Senator Eliot Shapleigh - El Paso, Texas

AUSTIN – Enrollment in the Children's Health Insurance Program dropped again this month, and state officials pledged a vigorous marketing campaign to make eligible families aware of how to sign up for and keep the coverage.

Health care providers and advocates for the poor want the state to go further and suspend new requirements, such as an enrollment fee of up to $50 per family each six months.

However, state Health and Human Services Commissioner Albert Hawkins continued Tuesday to defend rule changes his agency designed last year, such as the fee and making CHIP families submit pay stubs and supply more information when they apply for renewal.

"We want a straightforward enrollment process that is easy for families to understand," Mr. Hawkins said. "But we also have a duty to Texas taxpayers to ensure the information on the application form is correct and the benefits are going to children who are eligible for this program."

Texas has the highest percentage of children lacking health coverage – nearly 22 percent – of any state.

The latest numbers for CHIP, which insures children in families that make too much to qualify for Medicaid but not enough to pay for private coverage, were the lowest in five years. They are a setback for Mr. Hawkins, who had extended deadlines and ordered that families whose coverage is expiring receive additional reminders by phone and mail.

Enrollment was 292,681, down from 302,020 last month.

Mr. Hawkins said about 5,000 children were removed from the program because their families failed to pay the fee.

Enrollment has dropped by about 30,000 children since late November, when the state changed vendors for checking families' eligibility for CHIP and began enforcing new rules.

Though some critics of a broader outsourcing of social program sign-ups have blamed the privatization effort, others who closely watch state health insurance programs say that budget cuts and downsizing of CHIP marketing efforts in 2003 also took a toll. And some say new private-sector employees handling the applications are poorly trained.

"We're seeing countless cases of people turning in all their information and still getting terminated," said Anne Dunkelberg of the Center for Public Policy Priorities, which advocates for low-income Texans.

Julia Easley, advocacy manager at Children's Medical Center Dallas, said, "I have talked with many families who are doing their best to complete all the appropriate paperwork and provide all the appropriate documentation, but they're having difficulties being successful."

Mr. Hawkins and his aides have said many CHIP families apparently are confused about new requirements. The state has commissioned a survey of 900 CHIP families to examine more closely why some fail to renew.

Stephanie Goodman, a spokeswoman for the Texas Health and Human Services Commission, said the state has found "some training issues and isolation situations" but no large flaws in its outsourcing effort.

Mr. Hawkins said the state has hired Sherry Matthews Advocacy Marketing of Austin to run a $3 million campaign that begins next month with statewide radio ads in English and Spanish. In the Dallas-Fort Worth area, there also will be spots on Spanish-language TV stations.