Enrolling in Medicaid through the National School Lunch Program: outcome of a pilot project in California schools

Strategies for expanding health insurance coverage in vulnerable populations

BACKGROUND

Health insurance has the potential to improve access to health care and protect people from the financial risks of diseases. However, health insurance coverage is often low, particularly for people most in need of protection, including children and other vulnerable populations.

OBJECTIVES

To assess the effectiveness of strategies for expanding health insurance coverage in vulnerable populations.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.thecochranelibrary.com (searched 2 November 2012), PubMed (searched 1 November 2012), EMBASE (searched 6 July 2012), Global Health (searched 6 July 2012), IBSS (searched 6 July 2012), WHO Library Database (WHOLIS) (searched 1 November 2012), IDEAS (searched 1 November 2012), ISI-Proceedings (searched 1 November 2012),OpenGrey (changed from OpenSIGLE) (searched 1 November 2012), African Index Medicus (searched 1 November 2012), BLDS (searched 1 November 2012), Econlit (searched 1 November 2012), ELDIS (searched 1 November 2012), ERIC (searched 1 November 2012), HERDIN NeON Database (searched 1 November 2012), IndMED (searched 1 November 2012), JSTOR (searched 1 November 2012), LILACS(searched 1 November 2012), NTIS (searched 1 November 2012), PAIS (searched 6 July 2012), Popline (searched 1 November 2012), ProQuest Dissertation &Theses Database (searched 1 November 2012), PsycINFO (searched 6 July 2012), SSRN (searched 1 November 2012), Thai Index Medicus (searched 1 November 2012), World Bank (searched 2 November 2012), WanFang (searched 3 November 2012), China National Knowledge Infrastructure (CHKD-CNKI) (searched 2 November 2012).In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via Web of Science to find other potentially relevant studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and Interrupted time series (ITS) studies that evaluated the effects of strategies on increasing health insurance coverage for vulnerable populations. We defined strategies as measures to improve the enrolment of vulnerable populations into health insurance schemes. Two categories and six specified strategies were identified as the interventions.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed the risk of bias. We undertook a structured synthesis.

MAIN RESULTS

We included two studies, both from the United States. People offered health insurance information and application support by community-based case managers were probably more likely to enrol their children into health insurance programmes (risk ratio (RR) 1.68, 95% confidence interval (CI) 1.44 to 1.96, moderate quality evidence) and were probably more likely to continue insuring their children (RR 2.59, 95% CI 1.95 to 3.44, moderate quality evidence). Of all the children that were insured, those in the intervention group may have been insured quicker (47.3 fewer days, 95% CI 20.6 to 74.0 fewer days, low quality evidence) and parents may have been more satisfied on average (satisfaction score average difference 1.07, 95% CI 0.72 to 1.42, low quality evidence).In the second study applications were handed out in emergency departments at hospitals, compared to not handing out applications, and may have had an effect on enrolment (RR 1.5, 95% CI 1.03 to 2.18, low quality evidence).

AUTHORS' CONCLUSIONS

Community-based case managers who provide health insurance information, application support, and negotiate with the insurer probably increase enrolment of children in health insurance schemes. However, the transferability of this intervention to other populations or other settings is uncertain. Handing out insurance application materials in hospital emergency departments may help increase the enrolment of children in health insurance schemes. Further studies evaluating the effectiveness of different strategies for expanding health insurance coverage in vulnerable population are needed in different settings, with careful attention given to study design.

Generational status, health insurance, and public benefit participation among low-income Latino children

The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children's Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33-3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14-0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25-0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.

Outreach strategies for expanding health insurance coverage in children

BACKGROUND

Health insurance has the potential to improve access to health care and protect people from healthcare costs when they are ill. However, coverage is often low, particularly in people most in need of protection.

OBJECTIVES

To assess the effectiveness of outreach strategies for expanding insurance coverage of children who are eligible for health insurance schemes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (The Cochrane Library 2009, Issue 2), PubMed (January 1951 to January 2010), EMBASE (January 1966 to April 2009), PsycINFO (January 1967 to April 2009) and other relevant databases and websites. In addition, we searched the reference lists of included studies and relevant reviews, and carried out a citation search for included studies to find more potentially relevant studies.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series which evaluated the effects of outreach strategies on increasing health insurance coverage for children. We defined outreach strategies as measures to improve the implementation of existing health insurance to enrol more eligible populations. This included increasing awareness of schemes, modifying enrolment, improving management and organis ation of insurance schemes, and mixed strategies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias . We narratively summari sed the data.

MAIN RESULTS

We included two studies, both from the United States. One randomised controlled trial study with a low risk of bias showed that community- based case managers who provided health insurance information, application support, and negotiated with the insurer were effective in enrolling and maintaining enrolment of Latino American children into health insurance schemes (n = 257). The second quasi-randomised controlled trial, with an unclear risk of bias (n = 223), indicated that handing out insurance application materials in hospital emergenc y departments can increase enrolment of children into health insurance.

AUTHORS' CONCLUSIONS

The two studies included in this review provide evidence that in the US providing health insurance information and application assistance, and handing out application materials in hospital emergency departments can probably both improve insurance coverage of children. Further studies evaluating the effectiveness of different outreach strategies for expanding health insurance coverage of children in different countries are needed, with careful attention given to study design.

Health insurance regain after a spell of uninsurance: a longitudinal comparison of youth with and without disabilities transitioning into adulthood

PURPOSE

To examine insurance regain among youth with no, nonsevere, and severe disabilities.

METHODS

The data source for this study was the Survey of Income and Program Participation 2001. We examined insurance regain among youth with no, nonsevere, and severe disabilities between the ages of 15 and 25 using a longitudinal design. Kaplan-Meier survival functions provided estimates of uninsurance spell durations measured in waves, or 4-month intervals. We conducted a discrete time survival analysis adjusting for personal characteristics.

RESULTS

This study includes 1,310 youth who entered the SIPP with insurance and became uninsured. 985 youth (75%) regained insurance. Based on SIPP waves, median duration of uninsurance was two waves (between 5 and 8 months) for youth with severe disabilities and three waves (between 9 and 12 months) for youth with nonsevere disability. Youth with nonsevere disabilities had decreased odds of regaining health insurance compared to youth without disabilities (odds ratio .73; 95% confidence interval: .57, .92; p=.01).

CONCLUSIONS

Youth with severe disabilities and youth without disabilities had similar odds of and durations to insurance regain. In contrast, youth with nonsevere disabilities had lower odds of regaining insurance and experienced longer durations of uninsurance compared to peers without disabilities. We recommend additional research into the implications of Medicaid eligibility pathways and employment barriers for youth with nonsevere disabilities.