Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): , Referrals, Expanded Insurance Coverage; Medicaid, Enrollment Assistance, PATIENT_CONSUMER, STATE, PAYER, Expanded Insurance Coverage, Medicaid

Intervention Description: The ACA Medicaid expansion is one of the most significant recent public investments in health insurance. The ACA was designed as a comprehensive reform of health care in the U.S., and one of its priorities was to reduce uninsurance. An important question in an evaluation of the Medicaid expansion is whether it had effects on health or well-being through enrollment in other social safety net prorams. This study investigates Medicaid expansion’s potential spillover participation in the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program). In addition to providing public insurance, the policy connects individuals to SNAP, affecting social determinants of health such as hunger. We use difference-in-differences regression to estimate the effect of the Medicaid expansion on SNAP participation among approximately 414,000 individuals from across the U.S. Not all states participated in the ACA Medicaid expansion, and there was inconsistent timing among those who did. This state-time variation in implementation provides a natural experiment for investigating the relationship between the two programs. Our study contributes new evidence on an important policy topic.

Intervention Results: SNAP, by addressing nutritional needs, can improve social determinants of health. We find support for our first hypothesis that Medicaid expansion leads to greater SNAP participation. We find that the ACA Medicaid expansion connects vulnerable individuals to SNAP, the primary nutritional safety net program in the country. The increase is likely a combination of new enrollments and continued participation among individuals who otherwise would have been disenrolled. The spillover affects children, who are not the target of the expansion, and produces large effects for very-low-income adults, many of whom were not connected to SNAP despite their limited resources. More specifically, there is a 2.4 percentage point increase in the average rates of participation in Medicaid and SNAP for households with children implying that some low-income children benefit indirectly through more access to SNAP. Furthermore, the increase in SNAP in very low-income households is likely to provide substantial improvements in access to food. Joint processing of Medicaid and SNAP appears to facilitate the spillover effect, suggesting that reducing administrative burden would be helpful for improving access to multiple safety net programs.

Conclusion: We find that the ACA Medicaid expansion connects vulnerable individuals to SNAP, the primary nutritional safety net program in the country. This main finding is consistent with the Oregon Health Insurance Experiment, as well as the handful of ACA Medicaid expansion studies in this area of research. The spillover affects children, who are not the target of the expansion, and produces large effects for very-low-income adults, many of whom were not connected to SNAP despite their limited resources. Joint processing of Medicaid and SNAP appears to facilitate the spillover effect, suggesting that reducing administrative burden would be helpful for improving access to multiple safety net programs. Although SNAP is a federal program and Medicaid is a state-federal program, states can streamline applications, recertifications, and other hurdles to accessing and staying enrolled in these programs. We find no spillover effect for ABAWDs, however, who are a vulnerable group of adults that need additional outreach and support to access programs for which they may be eligible. Our findings contribute to a body of evidence that the Medicaid expansion does more than improve access to health care; it connects eligible low-income individuals to multiple supports. Enrolling in SNAP increases access to food, an important social determinant of health, and an investment in population health for states.

Study Design: Quasi-experimental difference-in-difference

Setting: Policy (States with Medicaid Expansion and SNAP)

Population of Focus: Adults/families under 138 percent of the federal poverty level on Medicaid

Sample Size: 414,000 individuals

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Enrollment Assistance, Patient Navigation,

Intervention Description: Healthy Beginnings seeks to prevent or reduce health disparities through a community-based, coordinated care approach based in a high quality early learning center. Healthy Beginnings is a system of care that connects children and their families to health insurance and a medical home to support children’s continuing health and development. The system also ensures that children have immunizations, periodic developmental screenings, and follow-up care, with frequent check-ups and assessments where indicated. It also provides families with health education both individually and through monthly workshops for groups of parents. The Healthy Beginnings partners worked together to develop a system of care that supports high-quality preventive health care for all children enrolled at Educare Atlanta. The system is integrated with the work of teachers and other staff at Educare Atlanta, as well as local health care providers, and it ensures that there is an ongoing relationship between parent and physician. The Healthy Beginnings main components are care management, education and parent engagement, and collaborative partnership. Healthy Beginnings employs one registered nurse, known as a health navigator, who supports parents and helps them learn how to work with health care professionals on behalf of their children; the health navigator also coordinates regular visits to pediatricians and other health care providers and resources.

