids program manager in the county. “It’s not easy for people on the outside to come in.”

A key goal of the communications strategy was to find as many outlets as possible to disseminate information about the government health coverage programs for children. To bolster both its local grassroots operations and the advertising campaign, the communications team recruits national organizations and corporations to help raise the visibility of Medicaid and SCHIP. More than eighty national associations and nonprofits representing educators, faith-based groups, child advocates, unions, and medical professionals are distributing information to their members and the public. They also encourage their local chapters and offices to develop ties to community groups, reinforcing the strength of the local coalitions. The communications team at GMMB designed the promotional materials that these groups distribute.

Linda C. Wolfe, president of the National Association of School Nurses, says the association sends Covering Kids information to eleven thousand members in its newsletter. When a parent visits a school to pick up a sick kid, the nurse can hand over a SCHIP brochure and, in some states, enroll the child on the spot. The American College of Emergency Physicians, which represents fifty-five hundred emergency department directors, has mailed its members Covering Kids posters to hang in the waiting room, brochures to distribute to parents, and advice on running enrollment programs. “Getting more children insured is a high priority for emergency physicians,” says Colleen Horn, public relations manager for the college.

Nurses and doctors are natural partners, but large corporations are a harder sell. Still, the Foundation believes that businesses have an important audience for a communications message: a customer base of potential enrollees and part-time employees who are not covered by the company health plan. Kelly Carey, a GMMB vice president, has developed relationships with corporate trade groups and major retailers, mostly pharmacy and grocery chains.

Carey’s efforts are paying off. Twenty-five companies in forty-seven states participated in Back-to-School 2001. In March 2002, some twenty-four hundred Albertson’s stores in thirty-three states started distributing two hundred million grocery bags emblazoned with the hotline number and sixty-five million advertisements and circulars. CVS is displaying promotional materials in the pharmacy department in two hundred of its stores in Maryland, Virginia, and the District of Columbia. The GMMB strategists customized the materials with the participating company’s logo.

For corporations with stores in the local community, participating in Covering Kids enrollment efforts makes good business sense. If more children obtain health coverage, pharmacy departments make more money. Enrollment events bring customers into the store and generate positive publicity. It also has philanthropic appeal. Phillip Schneider, vice president of the National Association of Chain Drug Stores, said it was a “natural mix” for pharmacies and Covering Kids to work together. “Every day pharmacists see mothers come in asking for information about a child’s illness,” he said. “They don’t have the money to fill a prescription.”

Carey has also trained social service advocates to approach Main Street businesses and work with the local chains once she’s opened doors with corporate headquarters. The advice runs the gamut, from writing letters to company executives to enlisting enough volunteers to operate an enrollment table. One such success: in New Mexico, El Paso Electric agreed to send an informational flyer with its bills.

Any initiative that involves so many far-flung players is sure to run into problems. Although the enrollment drives may have appeared to come off without a hitch, the road to getting there was often rocky. The Foundation-GMMB partnership had to balance the need for centrally controlled communications with the preferences of people at the state and local levels. Tensions rose during the months leading up to Back-to-School 2000, since the marketing team had a tight deadline to prepare and test the ads. Those working in the target markets had to approve every word. Each state wanted to use its own brand name for the program, and some wanted to use a local hotline number. A couple of states wanted to mention that the program offered prescription drugs; others wanted to mention that it offered an insurance card. It took dozens of long conference calls to work out the snags.

At times, local sensitivities caught GMMB by surprise. In the March 2001 phase, the communications team believed its Spanish-language TV spots for Univision could run in every Spanish-speaking community across the country—until the Texas grantee told the ad maker that Spanish dialects differed from region to region. So the agency scurried to create several Spanish versions of the same ad to run in different locations.

In some cases, tension arose between the national campaign and some states reluctant to use precious financial resources to pay for health insurance for more children. In other cases, a source of tension was the capacity of states to carry out the program.

As the communications campaign moved into its final year, the Covering Kids communication team planned a new round of target markets for Back-to-School 2002. Because of the success of the nationwide television and radio ads during the 2001 drive, the Foundation was again placing ads across the country. GMMB was considering “communications boot camps” to train grantees in how to pitch a story to the press, conduct an interview, and stage a press conference.

Foundation staff members believe that coalitions have developed so much expertise in outreach and communications that they can step up enrollment efforts throughout the year; Covering Kids has offered its market research and ad spots to any government agency that wants them. Similarly, they expect that national organizations and corporations will continue many activities without intensive direction from Covering Kids. The campaign will also broaden its outreach to restaurants, video rental companies, and other types of companies that have customers whose kids need health coverage.

Though funding for the communications campaign continues through 2002, grants to states and local pilots under the Covering Kids program began expiring in January 2001. In April of that year, the Foundation approved a new four-year initiative called Covering Kids and Families. The new $55 million program supports coalitions in all fifty states and the District of Columbia working to enroll children eligible for Medicaid and SCHIP and, in up to thirty states, working to enroll eligible adults. Since the communications campaign’s funding continues until the end of 2002, the communications team focused its efforts on this new initiative. Wirthlin researched new messages. “We need special strategies to attract adults who are not parents of eligible children,” Shuptrine said.