Intervention Results: Results suggest that the Healthy Beginnings System of Care has been effectively implemented and has exceeded expectations in terms of achieving the goals of the State of Georgia Governor's Office for Children and Families. Data indicated overwhelmingly positive satisfaction with the system of care: 74% of respondents strongly agreed that they were satisfied. Very few respondents (fewer than 6%) reported that they were neutral, and none strongly disagreed that they were satisfied. In terms of short-term outcomes for participating children, Healthy Beginnings exceeded all of its performance requirements from the Governor's Office for Children and Families in 2013. For example, more than 90% of the children had health insurance and were up-to-date in their immunizations. Nearly all children visited a medical home at least annually, and 98% were current with developmental screenings, according to the Ages and Stages Questionnaires. By building upon the partnerships formed through the foundation’s community change effort, Healthy Beginnings has dramatically increased neighborhood children’s access to health care and forms the basis for cost-effective approach that can be replicated in other communities.

Conclusion: The Annie E. Casey Foundation has been investing in multiple human capital and housing and public open spaces redevelopment strategies in the neighborhoods of Neighborhood Planning Unit V in Atlanta for more than a decade. Although the Healthy Beginnings System of Care is still in its early stages, the foundation has found the concurrent focus on community change and health to be highly compatible with its family strengthening strategies—and a critical contributor to the well-being of the community’s children and families.

Study Design: Systems of care framework

Setting: Community (Community-based organizations in Atlanta, Georgia)

Population of Focus: Low-income young children and families

Sample Size: 279 children

Age Range: 0-10 years

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), PROFESSIONAL_CAREGIVER, Educational Material (caregiver), Patient Navigation (Assistance), Outreach (Provider), Enrollment Assistance

Intervention Description: Community Health Centers (CHCs) serving low-income populations are well-positioned to support patients navigating the complexities of the public health insurance application process and prevent lapses in coverage. Specialized staff, called enrollment assistants, can help to determine insurance eligibility and/or guide patients through application processes, including assistance with completing application forms, understanding requirements, and providing appropriate documentation.

Intervention Results: Enrollment assistants are valuable resources, and CHCs are effective at helping patients with public health insurance. The enrollment assistants helped families understand the process and avoid mistakes and delays while patients valued their advice and their pragmatic, hands-on application assistance.

Conclusion: Patients’ understanding of eligibility status, reapplication schedules, and how to apply, were major barriers to insurance enrollment. Clinic staff addressed these barriers by reminding patients when applications were due, assisting with applications as needed, and tracking submitted applications to ensure approval. Families trusted clinic staff with insurance enrollment support, and appreciated it. CHCs are effective at helping patients with public health insurance. Access to insurance expiration data, tools enabling enrollment activities, and compensation are needed to support enrollment services in CHCs.

Study Design: Observational cross-case comparison

Setting: Community (Community-health centers in Oregon)

Population of Focus: Practice members (e.g., managers, clinical and non-clinical staff, enrollment assistants) and families using community health centers

Data Source: Observations and interviews

Sample Size: 4 Community Health Centers (CHCs) in Oregon; 26 practice members; 18 adult family members who had at least one pediatric patient

Age Range: Parents and children; specific ages not stated

Intervention Components (click on component to see a list of all articles that use that intervention): STATE, Public Insurance (State), Enrollment Assistance