Another focus of the new Covering Kids and Families initiative, as well as of the communications team, was on the issue of “retention.” Although Covering Kids attracted new children to Medicaid and SCHIP, many fall off the rolls when their coverage expires. Few states notify families beforehand, and reenrollment can be even more arduous than the initial application process. The communications team developed messages that attempted to keep kids enrolled. Meanwhile, Covering Kids coalitions continued to work with states to simplify the reenrollment process.

Though Covering Kids is unique in many ways, social marketers (especially in the health care field) can look to its communication strategy for lessons in creating their own campaigns.

Awareness gap  The Foundation understood the fallacy of the notion “Build it and they will come.” Creating awareness of new services is just as important as building the services themselves. Repetition is important too; an occasional ad or PTA meeting won’t have the same impact as a saturation strategy. The Foundation proved that a well-designed campaign could generate enough interest to cause people to pick up the phone. Even so, a significant percentage of eligible parents who saw or heard the ads didn’t call to get more information.

Integrated campaign  Foundation officials argue that the advertising and grassroots activities were both important in generating interest among people whose children were potentially eligible for SCHIP or Medicaid. Social marketers considering an integrated approach should think about time-limited campaigns (in this case, four- and five-week blitzes) since, in the case of Covering Kids, this kept enthusiasm high.

Market research  Though it’s expensive, market research that pinpoints the most effective message can pay off in the long run, especially if there is strong collaboration between researchers and the media team. When the targets are people with low income, research is particularly important since most ad agencies are unfamiliar with this segment of the population.

Market segmentation  Social marketers must pay close attention to demographics. The Foundation found that although its overall communications framework appealed to all four targeted ethnic groups, subtle differences were taken into account in the final messages. For instance, African Americans connected to the idea of protecting a child, while Latino audiences responded to the financial-stress part of the message. GMMB’s having to create several Spanish-dialect versions of the ads underscored the reality that ethnic groups are not homogeneous.

Specifics  Creating an ad heavy in atmospherics does not necessarily prompt a target audience to take a specific action step. The research for the Covering Kids communications campaign showed that parents would place a call because they believed there was a direct benefit to them. That meant the ads had to convey specific information, such as an income eligibility figure or some idea of what the coverage offered (doctor visits, prescription drugs, and so on).

Coalition building  Working with state and local professionals who understand the target population is essential. But building an on-the-ground coalition can be a difficult task, especially if much of the direction is coming from outsiders. Collaboration means open and frank discussion. In Back-to-School 2000, the short period between conception and execution created some tension; a marketing campaign requiring complex partnerships should build in extra planning time.

Wide net  By seeking an array of partners, Covering Kids was able to get out the word in many venues. The participation of churches, advocacy groups, corporations, national organizations, and officials from all levels of government helped ensure that the target audience heard the message repeatedly.

Business outreach  Many advocates of social change are intimidated about approaching businesses. But if a marketer can make an effective pitch, a business can be an ideal partner. It has customers, employees, deep pockets, and its own marketing know-how. Business involvement also can convince a wary target audience that an initiative is worthwhile.

Long-lasting change  Social change doesn’t have a time limit, but a marketer’s involvement usually does. In this case, the Foundation sought to build a structure that would last long after the Foundation and the communications team departed the scene. Local activists in coalitions have developed close relationships among themselves. The training materials and the market research that Covering Kids has given coalitions deepens their expertise. GMMB also has made public service versions of the ads available to agencies for local marketing efforts.

Removing structural roadblocks  William D. Novelli, a pioneer in social marketing and currently the executive director and chief executive officer of AARP, argued that a campaign’s success hinges on whether the target audience can easily make the behavior change the marketer desires. “You don’t want them to jump a fence and swim a river to get what they want,” he said. In the case of Covering Kids, simplifying the process was essential, from shortening the application form to making sure the hotline worked well. Before Albertson’s decided to place the number on grocery bags and in advertising, several vice presidents tested the hotline.

Although the communications strategists set out to enroll 2.5 million new children in SCHIP and Medicaid, this measurement of success ultimately may be the most difficult to gauge. In 2001, 4.6 million children were enrolled in SCHIP, up from 1.9 million in fiscal year 1999, according to the federal Centers for Medicare & Medicaid Services.³ But it’s difficult if not impossible to tease out the number of enrollments that are due to the Covering Kids communications campaign from enrollment due to other factors. It stands to reason that some of the people who called the toll-free hotline signed up their children for coverage under Medicaid or SCHIP. The communications campaign surveys and data collection all report extensive news coverage, grassroots activities, growth in the number of participants who were spreading the word, a rise in awareness among eligible families, and an increase in hotline calls. This may well mean that many children who otherwise would have remained uninsured are now enrolled and getting medical care when they need it.