Intervention Description: There has been increasing interest among policy makers, navigators, and consumer organizations in developing novel outreach methods to address diverse barriers to enrollment. This study evaluates the impacts of personalized, live outbound telephone calls from service center representatives on enrollment in California's ACA Marketplace, Covered California, which accounts for 13.5% of national ACA Marketplace enrollment. The intervention targets consumers who had initiated the enrollment process by submitting an application but had yet to select a plan. Households in the study population were randomly assigned to one of two groups at the outset of the intervention period: a treatment group that was assigned to receive a phone call (hereafter referred to as an “outbound call”) from a service center representative and a control group that was assigned to not receive an outbound call. This intervention could address enrollment barriers such as lack of awareness of health insurance options, low health insurance literacy or computer literacy, preference for in-language assistance, and the time and cognitive costs of shifting through options. Those in the control group, similar to any other consumers, could contact the Covered California service center by calling the publicly available number that had been provided to them.

Intervention Results: Personalized telephone calls from service center representatives increased take-up of Covered California health insurance. Outbound calls were placed to 27,123 households in the treatment group (49%). Receiving an outbound call increased Marketplace health insurance take-up by 2.7 percentage points (p<0.001) for consumers who received a call because of random assignment—a 22.5 percent increase over the control-group rate. Enrollment impacts were statistically significant for lower-income households (below 200% of the FPL) but not for higher-income households as well as those who were referred from Medicaid, those ages 30-50 or older then age 50, those who were Hispanic, and those whose preferred spoken language was Spanish or English. The total intervention cost to Covered California was approximately $243,000, or approximately $224 per new member acquired. Our calculations suggested that the return on investment was 102%. Similiar to prior studies, we found that information interventions do not fully overcome barriers to enrollment for many consumers. Nonetheless, informational interventions may induce modest gains ine enrollment among certain segments of the population while yielding a positive return on investment.

Conclusion: The intervention provided a two-to-one return on investment. Yet absolute enrollment in the target population remained low; persistent enrollment barriers may have limited the intervention’s impact. These findings inform implementation of the American Rescue Plan Act of 2021, which expands eligibility for subsidized coverage.

Study Design: RCT

Setting: Service Center for Marketplace Insurance Enrollment in California

Population of Focus: Consumers who had applied but not selected a plan

Sample Size: 79,522 consumers (treatment group=55,519; control group=24,003)

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Mini Grants, Enrollment Assistance,

Intervention Description: eorgia’s Utilization Minigrant Program was designed to enhance the utilization of children's health services in Georgia by providing small grants to community-based organizations. These grants aimed to support locally tailored strategies to promote appropriate utilization of primary and preventive care services for children enrolled in Medicaid and PeachCare for Kids. The program emphasized collaboration with healthcare providers and community stakeholders, recognizing the importance of grassroots initiatives and local expertise in addressing the specific needs of the target population. Grantees were tasked with developing innovative approaches to improve service utilization, and the program's evaluation provided valuable insights to guide future outreach efforts

Intervention Results: The Georgia’s Utilization Minigrant Program was successful in improving the enrollment and appointment-setting for essential health services for children enrolled in Medicaid and PeachCare for Kids. The program facilitated increased referrals to other services and fostered collaboration with community partners, leading to improved access to care. The intervention allowed for the development of innovative projects with local reference, empowering grantees to propose unique solutions tailored to their communities' specific needs.

Conclusion: The Georgia’s Utilization Minigrant Program demonstrated the value of community-based, locally driven initiatives in promoting the appropriate utilization of children's health services in Georgia. The program's emphasis on collaboration with healthcare providers and community stakeholders, as well as the provision of small grants to support locally tailored strategies, proved effective in improving enrollment, appointment-setting, and referrals. The program's evaluation provided valuable qualitative insights into common facilitators and barriers to success, which informed programmatic recommendations for future outreach funding programs. The program's success highlights the importance of empowering community-based organizations to play a pivotal role in promoting the appropriate utilization of Medicaid and CHIP services for children.

Study Design: mixed methods (quasi-experimental)

Setting: State (Georgia)

Population of Focus: Children enrolled in Georgia Medicaid/CHIP

Sample Size: 16 organizations awarded minigrants

Age Range: 0-18 years